Gender affirmation surgeries resume. But trans people still struggle because of the pandemic.
Fifi Dosch, a transgender woman in California, started hormone replacement therapy the day before the state lockdown order in March 2020. She was already socially transitioning, and this was the first step in her medical transition.
“[Now] I’m prepping up for bottom surgery and all non-essential surgeries are getting pushed to the bottom of the list,” Dosch said. “Which I understand, but I don’t like. I think if a cis person woke up with the wrong genitals, they’d consider correcting it an essential service.”
These surgeries are slowly getting back on track after delays and cancellations due to the COVID-19 pandemic. And trans people are now able to schedule and undergo surgeries to affirm their gender.
Gender affirmation surgery is considered elective and plastic. Several types can be performed for trans people. Top surgery is performed on the chest to either remove breast tissues or add silicone breast implants. Bottom surgery can include a vaginoplasty (surgical construction of a vagina) or a phalloplasty (surgical construction of a penis).
Early in the pandemic, the American College of Surgeons recommended that hospitals minimize, postpone, or cancel all scheduled elective surgeries. The U.S. Centers for Medicare & Medicaid Services also released guidelines to limit all elective surgeries
“With pandemic protocols being changed on a monthly basis, and the length of the pandemic dragging longer and longer, the factors change and the decisions need to keep being updated,” Aaron Almanza, executive director of the LGBTQ National Help Center, said. “Many [trans people] have needed to delay their surgeries, which has meant that the pre-surgery arrangements were wasted or needed to be changed.”
Sidhbh Gallagher, a gender affirmation surgeon who runs her private practice in Miami, stressed how little doctors knew about what was coming next, as things quickly changed.
“For my patients, it was pretty devastating,” said Sidhbh Gallagher, a gender affirmation surgeon who runs her private practice in Miami. “There are several instances that I could think of folks who were about to get their top surgery.”
According to doctors and researchers, receiving gender-affirming care improves the well-being and mental health of trans people, including reductions in anxiety, depression, and substance use.
Many elective surgeries were able to resume in the summer months of 2020, as the numbers of surgeries performed in July recovered to pre-COVID-19 levels. But, at least 106 hospitals across the country canceled or postponed elective procedures after a surge of coronavirus infections late last year..
The U.S. developed a nationwide backlog of millions of elective surgeries. Demand for elective surgery has grown, as plastic surgeons report an unprecedented number of requests for procedures.
In 2020, Gallagher performed around 200 gender affirmation surgeries. She charges $9,000 for female-to-male top surgery and $30,000 for bottom surgery. So far, 2021 is just as busy for Gallagher.
“We were seeing more people than expected schedule surgeries. People were making use of the opportunity that they were at home [and] working,” Gallagher said. “I’ve seen a lot of folks who socially or medically transition for ten years are now during this time finally getting around to surgical transition if that’s what they wanted to do.”
The MetroHealth Pride Network in Cleveland, Ohio, has provided healthcare services for the LGBTQ community during the pandemic. For trans patients, that care includes gender affirmation surgery, hormone replacement therapy, and voice training.
“I know a number of people that have seen physicians, been on hormones, [and] been making changes for a year, “ Ginger Marshall, the administrative coordinator for the network, said. “And all of a sudden are going to work, going to meetings, and they’re gonna be a different person because they [would] have spent this time transitioning.”
But since access to gender-affirming care differs from state to state, trans people across the country face inequitable treatment and support options, especially with the pandemic.
Multiple anti-trans bills have swept the nation in the past year. Arkansas passed a bill that banned trans youth from receiving gender affirmation care, including reversible puberty blockers and hormones. It also prevents public funds, such as Medicaid, from being used for transition-related care. But under the Biden administration, the Department of Health and Human Services has prohibited healthcare discrimination against trans people. President Joe Biden has previously expressed support for the trans community.
“Some people need to go to a medical facility for their scheduled [hormone replacement therapy] and have needed to weigh the need for the shot to the risk of being at the hospital or facility during the pandemic,” Almanza said. “Many people don’t have access to online medical appointments so they don’t have [those] options. Some people need to have tests done to tweak their hormones and tests can’t be done online or some states don’t allow for mail-in [hormone replacement] prescriptions.”
Almanza also said there is limited access to gender-affirming counselors and therapists during the pandemic.
“Before COVID, there might be 10 therapists in a city, four might be gender-affirming,” he said. “During the pandemic, out of [those] four, there may only be two that have been able to continue to see patients through online means and add to that the access to online options by the patient.”
However in the Cleveland area, access to hormone replacement prescriptions aren’t a big problem for most trans patients, Marshall said, because they can pick them at their local pharmacy or have them mailed in. The Metro-Health Pride Network and other LGBTQ services in Cleveland moved multiple trans support groups online with ease last year.
“We got an incredibly active LGBT center that has very quickly figured out moving support groups online,” Marshall said. “They provided good support as far they could.”
But that doesn’t mean trans people aren’t still struggling. “Every single medical health person [and] doctor that I’ve talked to about this has said my LGBT patients are suffering badly because of [COVID-19] and trans people are really having problems”, Marshall said. “Because of the isolation, unemployment, and being cut off from normal support.”
And access to reliable, affordable internet to see a gender-affirming therapist remotely might be out of the question for some. Since trans people are disproportionately burdened with financial hardships, Almanza said.
Nearly one in five trans people have experienced homelessness at some point in their lives, according to the National Center for Transgender Equality. Since 2016, the number of trans adults experiencing homelessness has increased 88 percent. And LGBTQ people are more likely to work in jobs that were affected by COVID-19 shutdowns. such as public and higher education, or “non-essential” retail businesses.
In New York, the Pride for Youth organization runs a COVID-19 relief program for the LGBTQ community. During the pandemic, they are providing free food assistance, psychological counseling, employment, and housing assistance services.
“For trans people specifically, we sorta tapped into multiple domains of human life,” Tiffany Vasconcellos, the prevention service manager who runs the program, said. Their housing assistance program uses hotel gift cards as a temporary solution for those who got kicked out of their apartments or struggling to pay rent.
Trans people have significantly lower employment rates, lower household incomes, higher poverty rates, and worse self-rated health, advocacy groups said. Dosch left her day job due to allegations of transphobic harassment, including her employer refusing to call her by her chosen name.
“I got tired of being disrespected and put down so much, and just the stress of [COVID and everything] was weighing on me too much,” Dosch said. She said she eventually had a mental breakdown because of it.
Dosch found support in her friends, but found even more on TikTok, of all places. The social media app exploded in popularity during the pandemic.
“It’s very reassuring because I was doing stand-up for the longest time and not really getting anywhere,” she said. She thought about giving up entertainment and moving back to her home state of Montana.
However, within the past year, Dosch has gained nearly 200,000 followers on the platform making humorous content. She is known for her “queen of Antifa” and “signs of the zodiac” skits.
“Then I started TikTok and I’m like thank you! I didn’t think I was crazy,” Dosch said. “It really means a lot to me all the lovely things people say on there.”
Now, Dosch is attempting to move her growing fanbase to Patreon, a subscription-based platform for content creators. She hopes it becomes a lucrative source of revenue for her.
The hope is that with coronavirus infections on the decline and vaccinations becoming more available, gender affirmation surgeries for trans people remain possible and have easier access to social support as the pandemic comes to an end.
This article has been updated to include the Biden administration prohibiting healthcare discrimination against trans people .