Medical autonomy

Rejecting Gatekeeping & Racism: Access & Medical Autonomy in Gender Affirming Care

Health justice includes the right to health information, informed consent for medical treatment, and gender-affirming care. Achieving this will require removing the exclusion of gender-affirming care by health care insurers, including rules that require mental health care providers to gate-keep care. Health justice requires trust in trans people to make the best decisions for their own care, and access to therapeutic services on our own terms. 

This page provides data about the different desires and levels of access to gender-affirming treatment among Transmasculine survey participants. We highlight uneven access to insurance coverage for gender-affirming care and racial inequities in access to surgical care. This page also provides evaluations of participants experiences seeking mental health authorization letters for gender-affirming care.

I have spent way too many appointments educating staff and health care providers about transgender 101 issues [...] It's often assumed I'm a trans woman when I attempt to access services, which goes back to lack of education of basic terms and terrible assumptions made on my voice or appearance. Please ask all of your patients (trans and cis) for chosen name and pronouns.

TMSHRJ:LA survey participant​

Access to trans-specific Primary care

PREFERENCES IN PROVIDERS

We asked participants about their preferences in SELECTING health care providers.

Participants prefer providers that…

have experience with trans patients
99%
specialize in trans health care
93%
specialize in LGBT health care
93%
ask about pronouns
92%
BIPOC

Many Black, Indigenous and People of Color (BIPOC) also preferred providers that are people of color.

 

AMONG BIPOC PARTICIPANTS, % THAT PREFERRED PROVIDERS WHO

Share their racial/ethnic identity
43%
are people of color
59%

Trans-specific Primary care provider

We asked participants if they currently had a primary care provider (PCP), and if so, if their PCP specialized in transgender health care. We compared participants who had a trans-specific PCP and those who did not on a variety of health indicators.

0 %

had a primary care provider (PCP) that specializes in trans health care

Health factors associated with having a specialist PCP

ACCESS to gender-affirming medicine & treatment

Testosterone

We asked participants if they had ever used testosterone therapy. if so, we asked if they currently used testosterone regularly and how many years they had taken testosterone. FOr those who started and quit testosterone, we asked participants to share their reasons. FOr those who had never access testosterone, we asked if they wanted to or did not want to use testosterone in the future.

We also asked about administration methods.

testosterone (t)

taken t (lifetime)
72%
uses t regularly
62%
wants T in the future
13%
does not want T (or unsure)
16%

Administration methods

I had one doctor ask me, on the first time meeting me, if I ever regretted transitioning. What the hell.

TMSHRJ:LA survey participant​

Gender-Affirming Surgeries

We asked participants if they had ever had chest reconstruction surgery (or “top surgery”) or Genital reconstructive surgery (or “bottom surgery”). We also asked if participants had a hysterectomy (for any reason). If not, we asked if they wanted or did not want this type of surgery in the future.

surgical Care

Top surgery

Bottom surgery

Hysterectomy

BIPOC

Fewer Black, Indigenous and People of Color (BIPOC) had accessed top surgery despite no differences in interest and desire for this kind of care. 

HAD ACCESSED TOP SURGERY

BIPOC
37%
WHITE
61%

Lack of insurance coverage

We asked participants if their insurance had covered some or all of their prescriptions for hormones and/or gender-affirming surgeries.

Insurance DID NOT COVER ANY COSTS RELATED TO:

top surgery
45%
testosterone
27%
hysterectomy
24%

Only 5 participants had accessed bottom surgery. 4 out of 5 had insurance coverage for some or all of the treatment.

My school doctor refused to prescribe hormones and the nearest person who would was a 30 minute car drive away (3 hours by bus) and she doesn't take insurance. I didn't have a car and couldn't afford to buy testosterone without insurance and I couldn't afford to get over to her office.”

TMSHRJ:LA survey participant​

Mental health gatekeeping

MEDICAL AUTHORIZATION LETTERs

We asked participants if they had ever asked a mental health care provider for a letter in order to access gender-affirming medical care. If yes, we asked several follow up questions about that experience.

0 %

had asked a mental health care provider for an authorization letter for obtaining gender-affirming medical treatment

getting a letter was easy
58%
got a letter in My first appointmenT
25%
was helpful in making medical decisions
51%
I could not be honest about my mental health
41%
I could not be honest about my gender identity
31%
do not believe a letter should be REQuired
49%
BIPOC

A smaller percentage of Black, Indigenous and People of Color (BIPOC) had sought a letter from a mental health provider for gender-affirming medical treatment compared to white participants.

 

SOUGHT A MENTAL HEALTH LETTER FOR TREATMENT

BIPOC
59%
WHITE
75%
I wound up seeing three different therapists for my hormone letter. One strung me along for more money and was horribly inappropriate, one produced a letter right away, and one I was required to go to due to a new trans health care program that was poorly implemented and wouldn't accept my existing letter; that last therapist was very supportive and worked with the program to address their requirement.

TMSHRJ:LA survey participant​

KEY TAKEAWAYS

want top surgery but haven't had access
1 %
insurance did not cover gender affirming care
0 %
sought an authorization letter for gender-affirming care. 75% did not get one in their first appointment
1 %
accessed gender-related medicine before age 18
< 1 %
OUr partners