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To see and be seen clearly

A trans perspective on treatment for gender dysphoria

Self-portrait of the author wearing glasses, November 2017.

Like many people, I have imperfect vision. This was not always the case. My eyesight was actually better than 20/20 when tested in ninth grade; I scored 20/13, if I recall correctly. But by the time I was a senior in college, after hundreds of pages of weekly reading for my liberal arts classes, I was nearsighted and required prescription glasses. I didn’t enjoy wearing them or how I looked in them, but didn’t want to deal with the hassle of contact lenses, especially as I only really needed glasses for distance. When I had better vision insurance, I got rimless styles that were as invisible as possible on my face.

To this day, 25 years later, I take my glasses off at home and any other place where I don’t need to see things at a distance. Though I’m now astigmatic and also overdue for an eye exam to be honest, I still hate wearing glasses, and still don’t want to get contacts. My astigmatism is mild, and not at all comparable to someone who is completely blind or legally blind without vision correction. But wearing glasses to see things at a distance clearly is medically necessary, as doing without them would have a significant negative impact on my quality of life.

For people with gender dysphoria —distress resulting from a mismatch between a person’s gender and the sex they were assigned at birth— doing without hormones or surgery can also have a significant negative impact on quality of life. Not everyone with dysphoria desires or requires medical intervention, just as not everyone with imperfect vision requires corrective lenses or ocular surgery. But no reasonable person would suggest that a significantly near- or farsighted person just learn to accept their vision the way that it is, that God intended them to squint, or that vision correction is a new fad for attention-seekers because eyeglasses, contact lenses, and laser surgery were not available in early human history.

Some might question this analogy because glasses and contact lenses, which are more typically prescribed than laser surgery, do not cause the permanent changes to the body that normally result from hormone therapy and gender-related surgery. I agree that the analogy is imperfect, and trans adults should be fully educated on the expected and possible effects of any proposed treatments. (Trans children in the U.S. are not prescribed cross-sex hormones or surgery; though they might offered puberty blockers, the effects of these are reversible.) But medical treatment for dysphoria should be provided on an informed consent basis, not subjected to invasive, trans-antagonistic questioning, demands of proof of a binary gender identity, “real life experience” tests or other medical gatekeeping.

Coming back to the analogy, while there are those in the Deaf community who do not consider hearing loss or absence to be a disability, I am not aware of a parallel activist movement for blind people. If there is one, please alert me to it because I do not wish to be ableist. My point for making this comparison is that gender dysphoria, like vision impairment, varies in intensity, but medical options are available and should be provided without gatekeeping, stigmatizing the patient, or subjecting them to financial burdens.

Financial burdens are sadly familiar to many trans people, as many are uninsured, and hormones and surgery are often not covered by insurance. I am privileged to be supported by my spouse, whose insurance only began covering trans-related prescriptions and procedures in 2013, the year I began my own transition. (The state of California later prohibited all insurance carriers from discriminating on the basis of gender identity, but many states do not have these protections, and the federal government has been steadily eroding trans rights and dignity since Donald Trump took office.) Many trans people are not so fortunate, and are forced to go without treatment that could greatly enhance their quality of life. Some die by suicide as a result.

Dysphoria manifests differently for every trans person. For me, it is significant discomfort with my female-assigned reproductive system, consisting of the vulva, vagina, uterus, and ovaries that are typical of an endosex (non-intersex) estrogen-dominant human. I have not sought out surgery for various reasons, so I have addressed this discomfort with hormone therapy. I started with biweekly injections of testosterone, the cheapest and most widely available option for transmasculine people in the U.S.

Injecting myself at home worked for awhile, until serious anxiety forced me to look into other options. I opted for testosterone pellet implants, which I was very optimistic about as they only needed to be done three or four times a year. But the minor, outpatient surgery left me in pain for a month. While this outcome was not typical, I was not willing to risk being incapacitated for that long again, whether our insurance covered the procedure or not.

Walgreens receipt for the author’s testosterone gel prescription. The insurance savings, $629.99, is circled.

I switched to a topical gel, which I had not wanted to do as I had heard negative things about its cost and effectiveness, plus it has to be applied every day. But I was running out of options, and since our insurance covered the product my doctor recommended, I made the change. I do not know many people who can afford to pay full price for this product; I was in shock when I saw that without insurance, I would be paying over $600 a month for a three ounce container. (The insured price was a much more reasonable $35.)

Like with most other transmasculine treatments, this gel was designed for and is marketed almost exclusively to cisgender men. My doctor imprecisely referred to these patients as “males”; I kept meaning to correct him (as trans men are also males), but I lack the energy to counter all the cissexist microaggressions I face daily. I don’t know all of the reasons that cis men with low testosterone would need this product, but I’m sure they are legitimate and recognized as such. I wish trans folks were afforded the same respect.

While stopping the influence of estrogen on my reproductive system was most important for my personal well-being, the visible changes that came with testosterone dominance were also welcome. After nearly four years on hormones my voice has settled in the baritone range, and I have finally grown enough of a beard to be worth displaying. Coupled with accelerating baldness, I am hoping that these male-typical characteristics will get strangers to stop calling me “Ma’am” or “Miss” once and for all.

Unfortunately, I can still expect to be misgendered on a regular basis, as I am agender and prefer not to be referred to with gendered pronouns, titles or salutations. Being addressed as a man is an acceptable compromise for now, but a reluctant one as it is still not accurate. This is one area where medical treatments for dysphoria have their limitations. No amount of hormones or surgery could correctly convey my non-binary identity to the public, because being non-binary, for me, is not something that can be expressed physically. My dysphoria will remain a problem until and unless society evolves to a place where non-binary genders are truly and fully accepted. (Legal recognition is one step, but it is not enough.)

For many trans people, however, physical alterations can help them be seen as their true genders. Some procedures, such as laser hair removal, are considered cosmetic and are almost never covered by insurance. But a trans woman with even the shadow of a beard can be at risk for violence, on the street or when entering a gendered facility such as a woman’s restroom.

Trans people in prison, many of whom are oppressively housed with inmates of their birth-assigned sex, need access to hormones and surgery as well. Those (including some trans people) who complain of the cost to the taxpayers of such procedures ought to work on abolishing the prison-industrial complex instead of keeping medically-necessary treatments from their fellow human beings.

The subtitle for this story refers to a trans perspective because this essay does not reflect the trans perspective on dysphoria. There is no one true representative trans experience or narrative. But trans stories are dominated by cis voices, and cis people are the gatekeepers who control our access to needed medical interventions. Cis allies can help by sharing stories written by trans people. With the annual Transgender Day of Remembrance approaching on November 20, now is a good time to amplify the voices of living trans people so that fewer of us are lost to violence and suicide. While our genders are authentic whether or not we pursue physical transition, medical treatment helps many of us live happier, fuller lives.