Gender Confirmation Surgery: The Cost of Freedom
Self-determination is a fundamental principle of modern international law. It’s enshrined in Article I of the UN Charter and states that all peoples have the right to determine their own destiny in regards to political, economic, cultural and social development. The concept arose in the early 1900’s and fueled the succession and decolonization movements of the century.
Now in the second decade of the 21st century, many young Americans have internalized the second-wave feminist idea that the “personal is political.” Self-determination is no longer only a right reserved for nation states, but something that each individual is entitled to pursue. It applies to all arenas of life — from dietary restrictions that support animal rights and decrease greenhouse gas emissions, to career paths that buck conventional capitalist aims in the interest of passion, to establishing familial structures outside of the heteronormative nuclear family.
An even more “radical” interpretation extends the principle of self-determination to the physical. The American Society of Plastic Surgeons (ASPS) reports that there were 23.5 million plastic surgery procedures in 2018 – 17.7 million of which were considered cosmetic, and the remaining 5.8 million were reconstructive. Most of us understand reconstructive surgery as the repair of visible biological malformations due to genetics, like cleft lips and palates, or physical trauma, like scars and facial bone fractures. But it also applies to less apparent conditions like gender dysphoria, defined by the NHS as a condition where a person experiences discomfort or distress because there’s a mismatch between their biological sex and gender identity.
Gender confirmation surgeries revise that mismatch and give transgender individuals the physical appearance and functional abilities of the gender they know themselves to be. The surgical options include top, bottom and facial procedures for both transmasculine and transfeminine candidates. According to the ASPS there were 2,885 male to female patients and 6,691 female to male patients in 2018, a 13% total increase from 2017. Even though the numbers are rising, that figure is still a small fraction of the estimated 1.4 million trans Americans.
Maybe this fractional number is due to a lack of desire. It’s within the realm of possibility that less than 1% of trans people are interested in surgery. Gender is, after all, not ultimately defined or represented by physical presentation. But it’s more probable that the low percentage is a result of cost prohibitive procedures. The Philadelphia Center for Transgender Surgery estimates that genitoplasty (bottom surgery) alone costs around $25,000. Breast augmentation is on average $9,000, facial masculinization can be up to $53,000 and feminization can be a whopping $70,000.
These prices are far beyond the financial means of most Americans, which makes insurance the only realistic pathway to surgical gender confirmation. Medicaid offers coverage for transition-related costs on a state by state basis and fewer than half of the nation (23 states) explicitly covers trans health care. Of the remaining 27 states, the majority do not have an explicit policy and a small collection of conservative states explicitly deny coverage, among them Alaska and Arizona. Private insurers fare even worse in terms of trans-inclusivity with only a minute group of progressive companies offering employee coverage.
In search of a more affordable option, many Americans are looking outside the US. Thailand is the most popular overseas destination with gender confirmation procedures clocking in a mere one-third of the stateside cost. According to Thaiger, a Thai lifestyle outlet, most doctors will require certain surgical prerequisites including: an age of at least 20 years or parental consent for those between 18 and 20, 12 months of continuous hormonal therapy and 12 months of real-life experience living as a woman (assumedly to ensure that each candidate is certain about making the transition). Hormone therapy, while not negligible, costs far less than the surgery itself at an average of $1,500/yr. For most transitional procedures, preparatory hormones, travel, surgical costs and recovery accommodations in Thailand combined are all still less than US surgical costs alone.
Thai age restrictions deny trans teens from confirmation surgery and in recent weeks, several US states have taken steps towards doing the same. On January 29th, South Dakota passed House Bill 1057 which criminalized medical treatment for transgender youth. The bill prohibits hormone treatment, puberty blockers and gender confirmation surgery for children younger than 16 years old. Offending doctors will face a Class 1 misdemeanor, which carries a penalty of one year in jail and a maximum fine of $2000. South Carolina, Florida, Colorado, Oklahoma, Kentucky and West Virginia all have introduced similar bills since the start of the year.
As social attitudes change, legislation is bound to follow for better or worse. The trans community, both young and old, is at a pivotal time in their communal history. Their bid for self-determination is now being supported in name, but how soon will structural action follow?
