Dear Legislators, Gender Transitions Are Not One-Size-Fits-All

By Lonna Dawson

Monique Fontaine. (Photo credit: Jessica Bal)

This story originally appeared on Narratively, a digital publication and creative studio focused on ordinary people with extraordinary stories — get thee to more amazing tales on the new face of adoptive parents, a series on paperless people, and clandestine love.

As laws change, legislators must recognize that not all trans people want the same thing.

New York State’s new law requiring coverage of gender reassignment surgery sounded like a game changer. The problem: not all trans people want the same thing.

Monique Fontaine eyes her cellphone screen as she records a video from Mount Sinai Beth Israel hospital in New York City. Flanked by cords and containers and a copious amount of beige, she and her doctor have agreed to enlarge her breasts, so she can look more feminine, from a B cup to a C cup, with implants surgically placed above the pectoralis muscle and filled with 425cc’s of saline. It’s not her first such procedure, but it is the first one performed in a medical facility, a far departure from the other locations — a Times Square hotel room, someone’s living room in Brooklyn — where she’s had work done before. “See ya on the flip side,” Fontaine says to her social media followers before the video ends. Fontaine is transgender, and, thanks to recent changes in New York State law, her procedure is covered by Medicaid. Not only does her breast augmentation come at no cost to her, but it comes with the peace of mind of being done safely and by a medical professional.

Procedures that transgender individuals like Fontaine undergo as a part of their gender transition typically include hormone therapy (for trans women, a combination of estrogen and the testosterone blocker spironolactone, which helps with inhibiting hair growth, redistributing body fat, growing breasts and softening skin), cosmetic surgery, and, often, gender reassignment surgery. Male-to-female gender reassignment surgery consists of removal of the testicles and penis and the creation of a vagina made from the remaining skin. In female-to-male procedures, the uterus and ovaries are removed and a penis is created from tissue taken from the forearm or thigh.

Monique Fontaine gets dressed in her apartment. (Photo credit: Jessica Bal)

Insurance companies tend not to cover the expenses of gender reassignment surgery, which can cost anywhere from $40,000 to $100,000, depending on the type of surgery. They also generally do not cover facial feminization surgery, which can consist of forehead and jawbone shaving, and run between $12,000 and $40,000. New York Governor Andrew Cuomo introduced a regulation, enacted into law in 2015, that requires Medicaid, along with private insurance companies in the state, to cover hormone therapy for trans individuals over the age of eighteen, as well as gender reassignment surgery for individuals eighteen or older, or 21 and older if the surgery includes a hysterectomy or otherwise results in sterilization.

For many transgender people, the ultimate step in transitioning is not reproductive organ surgery.

While the law was hailed as revolutionary for the transgender community, some trans women took issue with the fact that the law prioritized gender reassignment surgery, while leaving out procedures such as breast augmentation and facial feminization, which are deemed cosmetic. For many transgender people, the ultimate step in transitioning is not reproductive organ surgery.

A close-up of a scar from Fontaine’s recent breast enlargement surgery. (Photo credit: Jessica Bal)

Fontaine, for one, is not interested in having a vagina. Fontaine, who works as a beauty consultant at a Manhattan drugstore, feels it is precisely her trans identity that makes her unique and more attractive to certain men, including her boyfriend of four years. Fontaine had her testicles removed so that she could scale back on the hormone treatments, but she plans on keeping her penis. For one thing, she believes gender reassignment surgery would jeopardize her relationship with live-in boyfriend David Green, a cisgender male.

“Once I have gender reassignment surgery, I’m like any female, [except] I can’t have kids,” she points out. “In some ways, I stick out because I have male and female parts,” she asserts — and she doesn’t see that as a bad thing. “That’s a huge reason for being with a trans woman. I honestly don’t want to get gender reassignment surgery.”

Fontaine…feels it is precisely her trans identity that makes her unique and more attractive to certain men, including her boyfriend of four years.

Many transgender advocates and psychotherapists argue that all transgender individuals are not created equal. Lourdes Hunter, co-founder and executive director of the TransWomen of Color Collective, believes the legal framework of providing medical coverage to transgender individuals does not quite go far enough. “Trans people are not a monolith,” Hunter observes.

“It’s possible to feel trapped in the wrong body. It is possible to feel like I need to assimilate to this image that society and religion say I need to look like a women to be accepted. It is also possible to love your body the way it is and reject gender and be trans. It is possible to not take medication and not conform to gender performance and still be trans.”

According to SJ Langer, psychotherapist and executive committee member of the Psychotherapy Center for Gender and Sexuality, Fontaine’s decision is not an uncommon one among transgender individuals because of the diversity in gender identities. He worries that new laws might push people to go through surgery even if they’re not ready for it. “Gender is so complicated we can’t reduce it to one standardized set of traits,” he said. He’s also concerned that, as transition methods become standardized through Medicaid, that more people will feel as though they must undergo male or female surgeries.

Gender is so complicated we can’t reduce it to one standardized set of traits.

“There is nowhere in medical science that you find a definition for what is one hundred percent male and what is 100 percent female. Nobody knows how to define that,” adds Dr. Jamison Green, former president of the World Professional Association for Transgender Health, a professional organization that promotes and sets medical standards for transgender health.

Fontaine fixes her hair in the mirror .(Photo credit: Jessica Bal)

What Fontaine had long wanted, aside from her hormone therapy, are changes that were considered cosmetic, and not covered under the original New York State law. “I want facial feminization surgery, which would include my forehead, shaving down my brow bone, shaving down my jawline; and a little work done on my chin and nose. And I would want more body work like silicone,” she says.

What Fontaine had long wanted, aside from her hormone therapy, are changes that were considered cosmetic, and not covered under the original New York State law.

Fontaine is five-foot-ten. On a recent winter evening, her honey skin glows under the warm light of a Harlem coffee shop. Her high cheekbones hoist her lips into a permanent pout. Her natural hair is pulled up and her brown coils spring about unabashedly. She says she likes the way she looks, but at times she catches glimpses of herself that fuel her desire for more cosmetic surgery. “I still kinda see that boy here and there,” she says.

In July 2016, a federal judge ruled it unlawful for New York Medicaid to ban cosmetic procedures that are medically necessary for the treatment of gender dysphoria. Judge Jed Rakoff ruled that the exclusion violated the Medicaid Act, which requires coverage of medically necessary care. The ordered changes to the law took effect in December. That means transgender individuals in New York, like Fontaine, can now make the medical changes necessary to align their appearance with their gender identity.

Fontaine says she has wanted breasts her entire life. “It’s something that completes me as a woman in my mind more so than I was before and also in society’s mind,” says Fontaine. “As trans women, we have to be the epitome of femininity,” she says, calling breast enlargement “a rite of passage.”

“As trans women, we have to be the epitome of femininity.”

Green, Fontaine’s boyfriend, sits next to her in the Harlem coffee shop. His baseball cap fits low on his head and his precisely cut beard encloses his wide smile. He has the build of an athlete and works as a mechanic. Fontaine calls him “Teddy” — a nod to Green’s small nose, ears and “furry” face — and close friends and family have adopted the nickname for him too.

The pair met in December 2012 at a private trans-sex party known as Eden Underground in the Park Slope neighborhood of Brooklyn. Green walked through the crowd with a beer in hand looking for a “legitimate trans girl,” he says. “I was looking for a girl on hormones, not a man in a wig, and I was very picky about it.”

Green, who identifies himself as a straight man, says he is attracted to Fontaine as a woman, but supports her decision not to undergo reproductive organ surgery. “There is a little bit of attraction to that,” Green confesses, sheepishly. “That’s the whole premise of why men are attracted to trans women.”

Many trans-affirming professionals, like Dr. Green and Langer, are hopeful that as legislation concerning trans people continues to expand, lawmakers will become better educated on the diversity that exists within the transgender community. In addition, Langer believes that legislation will become more inclusive as the cultural landscape evolves and more people can safely talk about their identities without stigmatization. “On a macro level, people who are trans need to be out, so that people actually know that they are trans, because right now, most people think that they’ve never met a trans person, and most people have and they don’t know it,” he says.

“The big picture is a lot of people are trying to understand trans people. The only thing you need to understand is the human part.”

As Hunter puts it, “The big picture is a lot of people are trying to understand trans people. The only thing you need to understand is the human part.”

No matter how laws continue to be altered, they can’t affect how Fontaine thinks of herself. In her mind, she is who she is — a woman.

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