During the pandemic, trans people have faced yet more barriers to treatment
As a professional drummer, Rikki Bates knows something about keeping time.
Over the past year, time has moved at an agonizing tempo.
“You’ve got to go straight up the trail and, you know, cut down trees with nail files,” she said. “It just takes a long time. … Well, the clock’s ticking.”
She was 4 years old when she knew she wanted to play drums. Around that same time, she also realized she was different—and something felt wrong.
“I felt paralyzed. … I lost interest in absolutely everything and just felt like I wanted to die,” said Bates.
At last, in March 2020, she had access to a surgery she had known she wanted since she first heard of it in the 1970s. At 66 years old, she was finally ready to set a date for a gender affirming operation that would drastically improve the quality of her life.
Then the coronavirus hit, and the whole world paused.
“To think that I was all ready to have this facial surgery and then have the rug pulled out from under me was devastating,” said Bates. “It’s terrible.”
She had no choice but to keep doing what she had been doing for as long as she can remember—wait.
During a year that has been stressful and traumatic for everyone, transgender individuals seeking gender affirmation surgery faced the additional stress of postponed treatments that could be lifesaving.
Gender affirmation surgeries can be a pivotal stage in a person’s transition. Doctors today have surgical techniques at their disposal that make it safe and feasible to alter parts of the body to better align with a person’s true gender identity.
Commonly sought procedures include bottom surgery (below the belt), top surgery (waist up) and facial surgery, where parts of the skull that serve as gender cues are altered. Not all people who are transgender choose surgery, but some feel that one or a combination of these surgical interventions is necessary for them to live their most authentic life.
In Bates’ case, she had already received three gender affirming operations before the pandemic: two bottom, one top. These gender affirmation surgeries made life worth living.
“Before I had any surgery, I just didn’t care about anything anymore. I just didn’t care about anything at all and just didn’t want to be alive,” Bates said.
After the surgery, everything changed.
“I just felt like this mountain of lead weights just went away,” she said. “Right away. Right away, and it never came back.”
At every step of the way, she had to fight her insurance over the medical necessity of gender affirmation surgeries for her, a process that dragged on “at a snail’s pace” through months and years. But she never considered giving up.
“It’s the only path towards me being able to love myself, which isn’t easy if you’re transgender,” said Bates.
On March 15, 2020, operating rooms in Massachusetts shuttered their hermetically sealed doors to any surgeries that were elective or nonessential. That included gender affirmation surgeries, along with anything else that didn’t require immediate and urgent medical attention.
Operating rooms started performing nonessential surgeries on June 8, only to limit capacity once again when COVID-19 cases peaked in December. Over a tumultuous year, trans people waiting for their surgery dates were on an emotional roller coaster.
“This was really, really hard on a lot of folks who had already been waiting for a really long time for these services,” said Elly Humphrey, a therapist who facilitated a peer-support group for people whose gender affirmation surgeries had been postponed due to COVID-19.
But this hardship was nothing new.
“This situation overall is not an unfamiliar one to trans folks, just feeling disregarded or not important enough,” said Humphrey.
Humphrey works at Fenway Health, which recently marked its 50th year of providing health care to the LGBTQ community of Boston and beyond. Around 15% of the patients it cares for are transgender or gender nonconforming (meaning they fall somewhere outside the binary view of gender as male or female). Ensuring a gender affirming health care experience where patients feel safe and understood is a priority.
Candace Nguyen, 28, also works at Fenway Health as a clinical coordinator for STI and HIV prevention clinics. Like many of the other providers at the clinic, Nguyen is a woman of trans experience, so she knows the anxiety of waiting to express herself firsthand.
“The fact that you have to wait to do that, I think that’s more painful,” she said. Nguyen started her transition at 25 and had only been on hormone therapy, which in her case suppresses male hormones (testosterone) and supplies her body with the female equivalent (estrogen), for a year when COVID-19 hit.
“I had this irrational fear that when COVID-19 happened, that the world was gonna end before I actually get to fully live my life,” said Nguyen. “I don’t wanna feel like I wasted my whole life not living.”
Quarantining at home with family, she felt disconnected from her community and her identity.
“Every day I would just be waking up looking at myself in the mirror and it’s like I’m not happy with myself. I’m not happy with the body that I am,” Nguyen said.
Now that she’s seeing results from her hormone therapy, she feels like she’s living for herself.
“I’m finally like what I’ve always wanted to be, and I definitely feel much happier and more confident,” she said.
The process of transitioning looks different for everyone. Regardless of whether people have surgery, they are not defined by the form their body takes.
“Whether or not folks medically transition or not, our spirit and our character stays the same,” said Nguyen.
In the behavioral health department, mental health experts familiar with the experience of navigating the world as a person who is gender nonconforming can uniquely understand the collective pain of the past year.
“There’s been a really drastic impact by the start of the pandemic on lots of folks who are trans and nonconforming,” said Annie Crossman, an outpatient psychotherapist.
They have noted an extreme increase in their patients’ anxiety and depression over the past year, with more people seeking help for their mental health and experiencing symptoms of mental illness.
Crossman, 28, offers mental health counseling at Fenway Health. They have been working from home over the past year in an apartment they share with their partner in Brookline. Many of the people Crossman works with are from populations marginalized according to racial, socioeconomic, ability, and HIV/AIDS status, among other factors.
Crossman largely attributes the abundance of patients seeking treatment to social isolation and the postponement of gender affirming treatments.
“A lot of folks have been starring the calendar for quite some time and no longer have access. … It gave a lot of people hope to have those surgeries scheduled,” said Crossman. She worries about the trans people who, like all of us, have been isolated from their communities and barred from places that are normally safe spaces.
Moving individual and group meetings online offered one benefit—they were accessible to people who may have limited access to Fenway Health in normal times due to geography. People in rural areas, like Bates, who lives down in Cape Cod in Orleans, could easily attend Humphrey’s weekly support group meetings over Zoom.
For Bates, the opportunity to share her story with others who have been through similar trials helped her feel less alone in coping with the fact her procedure was delayed indefinitely.
“There’s just constantly one delay after another, after another, after another, and it starts to feel like I’m just beating my head against the wall and this is never going to happen,” Bates said.
She spent nearly a decade in court in order to secure her rights to transition-related medical care. Represented by lawyers from the New England-based GLBTQ Legal Advocates and Defenders, she appealed against her insurance, MassHealth, and its decision not to cover her transition-related care. This happened three times.
At every turn, there seemed to be another obstruction.
“Just trying to figure out all of it, getting all of these details to work, it was totally maddening,” said Bates. Finally, in 2014, she had the coverage she needed after former Gov. Deval Patrick directed MassHealth to provide coverage for hormone therapy and gender affirmation surgery.
Before COVID-19 shut everything down, Bates had an appointment with Dr. Branko Bojovic at Massachusetts General Hospital to schedule the first in a series of several facial feminization surgeries. Her desired result after plastic surgery is a softer, more traditionally feminine appearance. This process is a huge undertaking, and in her case will include breaking, recontouring, and reconstructing several parts of her skull.
“This is not about me expressing my gender how I want to,” said Bates. “This is about me being stuck in this thing that I was born into that was never, ever, ever fun and something that I would never, ever, ever, ever wish on anybody else.”
This procedure, while still considered plastic surgery, is not cosmetic. It has the potential to profoundly impact her life.
“To run into this situation where they’re essentially being told this thing that is so deeply, fundamentally important to you right now is nonessential, just felt like a smack in the face for so many people,” Humphrey said. “For people who have been struggling with, let’s say, severe gender dysphoria, which is causing depression, anxiety, sometimes suicidal ideation, it’s really, really hard.”
Gender dysphoria occurs when there is a dissonance between what a person feels internally and the form their body takes physically. It can have overwhelmingly negative effects on a person’s health.
There is a simple medical solution to gender dysphoria: gender affirmation treatments, which ought to be agreed upon together by the patient and provider.
“They’re not something that is emergent, but I do think of them as a procedure that is urgent for many people and lifesaving for many people,” said Dr. Robert Goldstein, who is the medical director of the transgender health program at Massachusetts General Hospital.
According to Goldstein, many patients experience a delay in finding the care they desire before coming to his clinic. These delays can range from a year or two up to 20 or 30 years. They can result from relatively minor administrative errors, like paperwork going back and forth between insurance and providers. In other cases, they are the effect of the patient experiencing discrimination as they sought treatment.
Once a patient has initiated the process, depending on the surgery that person wants, the first opening could be six months, a year, or even two years away.
“These are surgeries that are highly desired, and unfortunately, there’s only so much space in the operating room on any given day,” said Goldstein.
Bates had been waiting for her place in the operating room for close to five decades.
On March 25, Bates underwent a frontal sinus setback, the first in a series of about five facial-feminization surgeries she plans to have done at Massachusetts General Hospital. Her recovery is going better and quicker than she could have hoped.
“I only felt really bad for a couple of days this past surgery,” Bates said. “I’ve had years of torture, and that’s way worse.”
On April 16, Bates returned to have the stitches removed and was already feeling more healing than discomfort.
“I really feel whole,” she said.
The changes are subtle, but for Bates, the transformation is profound.
“I feel my forehead. I can feel what he did,” she said. “And it’s just so much softer and rounder and it just feels really good. I feel like I’m coming home.”
A thin pink scar that traces the edge of her hairline, the faint memory of the surgeon’s blade, is already fading. Even though there are a multitude of incisions still planned, more bones to be shaved and more flesh to be surgically altered in order to achieve her desired result, Bates has reason to hope that the most painful part of the process—waiting to live authentically, waiting to feel comfortable in her own body, waiting to receive health care that is gender affirming—is nearly over.
“I still got a whole bunch more surgeries to go, but the goal is about to get reached,” said Bates. “There’s been all these other delays along the way, and I’m still working, chipping away at some of this mountain that’s still left. But, you know, I can see that there’s sunlight up there.”
This article was produced in collaboration with and distributed by the Boston Institute for Nonprofit Journalism.