During the pandemic, my gender affirmation surgery was not considered "essential" — but it is

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ByFei Lu

Since I began hormone replacement therapy two years ago, my body has changed significantly. Bimonthly estrogen injections have yielded an S-line body, softer facial features, and 34B breasts. It’s a strange feeling to go through puberty (again) at 27.

When I look at pictures of myself at 25, I see a different person; I’m now well on my way to the person I was meant to be. But with that transformation still come debilitating anxiety attacks — especially when I see my genitalia and still-too-small chest. There’s also the space between my upper lip and nose, subtly angular jawline, and nose width: I see all these traits as too masculine compared to cis-female Asian faces. For instance, when I compare my face to a K-pop idol’s face — despite my friends insisting that this isn’t a realistic beauty standard — that feeling of not being feminine enough is searing.

In these moments, sometimes, I can’t breathe. Other times, I’ll break out into a cold sweat. And even with makeup, a push-up bra, and painful tucking (I once unintentionally tore my genital skin after an eight-hour tuck), it never feels like I’m doing enough. I don’t speak for all transwomen, but I need gender reassignment surgery, facial feminization surgery, and breast augmentation to live a pain-free life, both emotionally and physically. I don’t want these operations; I need them. Without them, every day is a reminder that I wasn’t born cis. It’s horrible. And this pandemic has pushed this process back for far too long.

In the United States — as in many other countries — getting gender affirmation surgery is complicated. Patients need to be on hormone replacement therapy for a minimum of one year, buy sometimes absurdly expensive insurance that covers the medical costs, find a surgeon with a good reputation and open schedule (certain surgeons are in extremely high demand), get surgery referral letters from two mental health professionals, complete surgical consultations, and undergo genital laser hair removal. Then they can get the operation.

And that’s the process only if you’re lucky. I started calling to schedule surgical consultations in May of 2019. Initially, I aimed for a transgender medical team based on the East Coast whose members are considered quasi-celebrities on trans-Reddit. for GRS. But by this past February, I still didn’t have a consultation established. I can’t remember how many times I called, but each time the hospital said they couldn’t process or verify my out-of-state medical insurance.

My insurance policy states transgender-related operations are covered only if deemed medically necessary, so I never was told exactly why they had difficulty processing my insurance information. I did not want to keep waiting endlessly for an answer from them, so I prepared to contact other surgeons.

Then COVID-19 hit. Throughout the country, all surgeries deemed elective were affected, including gender affirmation surgeries. Internationally, approximately 28 million operations were canceled. For trans people, that meant countless life-saving procedures were dismissed or indefinitely postponed.

For trans people, being socially recognized as the gender they identify as is life-changing. In a 2015 survey, UCLA’s Williams Institute reported that 51% of transgender individuals attempt suicide, citing reasons including social discrimination, being victims of violence, rejection by religious communities, and being recognized as transgender by others (colloquially known as being “clocked”). But the findings also noted that individuals who received hormone replacement therapy (HRT) or “surgical care” substantially lowered rates of suicide, compared to those denied the opportunity.

It makes sense, doesn’t it? Socially, being recognized as the gender you are (known as “passing”) also means literal safety. In 2020 alone, there have been at least 28 murders of transgender women. There were estimated to be 26 in all of 2019. Apparently, the pandemic has worsened this crime rate.

For all of those reasons, and several more, I needed to move things along. Earlier this year, every time I called a medical office, they all told me they needed to reschedule their canceled consultations first. Curious, I asked what their consultation waitlists were. One gender reassignment surgeon’s waitlist was two years. Another facial feminization surgery (FFS) surgeon was a year and a half. The earliest consultation I managed to schedule was for March 2021 for breast augmentation. If COVID-19 hadn’t been debilitating to the U.S., I could have had my breast surgery scheduled earlier this year. Now, I’ll be surprised if I can have my breast and face operated on by the time I’m 30.

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“In Massachusetts, we were shut down from doing any elective surgeries for almost three months, like March through early June,” Jeffrey Spiegel, a Massachusetts-based plastic surgeon specializing in FFS, tells Mic. As an ally and a socially aware physician, Spiegel understands how important FFS can be for some transwomen.

“For a transgender woman, certain facial features don't send the message that is right for that person. That's disconcerting, and where dysphoria comes from,” he says. “The problem is that people see you, and they don't see you. I think [facial feminization surgery] can generate a tremendous amount of wholeness, and this sense of completeness that, okay, now finally people see me for who I am.”

But even with that empathy, he couldn’t help when the coronavirus pandemic impacted his practice. Unless an operation was deemed essential, all bets were off. “A gunshot wound is not up for discussion,” he tells Mic. “But getting facial feminization surgery or breast augmentation — where you're not going to die tomorrow if it doesn't get done — fits into the category of having to wait.”

Before the pandemic, he met approximately “30 people a week” and operated on “six to 10-plus people every week,” estimating he had to reschedule over 100 patients when (unofficial) lockdown hit. That meant all the patients had to wait, with no timeline, for arguably one of the most important operations of their life. Doctors like Spiegel might be plastic surgeons on paper, but in reality, they’re why many trans people are alive today.

Having to wait another year to have a surgeon just look at me (not even operate), was heartbreaking and deeply depressing. Stuck in quarantine, I spent uncomfortable amounts of time crying and staring at my body, acutely aware of what areas weren’t supposed to be there. But I kept looking, hoping someone had a reasonable waitlist.

In early July, I reached out to a surgeon at the “celebrity” East Coast hospital to ask if they performed gender affirmation surgeries. That same day, while browsing Reddit’s /asktransgender sub-forum, I came across an unfamiliar name in New Jersey — plastic surgeon Jonathan Keith. He was rumored to have a short waitlist, successful results, and great aesthetics (one Redditor said he specialized in “porn star vaginas”). Make your own judgments about that one, but to me, he sounded incredible. Plus, his credentials were impressive; he founded the Rutgers Center for Transgender Health and has taught and been trained at some progressive, lauded institutions.

I emailed his team, received a call to schedule a consultation a few hours later, and forwarded my insurance information afterwards. In less than 24 hours, I had a consultation appointment for August. I was shocked by how seamless the process was. The appointment itself went really well, and I was referred to an urologist whom he’d be working with. One week later, I was approved for surgery by both him and the accompanying urologist.

I don’t know when I can schedule the operation itself, as I’m waiting for referral letters from my psychiatrists, but I’m incredibly lucky to have found Keith’s practice. I’m also incredibly lucky that, while this awful pandemic has lingered in the U.S. for unfortunate reasons I won’t specify here, it has lifted enough to allow some doctors to prioritize trans people’s health.

People often ask if I’m scared of the recovery process, and I always say, “At least I’ll be on pain killers post-surgery — all I’ll need to do is lie back and recover. Scheduling these appointments is the part that’s killing me.” Thankfully, I have a small sense of peace knowing my vaginoplasty, FFS, and breast augmentation processes are finally all in motion.

I know that COVID-19 has thrown everyone’s schedules to the wind, and has created or worsened unfathomable mental health issues for so many people. But it hurt me in such a specific way. The truth is, there’s nothing anybody can say to “make me feel better” — it all comes down to when I get “thrown on the surgeon’s chopping block,” as I like to put it to my friends.

Sometimes, it feels like LGBTQ+ civil rights are still seen as frivolous. Until we start prioritizing transgender mental and phsyical health, safety for transpeople will continue to be jeopardized by social, medical, and political negligence — such as classifying gender affirming surgeries as elective.

I remember a classmate once telling me, “You should be grateful for how things are right now. It could be a lot worse.” We haven’t spoken since. It is not a selfish or unreasonable demand that transgender people be able to live without suicide, murder, and judgment constantly looming over us. And until the trans community’s struggles are officially recognized, I have no intention of being quiet about my transition — no matter how uncomfortable it makes others feel.