Don’t just remember us: The loss of trans lives is preventable (part two)

In this second installment of a two-part series in connection with Transgender Day of Remembrance on Nov. 20, Catherine Grace Bielick, MD, MSc, MSc, shares more of her story and underscores the important role of physicians in providing and protecting gender-affirming medical care. Don’t miss the first post in the series.   

We moved to Florida for medical school, my wife got a job as a post-anesthesia care unit nurse nearby, and I started hormone replacement therapy in my third month. Changes were slow, but I was living in the closet with secret hopes that medication alone would change my body enough that my wife and I could both be satisfied — or at least enough for both of us to live sustainably in the mutual discontent of two-party compromise. I kept this up for two years, but in my third year I nearly became someone that you might instead be remembering today as another lost trans life. Twice. It was then that the definition of “medical necessity” took on an intensely personal meaning to me, which I carry to this day. We both agreed that nothing short of a full medical, social and professional transition would be survivable.

I changed my name and paid for facial feminization surgery out of my student loans. I shared my story with classmates and created an LGBT health night at the free clinic I was volunteer directing, but I eventually moved across the country for residency in Massachusetts. I missed my first day of intern year to attend my court date for divorce back in Florida and started the following year living fully as a woman, externally, internally and interactively. My colleagues provided a safe space as they were able, but voice training was unsuccessful for me, so my background as a person assigned male at birth was fairly obvious.

Some memories come to mind: As an intern, a consultant called me back explicitly asking for me as a man despite knowing my name was Catherine since “it was a male voice on the phone.” I rotated through the emergency department, where I remember walking out of a room where I had just finished a manual disimpaction and was flagged by a woman boarding in the hallway yelling at me for an orange juice. When I told her she’d have to wait for me to clean up, she called me a “f***ing f****t.” A man I was discharging took a swing at me when he heard my voice pitch while telling him I wouldn’t give him an opioid prescription for his Behçet’s disease that he was self-treating by rubbing cocaine into his ulcers.

I navigated the COVID-19 pandemic probably as ungracefully as everybody else could manage, but I took time off for voice feminization surgery recovery, paid for by personal loan, and neovaginoplasty. The latter was the first of all the surgeries that was covered by my health insurance and would have otherwise been impossible. 

My life changed for the better. Though I have worked through more than a fair share of guilt, I regret nothing. I’ve had a lot of time to think about how my story might be used to do the most good for other people like me. I created a residency curriculum to teach people how to prescribe hormone replacement therapy and give institution-specific direction for surgery referrals, but it isn’t enough. The politicization of trans people has given some moderates in our profession hesitation about whether even adults should be treated — as if withholding medication from children or adults is somehow a neutral option. Concerns for sports integrity, drag performance and bathroom sanctity have distracted from our need for health care. We are painted as predators who want to recruit children into some kind of gender abolitional social movement to gain access to spaces in which we can inflict psychological and physical harm. In reality, one report found that 36% of trans and nonbinary youth were actually the victims of sexual assault in bathrooms that they thought were safe.

Gender-affirming medical and surgical treatments are medically necessary and are endorsed by the World Professional Association for Transgender Health, the Endocrine Society, the Center of Excellence for Transgender Health at the University of California-San Francisco, the American Medical Association, the American Psychiatric Association, the American Psychological Association, the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists, in addition to IDSA and HIVMA. In spite of these resolutions, numerous states have drafted legislation that limits health care access for trans adults, enshrines the ability of health care professionals to discriminate against trans people based on their “conscience,” places barriers on changing legal documents, incorporates vague terminology to ban “drag performances” (or a mere perception of cross-dressing), and innumerable prohibitions related to criminalization and health care coverage bans for trans youth independent of a pediatrician’s assessment.

All medically necessary health care must be legal and covered by health insurance. The determination of what is medically necessary must be made by a physician, not a legislator or payer. Would you think it acceptable for a governor or insurance payer to disallow public or private coverage of metformin? Would we tally the people dying of diabetes-related complications to create a Diabetes Day of Remembrance, or would we rattle our stethoscopes at the personal gates of the legislator or administrator who had the audacity to come between us and our patients? And what would it matter if it was banned in word or effect if you didn’t know how to prescribe it?

We stand alone as physicians at the highest level of medical expertise. In the U.S., we have dedicated our college years and four additional years of intensive coursework to graduate as a fully pluripotent physician. We spent three to five supervised years honing and practicing our skills for a minimum of 15,000 hours and, in many of our cases, another two to three years of specialized training. We are ID physicians. Nobody has studied HIV more than our field, and few domains rival our collective time spent studying social determinants of health, devastating syndemics and intersectional minority statuses. We should be rallying in a single unified voice: Legislators and insurance payers shall not practice medicine. Neither group has taken an oath to do no harm, and as Michelle Ogle, MD, has elegantly stated, “We have not taken an oath to them.”