On March 14th, 2020, the U.S. Surgeon General Jerome Adams tweeted that hospitals and healthcare systems should consider stopping elective procedures until the U.S. is able to flatten the curve. For many trans people, this meant that their gender-affirming surgeries and appointments for hormone replacement therapy (HRT) were cancelled or postponed indefinitely. This was done in an effort to limit the risk of exposure to COVID-19 and to save medical supplies, hospital beds, and doctors for only the most urgent cases. While necessary, this move raises an important question: what counts as an essential medical service?
For transgender people, gender affirming surgeries are often necessary and life-saving. Both scientific research and the lived experiences of trans people confirm that these surgeries are medically necessary. However, most health insurance carriers currently consider gender-affirming surgeries to be cosmetic procedures, and over 30 states allow insurance providers to exclude transition related services from coverage. Clearly, transition related procedures are far from cosmetic. Arguably, these procedures are not even elective, since, as licensed clinical social worker and psychotherapist Laura A. Jacobs notes in an interview with NBC, “existing daily in a body that doesn’t match your sense of self isn’t just uncomfortable, it’s traumatic”. In many cases, states and insurance carriers fail to recognize this fact.
Trans people face significant barriers when accessing healthcare, including "financial barriers, discrimination, lack of cultural competence by providers, health systems barriers and socioeconomic barriers”. Because of this, the cancellation and postponement of transition-related care has been devastating for many trans people, many of whom have fought for years to be able to schedule and fund these procedures.
In a NBC News video report, a trans man named Jaceon Coronado narrates his experience with having his top surgery postponed indefinitely. Jaceon notes that while on paper the surgery was considered medically necessary, he was told by his case manager that the procedure would be considered elective because of the pandemic. Jaceon notes that he cannot shake the sad feeling that has come over him since his surgery was cancelled. In the same news report, licensed clinical social worker and psychotherapist Laura A. Jacobs notes the detrimental impact of these cancellations on the mental health of trans patients.
“I know that some people often question whether these surgeries are cosmetic or just superficial. But far from that, these surgeries have well documented and real critical outcomes and improvements in outcomes for these communities. It’s not just a daily inconvenience to live in a body that feels inauthentic. It is daily and ongoing suffering and trauma. Being told that their surgeries are postponed is just another instance of them having to live in that dysphoria place, that place of trauma.”
Laura A. Jacobs, Licensed Clinical Social Worker and Psychotherapist and board chair at Callen-Lorde Community Health Center, a New York-based LGBTQ health center
A second trans man named Benton Sorensen also narrates his personal experience with having his top surgery postponed in a YouTube video. Benton describes being scheduled with a new surgeon and the lack of communication from his medical providers. He describes a phone call with the surgical center, saying “I didn’t even know the [new] surgeon’s name...they didn’t have any answers for me”.
Benton also describes a moral dilemma he faced when considering whether he would want to go ahead with the surgery or not if given the opportunity:
“I’d been having this moral debate with myself about whether or not I would even proceed if they said it was a go-ahead. I just don’t know if I could deal with potentially taking a bed, taking the resources from somebody who really needs it”
Benton Sorensen, YouTube Creator
In addition to transition-related medical services like gender-affirming surgeries and HRT, doctors faced the difficult decision of suspending other medical services as well. The line between elective and non-elective quickly becomes blurry. ABC News reported that doctors are now having to decide “whether to proceed or postpone prostate surgeries, colonoscopies, skin cancer removals and a range of other procedures that could mean life or death for their patients”. When it comes to deciding which procedures to cancel and which to go ahead with, doctors and healthcare institutions may look to the government to provide guidance.
On March 18th, the Centers for Medicare and Medicaid Services (CMS) released their recommendations for non-emergent, elective medical services. The CMS defined non-essential surgeries and procedures as those that could be deferred, such as non-emergent, elective and preventive medical services. They also recommended a tiered framework “to prioritize services and care to those who require emergent or urgent attention to save a life, manage severe disease, or avoid further harms from an underlying condition.”
“CMS, in collaboration with medical societies and associations, recently created recommendations to postpone non-essential surgeries and other procedures. This document provides recommendations to limit those medical services that could be deferred, such as non-emergent, elective treatment, and preventive medical services for patients of all ages."
Centers for Medicare & Medicaid Services
The CMS defines “Tier 3” medical services as services that would result in harm to the patient if they were withheld. The examples the CMS give include situations where the patient is showing symptoms of COVID-19. It is clear that withholding gender-affirming care also has a real potential to cause harm to transgender patients. Preventing harm in the present context primarily means preventing the harm caused by COVID-19 infection. Treating and preventing other forms of patient harm is deemed to be less essential.
The Johns Hopkins Center for Transgender Health released a message to their transgender patients defining what is meant by “elective surgery” and emphasizing the importance of gender-affirming surgeries.
“In discussions you may hear the term “elective surgery” used, which refers to procedures that can be rescheduled to a future date, as the timing of these cases is flexible and is unlikely to significantly impact the patient’s health outcome in the short term. This term in no way downplays how critical and important these surgeries are for our patients.”
Johns Hopkins Center for Transgender Health
U.S. Surgeon General's Tweet
NBC News Report: "Trans surgeries postponed indefinitely amid coronavirus pandemic"
Healthcare Laws and Policies Map
Barriers to Health Care for Transgender Individuals https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4802845/
NBC News Video Report: "Trans Surgeries Put On Hold During Coronavirus Outbreak"
YouTube Video: "I was supposed to have top surgery today."
ABC News Report: "As COVID-19 bears down, doctors confront difficult choices on elective surgeries" https://abcnews.go.com/Health/covid-19-bears-doctors-confront-difficult-choices-elective/story?id=69693791
Centers for Medicare & Medicaid Services "Non-Emergent, Elective Medical Services, and Treatment Recommendations" https://www.cms.gov/files/document/cms-non-emergent-elective-medical-recommendations.pdf
Ambulatory Surgery Center Association "State Guidance on Elective Surgeries"
Johns Hopkins Center for Transgender Heatlh