From an early age, Pasha Rangel felt different. She said that society’s expectations of boys and many traits of masculinity did not match what Wrangel felt in her mind.
Bullied and ostracized, Rangel began repressing his feelings in middle school and kept them locked up for a long time. That led to decades of grief, loneliness, and even several suicide attempts. What plagued Rangel was the widely recognized gender dysphoria in the medical community, which causes severe distress to people whose sexual identity does not match the sex assigned at birth.
“It just feels unfair, like someone put his arm around my head so badly, it just hits me in the face every time,” said Wrangel, 38, who grew up and still lives in this idyllic Central California beach community. said. His facial and body hair are particularly disturbing. “Whenever I look at my face in the mirror and have to get my hair done, it’s uncomfortable. I hate looking at my hair.”
Wrangel is non-binary, meaning neither masculine nor feminine, and uses the pronouns ‘they’ and ‘they’. For more than three years, they have undergone gender reassignment treatments to develop more feminine physical characteristics. These treatments include genital transformation known as hip surgery. Treatment with the female hormone estradiol. Electro-epilation of the face, neck and chest is also possible.
The full amount will be paid for by California’s Medical, a federal Medicaid insurance program for low-income individuals. California law requires Medi-Cal and all other state-regulated health care plans to cover gender-positive care deemed medically necessary. But there is a problem.
Wrangel, who is a member of the Central California Health Alliance, the only medical plan in Santa Cruz, said getting the care she needs can be challenging. They wrestle with endless paperwork and phone calls to prove what they have already established: that their need for treatment is real and continues.
“Among the transgender community, jokes like, ‘Oh, did they think I stopped being trans or did I just magically lose my hair?’ are always asking for letters. ‘, said Rangel.
And it takes a lot of work to find and vette the small number of gender-affirming providers who accept Medi-Cal patients, Rangel said.
More than 1.6 million people over the age of 13 in the United States are transgender, according to the Williams Institute at UCLA School of Law, which conducts legal and policy research on gender identity and sexual orientation. According to data from the Institute, an estimated 276,000 transgender people in the United States have Medicaid, including 164,000 in states with guaranteed transgender care. 36,000 of them live in California, one of 25 states, and Washington, DC, where Medicaid policies target gender-positive care.
“I think there’s a lot of pressure in society to fit into a very narrow set of stories, and I honestly don’t think that works for most people,” Rangel said. “
National surveys of transgender people show that they unfairly experience physical abuse, economic hardship, and mental health problems. And research has found that gender-affirming care significantly improves their quality of life.
But as Rangel has learned, coverage and care are not the same thing. Hair removal, their number one priority, was hard to come by. After two-and-a-half years of electrolysis therapy, he spends only about half the total time an electrologist needs.
Permanently removing the facial hair of a transgender person who was assigned a male gender at birth may require more than 400 hours of electrolysis over several years. For those paying out of their own pocket, the cost could easily run into the tens of thousands of dollars. This does not include the cost of face, buttocks or body plastic surgery.
Rangel said their medical plan limits the number of sessions allowed at one time and requires periodic reauthorization.
Denise Shay, Chief Medical Officer of the Central California Health Alliance, said the health plan recently updated its policy to allow more than 50% electrolysis in three months and to submit photographs of relevant body parts to patients. said it had abolished the rule requiring
She acknowledged the shortage of providers and said she has partnership agreements with clinicians in multiple counties to provide more options.
Kellan Baker, executive director of the Washington, D.C.-based Whitman-Walker Institute, said the challenges transgender people face in seeking care are similar to what many face in “the dome of terror that is America’s health care.” said that it is almost the same as I research and educate on topics of interest to gay, bisexual, and transgender people. “Many people are unable to get the medical care they need for their conditions, including gender dysphoria, cancer, and diabetes.”
Legal aid lawyers and transgender activists say another big reason why gender reassignment care, especially hair removal, is denied or delayed is that many in the medical community still think it’s cosmetic. says that it is
Medi-Cal, like most commercial insurance plans, doesn’t cover cosmetic treatments. “But if it’s affecting your mental health, it’s affecting your life opportunities, it’s affecting your ability to get a job, it’s affecting your ability to get housing, it’s superficial. Is it?” asked Elana Redfield, director of federal policy at the Williams Institute.
Rangel said the treatment has improved their lives, even though they struggle to get it. According to them, taking estradiol “makes you feel less irritable all the time and much more relaxed.” And while Rangel is happy with the rare butt surgery he underwent last October, he faces more paperwork for the follow-up surgery he needs.
They are dissatisfied with all the bureaucracy they have encountered so far because the cure works. “This is working,” Rangel said. “Please let me finish.”
This article is reprinted from khn.org With permission from the Henry J. Kaiser Family Foundation. Kaiser Health News is an editorially independent news service and a program of the Kaiser Family Foundation, a nonpartisan health policy research organization independent of Kaiser Permanente.