For the past two years, she said, her insurance provider has refused to cover a medically recommended facial reconstruction surgery.
It’s a problem many transgender people in Washington state have encountered, despite a state law that bans insurance companies from discrimination based on a person’s gender identity. According to the state Office of the Insurance Commissioner, insurers have sometimes labeled gender-affirming treatments — such as mastectomies and other transition surgeries — as cosmetic procedures that aren’t medically necessary, even when they are recommended by a person’s doctor.
Under a new bill approved by Washington’s Legislature this year, such denials will no longer be allowed. Senate Bill 5313, which awaits a signature from Democratic Gov. Jay Inslee, will require insurers to cover gender-affirming treatments starting in January 2022.
Gender-affirming treatments include not just surgeries, but also talk therapy, hormone treatments and medications that can delay the onset of puberty. All are among the medically recommended treatments for gender dysphoria, which is when someone’s gender identity doesn’t match the sex they were assigned at birth.
For Aoki and others who have been denied coverage for their treatments in the past, the bill’s passage is a huge relief.
“We wanted to be recognized, and we did it,” Aoki said this week. Aoki said trans people’s work and advocacy was a major factor in getting the bill across the finish line.
Washington state’s push to protect transgender people’s access to health care stands in stark contrast to bills considered in other states this year.
According to GLAAD, a national organization that advocates for LGBTQ people, more than 30 states this year have weighed bans on transgender people participating in youth sports, while at least 22 states have considered bans on transgender youth accessing health care treatments.
A handful of those measures have won final approval. In Arkansas, for instance, lawmakers recently passed a law banning people under 18 from receiving gender-affirming care. The Arkansas ban extends to prescribing puberty-suppressing hormones, a treatment that doesn’t involve surgery.
State Sen. Marko Liias, D-Lynnwood, said his hope in Washington state is to improve the mental health of transgender people by ensuring they can access the medical care they need.
“I am proud that our state is sort of standing up to this hysteria sweeping the country of intolerance and hatred of trans people,” said Liias, the primary sponsor of SB 5313. “We are going the opposite direction saying that, here, people are welcome and we support them.”
Aoki said that when her facial reconstruction surgery was first denied two years ago, she became very depressed. The thought that she wouldn’t be able to complete her transition and wouldn’t be able to live her true identity made her think about killing herself, she said. Previously, she said her mental health had improved as she moved closer toward an appearance that matched her gender identity.
“I’m proud I chose life,” Aoki said this week.
Dr. Kevin Wang, who teaches medical residents at Swedish First Hill in Seattle, said suicide attempts are incredibly common among trans people. At a recent public hearing, he said roughly half of transgender and gender-diverse people attempt suicide, a rate nine to 10 times higher than among the general population. For transgender youth and transgender people of color, the rate of attempted suicide is even higher, Wang said.
Meanwhile, gender-affirming care has been shown to reduce thoughts of suicide among transgender people and increase their overall psychological well-being, according to a Cornell University review of 72 studies on the topic.
“What some may consider to be a cosmetic or aesthetic procedure, I really do want us to start thinking of as life saving,” Wang, the doctor at Swedish, told state lawmakers in March.
“These are folks where their gender identity does not match the body in which they were born into,” he said. “And this is a way to help these people, to help the gender diverse community, really become comfortable and become productive citizens of our region.”
Several transgender people told lawmakers that they and others they know have gone to dangerous lengths to access gender-affirming treatments when they couldn’t get them covered by their insurance.
Donato Fatuesi, a trans woman who testified at a public hearing in February, said that in 2011, she compromised her safety by taking hormones she got on the black market. Three years later, she raised money for laser hair removal through sex work, seeing no other way to pay for the procedure. Then, in 2017, her insurance company declined to cover a surgery her doctor had recommended, despite the doctor’s declaration that it was medically necessary. Fatuesi is the operations manager at UTOPIA, a group that represents trans and queer members of the Pacific Islander community.
Others shared similar stories of being denied coverage.
“To me, this feels the same as telling a cancer patient they aren’t going to cover chemo,” said Ander Lyon, who is trans and testified before lawmakers in February.