Barriers to gender-affirming care harm trans Dane County residents

Barriers to gender-affirming care harm trans Dane County residents

Though Dane County has positioned itself as more open and accepting of transgender residents than other parts of the state, barriers to gender-affirming care in the county continue to keep trans residents from receiving vital services, according to advocates and health experts.

Tessa Jade Price waited a year to be able to schedule a consultation about receiving her gender-affirming surgery. 

To schedule this consultation, she needed to receive letters from multiple care providers stating she was ready to speak with doctors about scheduling a surgery. But this process was made even more lengthy by reschedulings and appointment cancellations. 

“This is for me, an adult, so there's already a ton of hurdles in the way, and it puts even more [difficulty] for youth and people who can't afford to switch insurers,” Price said.

Price said she and other transgender Dane County residents have faced difficulty receiving gender-affirming care due to social stigma, financial barriers and long wait times impeding access to various services.

Gender affirming care includes any type of care designed to affirm someone’s gender identity by aligning their body more closely with their gender identity. This can be done through surgeries, hormone therapy, voice therapy, social affirmation and other types of care.

Price is one of the founders of Trans Advocacy Madison, a local community-based organization created in 2021 that seeks to advocate for trans rights and provide a welcoming community for trans residents. She said substantial barriers to gender-affirming care exist even in relatively liberal Dane County, and she has been pushing the county and community to do more to remove financial barriers and combat the social stigma surrounding receiving gender-affirming services. 

For trans and gender non-conforming people, this type of care is often essential to their overall mental and physical health. But, Price said, many people have difficulty convincing their care providers and insurance companies to cover much of this care.

“It’s a strange combination of having more options than ever and at the same time facing bans, if not in Madison and Wisconsin, in nearby states that impact our waitlists and fear of being treated like we’re some sort of criminal for who we are,” Price said.

High costs create barriers to receiving care

For some types of gender-affirming care, particularly surgeries, residents experience long waits to even see therapists or consult with health care providers about their options, according to Price.

“It takes years to get over the pressure that you might have grown up with that this is wrong or this isn't real, to get the information that you can even [get care] in the first place which is kept from tons of people, to be financially independent enough, to be geographically convenient,” Price said. “There's a lot of misconceptions around how that works and ideas that there's some sort of terrible permanent thing happening right away. That's practically impossible if you don't have a lot of money and a lot of resources.”

This is compounded for people who have fewer financial resources, according to Kaleb Her, queer justice manager at Freedom, Inc., a local nonprofit organization that works with low-income communities of color and LGBTQ communities in the county. 

The estimated cost of gender-affirming care for an individual ranges from $25,000 to $75,000, according to the Human Rights Campaign Foundation. These costs are incredibly difficult to pay for those who cannot cover them through their insurance, Her said. 

Social stigma leaves people hesitant to seek care

This fall, the Wisconsin Legislature introduced a series of bills targeting trans Wisconsin residents. One bill would force trans prisoners to live in a prison for the sex they were assigned at birth, while another would restrict access to gender-affirming care, including reversible forms of care such as puberty blockers, for minors. 

Though the Legislature passed the bill restricting gender-affirming care for minors, Wisconsin Gov. Tony Evers vetoed it on Dec. 6. But these bills pose a threat to trans residents even if they don’t become law, according to ACLU of Wisconsin policy analyst Jon McCray Jones. 

“Wisconsin is part of a larger national plan that's creating a moral panic around trans issues, specifically around health care,” Jones said. “By framing adults as groomers and framing the kids as victims of abuse, what that does is create this toxic environment around trans issues that rallies up a lot of hatred and violence against the community.”

The social stigma surrounding care for trans people leads many to feel unsafe or that they are unable to access gender-affirming care without facing judgment or ostracization from others, according to Price. 

Systemic racism creates greater barriers for residents of color

Black Dane County residents experience worse education, employment and health outcomes than white residents due to “profound and persistent” systemic racism, according to a 10-year report from Wisconsin antiracist policy organization Kids Forward. Black Dane County residents are less likely to have stable housing, high-paying jobs and reliable and adequate health care.

For Black trans residents and trans residents of color more broadly, financial precarity can mean having to choose between receiving gender-affirming care or covering costs of living, according to Her.

“They're always talking about how they had to make a sacrifice — it’s, ‘do I want to eat this month, or do I want to get my HRT this month, or do I want to be able to get a hotel?’” Her said. “And some folks don’t have access to any of these things.”

The combination of systemic racism and transphobia in health care also creates greater hurdles for trans people of color to receive adequate gender affirming care, according to Her. 

“A lot of LGBTQ, trans folks come in struggling with institutionalized racism being people of color on top of being targets of homophobia and transphobia,” Her said.

Additionally, among some BIPOC communities in the county, language barriers make it difficult to effectively communicate needs related to gender-affirming care to relatives and care providers, Her said. Translators are also often not aware of how to communicate between two languages. 

“Folks who are translators also need education on gender-affirming care to be able to translate properly,” he said.

Lack of providers leads to longer wait times

In July, Catholic health provider SSM Health stopped offering gender-affirming surgeries to trans patients following pressure from the Catholic Church, according to an investigation by Channel 3000. The provider is one of many that Dane County’s health care plan, Dean Health, sends county employees to receive care. 

“When you look at something like SSM’s decision to cut off all trans surgeries — not all gender affirming surgeries, all transgender surgeries for adults and children — it kind of gives the game away a little bit,” Price said. “It’s not so much that they’re against children getting access to things that they feel like they shouldn’t, even if their doctors disagree. They don’t think it’s right that we have access to gender affirming care and that, frankly, trans people exist in the way that we do and the way that we always have. And that’s a scary thing.”

When providers stop offering a type of care, other providers can see their waitlists grow as people have to look elsewhere. After SSM Health ended their gender-affirming surgeries in the summer, Price said, waitlists at other providers were affected. 

The need for gender-affirming care has risen across the country, according to Callen Smith, gender services coordinator for UW Health. Smith said they have seen a similar increase in need for gender-affirming services in Dane County over the past few years, which translates to longer wait times. 

“I think a lot of that can be tied into awareness of the services that are offered,” Smith said. “We have seen an increase in need over the past couple of years, but again, that seems to be pretty much consistent with the wait times that we're seeing in other areas of the country.”

For community organizations, reducing stigma and covering costs is key

Much of Trans Advocacy Madison’s efforts to reduce barriers on gender-affirming care focus on combating social stigma that still leaves trans residents marginalized. 

“The social stuff is probably the easiest for us to do just by virtue of being part of the community, of being able to talk to people,” Price said. “Our community does it all the time — you’ll see trans people talking about being trans all over town, and it’s a beautiful thing.”

Trans and nonbinary young people were less likely to report attempting suicide if they had access to affirming spaces, such as supportive schools or home environments, according to a 2023 report from the Trevor Project, a nonprofit organization that focuses on suicide prevention efforts for LGBTQ youth. Trans and nonbinary young people whose loved ones respect their pronouns also report being less likely to consider suicide. 

Trans Advocacy Madison has organized campaigns against businesses who have been hostile to trans residents and testified at hearings related to policies affecting trans people, Price said. The goal is to build an environment that protects and welcomes trans residents, which will help them feel more safe pursuing care. 

To reduce barriers to gender affirming care, local organizations including Trans Advocacy Madison and Freedom, Inc. also look to give trans Dane County and Wisconsin residents a network that can provide financial and social support. 

Freedom, Inc. helps residents pay for the therapy sessions required for them to receive a letter of readiness from mental health professionals that will allow them to consult with doctors about scheduling gender-affirming surgeries. Residents typically need to receive a letter from one or two mental health professionals, a process that can take months and cost them hundreds of dollars, depending on the professionals’ rates. 

This program helps lift some of the costs along the long process of receiving gender-affirming care, according to Her. 

“For the financial support, a lot of it’s getting that second-letter readiness for surgery — you're paying for one therapist, getting another letter can be costly, so we would support that,” Her said. “And even with a name change, you have to pay for a fee for submitting those applications, so that's something we have helped with as well.”

However, much of the work to remove financial barriers must come from changes to county and state policy. Amid an uncertain legal and social environment, Price said reliable access to gender-affirming care remains in doubt.

“I think that the biggest thing is this uncertainty,” Price said. “Is Wisconsin going to be a safe place for trans people? That’s a question that I don't have an answer to right now.”

Wisconsin State Capitol. Photo provided by Madison Commons.

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