NEWS

The Mental Health Impact of Delays to Gender-Affirming Surgery

transgender individual on the phone

Mireya Acierto/DigitalVision/Getty Images

Key Takeaways

  • The pandemic canceled most surgeries unrelated to COVID-19, including gender-affirming options.
  • Trans people faced delayed and canceled surgeries as well as a loss of means to afford them.
  • The mental health impact of not being able to access gender-affirming surgery can be life-threatening.

When Boston-based Willow learned their company would start offering health insurance to employees in February 2020, they knew this was finally their chance to get top surgery. Willow immediately started setting up consults and scheduled an appointment for last summer with one of the best surgeons in Boston. Then, suddenly, the pandemic started in March, and mass cancellations of surgeries followed.

“At the beginning of the pandemic, I was notified that it was postponed indefinitely,” says Willow. “Then I got laid off and lost the health insurance that was going to pay for it. So I didn’t know when it was going to happen, but I knew that I’d have to start over with a different doctor, setting up consults again. I’d likely have to pay more out-of-pocket for lower-quality results,” they add.

LGBTQ Individuals Were Disproportionately Affected By the Pandemic

An April 2020 survey on the COVID-19’s impact found that, at the time, LGBTQ people were more likely to have their work hours reduced, 30% compared to 22% of other people. They were also more likely to report their finances were “much worse off” than a year ago, 20% compared to 11% of other people.

“Let’s say you saved, and you saved, and you saved, and you saved, and here is the moment and then all of a sudden you lose your job due to the pandemic,” says D’Lessia T. Wedley, LMFT, a therapist in Memphis, Tennessee. “So now this money that was going towards your surgery that you’ve been wanting and excited about? You have to pick and choose. Do I want surgery, or do I want to have a roof over my head?”

The Importance of Gender-Affirming Surgery

While gender-affirming surgery is not a step all trans people want to or can take, for many people it can be the difference between being comfortable in their body and constantly distraught.

The Report of the 2015 U.S. Transgender Survey from the National Center for Transgender Equality found that 25% of participants previously had some form of transition surgery. It was most common among transgender men at 42%, compared with transgender women at 28% and non-binary people at 9%.

“[Individuals] have endured an exacerbation of mood and anxiety concerns due to a delay in gender-affirming surgery. Some of my patients have experienced suicidal ideation and self-injury due to delays in gender-affirming surgery,” says Leela R. Magavi, MD, a Johns Hopkins-trained adult, adolescent, and child psychiatrist and regional medical director for Community Psychiatry, California's largest outpatient mental health organization.

Magavi elaborates that these delays can negatively impact functionality, self-esteem, and relationships, among other aspects.

D’Lessia T. Wedley, LMFT

If you were struggling with depression or you’re having body dysmorphia, then everything is heightened. Because you’re constantly, day in and day out, looking at yourself, and this isn’t the person that you want to see.

— D’Lessia T. Wedley, LMFT

“It can prolong the need to hide one's gender identity, particularly for large-breasted transgender men,” says KT Hiestand, PhD, a psychologist at Hiestand Psychological Services. “The fact that you have to hide something about yourself gives your brain the message that something is wrong with you.

"Self-esteem drops. Depression can develop. Anxiety can also develop over worry that someone will figure it out. Given the fact that violence is so prevalent against transgender individuals, the consequences of someone figuring it out can be dire,” says Hiestand.

Navigating Post-Pandemic Bureaucracy

Once surgeries resumed, doctors had a backlog to get through. Eventually, Willow went on Massachusetts Health Connector and made an appointment for a surgery consultation this summer. Instead of finally being able to take that step, their insurance denied the referral.

According to the U.S. Transgender Survey, 55% of participants who sought coverage for transition-related surgery in that past year had coverage denied.

For Willow, the delay means having to wait another year for surgery. “I personally am lucky that I have a fairly small chest, and it’s easy enough to kind of hide it. It gets a little harder in the summertime,” says Willow. “I counted it in terms of summers. I was supposed to get it last summer. It looks like it’s going to be next summer—a full two years later. That’s tough to think about because it’s a lot easier in the wintertime when I can just wear a hoodie.”

Willow

I’d likely have to pay more out-of-pocket for lower-quality results.

— Willow

Willow is far from the only person who has faced delays in gender-affirming surgery due to the pandemic. Levi, who lives in Alberta, Canada, knew he wanted top surgery since before starting hormone therapy two and a half years ago. “My dysphoria regarding my chest has only worsened with time, and on top of the mental health effects, because I had a larger chest, it was extremely taxing on my body to bind my chest for eight-plus hours a day,” he says.

After waiting two years for a referral to the psychiatrist who refers to the province-covered surgeon, Levi took matters into his own hands in early 2020. He put his entire tax return towards the surgery and set up a GoFundMe page—raising about $8,000.

With the money raised, Levi’s next obstacle came through delays in booking the surgery itself. “During my initial phone conversation in May 2020, I was told I could get a date for January 2021 booked in the fall. But, I was not able to get a date secured until December, less than two months before I had surgery. Even then, they ended up changing my date by one day because of limited availability with the anesthesiologist,” says Levi.

The short notice and eventual date change meant booking flights and hotels in the middle of a pandemic and then moving them, all while Levi worked retail during the holiday season. “Typically, the individual needs help with aftercare, so canceling and rescheduling can be a logistical nightmare,” says Hiestand.

KT Hiestand, PhD

The one thing that sometimes can help someone who is struggling with surgery being postponed is to focus on how much progress they’ve already made.

— KT Hiestand, PhD

The delay and uncertainty greatly impacted Levi’s mental well-being. “I spent so much time worrying about them canceling my surgery, that it would need to be postponed even further, that something would go wrong or that they would decide I was not eligible,” says Levi. “Since I’d never had surgery before either, that didn’t help my anxiety. I definitely had more than a few meltdowns because I thought I would never get surgery.”

Mental Health Support Before and After Surgery Is Critical

Gender-affirming surgeries are complex, and getting ready for these surgeries and the recovery is mentally taxing on its own, says Kayla Rena Gore, co-founder of My Sistah’s House, a trans-led nonprofit that provides equitable housing, healthcare advocacy, career resources, and community space-holding to the transgender and gender non-conforming community in Memphis.

“They prepare you prior to surgery for the mental aspect of what's going to happen after the surgery, your first thirty days, sixty days, or ninety days. After you have surgery, the initial appearance is that your body is mutilated and sometimes you don't see the beautiful until a year later," Gore says.

Oftentimes people may need to request help from a loved one or ask for time off from work, coordination that requires ample time and can be difficult to recreate when faced with a delay.

The idea of repeatedly preparing for this process can be overwhelming. “I've had this with certain clients that they put themselves in that situation, and they become afraid to go back into that situation. It can make it a prolonged period of time until they'll try another surgeon or they’ll try another date,” says Sarah M. Steelman, PhD, LMFT, a therapist in Las Vegas, Nevada.

Then there is the matter of having to wait longer to feel comfortable in your own skin—an issue potentially intensified by the pandemic’s isolation. “If you were struggling with depression or you’re having body dysmorphia, then everything is heightened,” says Wedley. “Because you’re constantly, day in and day out, looking at yourself, and this isn’t the person that you want to see.”

On the matter of gender dysphoria, Steelman says, “Even if it's not something that is super dysphoria-inducing to someone, there is a huge mental health impact of just the absence of gender euphoria, being and feeling as though something is off, and not experiencing things being correct.”

Then there’s the concern about gender-affirming surgery becoming no longer an option due to discriminatory policies. “It is a fairly recent thing, that most insurance companies will cover trans-affirming care, that people are starting to expect that at least their state will have some providers that understand trans-affirming care,” says Steelman. “There’s also a lot of legislation that is actively trying to take this stuff away.”

In May, the Human Rights Campaign declared 2021 the “worst year in recent history for LGBTQ state legislative attacks.” At that point, an anti-trans medical care bill had passed in Arkansas, and state legislatures had introduced at least 35 bills that would stop access to age-appropriate, gender-affirming medical care.

Caring for Your Mental Health While Waiting for Surgery

While gender-affirming surgery has restarted, factors from lack of coverage to long wait times mean it is far from a quick process. The interim can be an incredibly difficult time for your mental health. Wedley emphasizes the importance of giving yourself space and allowing yourself to feel how you feel.

“The process of transitioning is an exercise in patience. It is punctuated by significant events—surgeries, coming out, legal processes, starting hormones, short periods where noticeable change occurs, and longer periods where change may be happening, but it’s too slow to detect,” says Hiestand.

“The one thing that sometimes can help someone who is struggling with surgery being postponed is to focus on how much progress they’ve already made. Appreciating how far you've come can take the focus away—at least for a moment—from the next step that suddenly feels out of reach,” adds Hiestand.

If you can, check in with a therapist. Look for sliding scale options or explore free programs offered by counseling students. With Wedley’s help, My Sistah’s House offers mental health services at no cost to people in the Memphis area. “The last thing people are going to go in their pocket for when they’re already financially strained is to pay for a therapy session,” says Gore.

What This Means For You

Take this time to reevaluate your plan. Did you want to stick with the doctor you picked? What steps can you take right now? “Creating a concrete plan to access resources and finances to move forth with the procedure helps alleviate mood and anxiety concerns,” says Magavi.

Certainly, the end goal of surgery makes the most significant change to your well-being. As for post-surgery mental health, Levi says he feels “even better than I could have imagined. It’s cliche, but I feel like a new person. I feel so much happier in my own skin, more confident, and I have almost no back or rib pain.”

The information in this article is current as of the date listed, which means newer information may be available when you read this. For the most recent updates on COVID-19, visit our coronavirus news page.

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