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By Elizabeth Thompson
After what LGBTQ advocates say was a record-breaking year for anti-transgender legislation, they are celebrating a small victory in North Carolina.
Blue Cross NC, formerly known as Blue Cross and Blue Shield of North Carolina, will now include coverage for gender-affirming facial surgery and voice therapy for transgender and gender-nonconforming people as medically necessary care. The move follows advocacy from the Transgender Legal Defense & Education Fund (TLDEF), on behalf of Equality NC, the LGBTQ Center of Durham and two transgender women.
“Across the country, health insurance companies are increasingly recognizing the need to end systemic denials of lifesaving gender-affirming health care for transgender people,” said Noah Lewis, director of the Trans Health Project at TLDEF, in a press release.
The nationwide trend to remove the exclusion of gender-affirming care follows President Joe Biden’s May declaration that the Department of Health and Human Services will prohibit discrimination of LGBTQ people by health care organizations that receive federal funding. In addition, a June 2020 Supreme Court decision found that discrimination based on sexual orientation and gender identity at work violated federal civil rights laws.
LGBTQ advocates in North Carolina say this is just the beginning.
Kathryn Vandegrift, a transgender woman from Asheville who was one of the two women TLDEF advocated for, scheduled her facial surgery for July 18, after about a year of waiting. She said it means that she “might finally actually be able to exist fully as myself,” in an interview with NC Health News.
“Having these repeated denials during the course of the last year was just a devastating process to endure,” Vandegrift said. “The lack of treatment makes my body really hard to live in, it’s uncomfortable. I’m happy about the opportunity to move past that.”
Vandegrift approached Equality NC, a statewide organization that advocates for LGBTQ rights, last year after she realized her Blue Cross NC insurance would not cover facial surgery.
It could have cost anywhere from $20,000 to $50,000 out of pocket, according to Healthline, a consumer health and wellness website.
“It’s not that the surgery itself is unduly expensive,” Lewis said, in an interview. “It’s just that nobody can afford to pay for surgeries out of pocket.”
Since Equality NC uses Blue Cross NC as its insurer for employees, Equality NC used its status to pressure the company to expand its coverage, said Executive Director Kendra Johnson, in an interview. This victory is an example of how people and institutions can use their status as patrons or customers to advocate for changes, Johnson said.
“That is the role we would like everyone to play in terms of advocacy,” Johnson said. “To protect the folks who are most marginalized and ensure that they have access to critical, life saving services.”
Blue Cross NC expanded its coverage on facial surgery, genital and chest procedures, tracheal shave and voice lessons effective July 1, spokeswoman Jami Sowers said in a statement to NC Health News.
“Blue Cross and Blue Shield of North Carolina has long recognized the importance of gender dysphoria as a medical condition and has covered treatments related to gender affirmation as a standard benefit on all plans,” Sowers said. “As part of an ongoing review process that includes practicing physicians both employed by and independent of Blue Cross NC, Blue Cross NC has made updates to its Gender Affirmation Surgery and Hormone Therapy Policy.”
A victory that counts
Advocates lauded the victory despite what they called a bad year for anti-LGBTQ legislation.
Nationwide, state legislatures introduced more than 100 bills to restrict transgender people’s rights, including a bill in North Carolina that would prevent doctors from performing gender-affirming surgery on people younger than 21, a bill to limit school sports participation for transgender athletes and another bill which would allow medical providers to refuse to participate in a health care service that violates their conscience.
The change also comes as at least 30 transgender or gender-nonconforming people have been killed in the U.S. in 2021, according to the Human Rights Campaign — including at least three women killed in North Carolina.
This victory is much bigger than it seems because it helps transgender and gender-nonconforming people avoid discrimination, said Dana Cea, an online therapist from Wilson, North Carolina, who identifies as queer.
“If we look at what insurance covers,” Cea said, “it’s really looking at what is deemed medically necessary.”
Discrimination against transgender and gender-nonconforming people in the medical field can have an impact on their health — especially when it comes to preventative care, Johnson said. One-third of respondents in a 2015 report from the National Center for Transgender Equality reported at least one negative experience with a health care provider related to being transgender and one-quarter of respondents reported that they did not seek health care because they were worried about being discriminated against.
For this reason, Johnson said transgender people face barriers to accessing health care for anything from the common cold to cardiac problems to COVID-19.
The fight continues
The most recent change will allow Vandegrift to start the first part of surgically transitioning.
“If we get a positive outcome, people won’t be able to tell I’m trans just from looking at me,” she said.
But other North Carolinians in Vandegrift’s situation may still not be covered for some gender-affirming surgeries. TLDEF and Lambda Legal are currently suing the state of North Carolina for denying access to gender-affirming care to people on the North Carolina State Health Plan.
The process of actually qualifying for these surgeries is also riddled with barriers, Cea said.
People looking for gender-affirming surgery must first get a diagnosis of gender dysphoria — which Cea called a “Catch-22” – since it’s still classified as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The World Health Organization moved “gender identity disorder” and “gender incongruence” from its list of mental illnesses in 2019 to its sexual health chapter, so transgender people can receive care without being considered mentally ill.
After their diagnoses, people looking for gender-affirming surgery may be required by their surgeon or insurance to provide a letter from their therapist affirming that they have an ongoing relationship in order to get the surgery.
All of those appointments cost money — and mental health services are often under-covered by insurance. A 2019 report by the governmental consulting agency Milliman found that 17.2 percent of behavioral office visits were to an out-of-network provider, compared to 3.2 percent for primary care office visits.
“I’ve received requests for letters, and this is requested by insurance, it’s also requested by surgeons or the medical providers, and sometimes it requires an ongoing relationship with the provider,” Cea said. “So I, for example, would have to put in the letter not only some of the personal details and background of this individual and their relationship to their gender, and then I’m also giving this diagnosis, which can be detrimental, considering that it’s considered a mental diagnosis instead of physical diagnosis.”
Johnson and Equality NC are working to broaden health care systems’ knowledge of the LGBTQ community through education, since “there’s very limited content that’s given specifically to the LGBTQ-plus population,” she said.
“Transgender health care is health care,” Vandegrift said, “and health care is a human right. I don’t think anyone should be denied medical care that they need.”