Jessica Crowe has spent years and thousands of dollars seeking what most of us take for granted: feeling genuine.
She's not quite there yet.
"At this point," the 35-year-old Berthod resident says, "all I have achieved is full social permission to cross dress ... there's a big difference from being able to cross dress and being an actual woman."
While not all transgender people want gender confirmation surgery, for some, like Crowe, nothing but a full transformation feels appropriate.
But surgery has been prohibitively expensive, especially since she came out a few years ago as a transgender woman. She'd been making almost $75,000 a year in the oil and gas business, but after her announcement, she was demoted and earned less than $35,000, she says. When layoffs rolled around, she was the first let go. Now she's surviving on unemployment and thinking of going back to school.
Nevertheless, Crowe will soon undergo surgery. She can thank her new health insurance, provided via the Affordable Care Act, which is subsidized due to her low income, changes to the interpretation of Colorado laws, and a new health insurance company that is covering gender confirmation surgery. She'll be seeing one of the nation's top surgeons in the field, which likely would have cost tens of thousands of dollars in the past, yet her out-of-pocket maximum means she won't pay more than $1,350 for the procedure.
Asked how it feels to finally be getting the surgery, she's thoughtful: "It almost seems like a dream."
Last March, the Colorado Division of Insurance changed the lives of transgender Coloradans by issuing a bulletin stating that in the division's interpretation, state law prohibits "the denial, cancellation, limitation, or refusal to issue or renew health coverage because of a person's sexual orientation."
Vincent Plymell, communications manager for the Colorado Department of Regulatory Agencies, says one of the main objectives of that finding was to ensure that trans people could access care that's usually exclusive to a gender — for instance, prostate exams or mammograms. Once a person transitions and their gender changes, they can lose access to these services, even if they still need them.
Plymell says that while there are no fines for noncompliance associated with the bulletin — it doesn't carry the weight of law — he's yet to hear of any insurance companies refusing to get in line. Still, the bulletin only goes so far. It requires companies to cover services they'd cover for a straight person. Asked if that means companies must cover hormone therapy for transgender people, since they'd cover it for a menopausal woman, Plymell says that's "a gray area." And there's no question about whether insurance companies have to cover gender confirmation surgery. They don't.
That's too bad, says Dr. Erin Jacklin, a licensed clinical psychologist in Denver who specializes in transgender issues.
Jacklin notes that a recent study by the National Transgender Discrimination Survey found that 41 percent of people who are transgender or gender non-conforming have attempted suicide, at least nine times the national average. While transgender people have the same mental health issues as anyone else, she says trauma and lack of acceptance can compound those problems. But mental health issues in trans individuals do respond remarkably, she says, when a person reaches a comfortable state in his or her transformation— whether that's hormone therapy or surgery.
"Sometimes it almost feels like [the mental problem] is magically gone," she says.
Pockets of acceptance
While insurance companies aren't required to cover all trans-related expenses, some are doing it anyway. Kaiser Permanente, for instance, is offering coverage to transgender people under all plans overseen by the Colorado Division of Insurance. With some exclusions, it's covering a full range of medical services, including hormone therapy and gender confirmation surgery.
The division could not provide a full list of carriers that are following suit, but one other carrier does stand out. The nonprofit Colorado HealthOP, where Jessica Crowe is a client, has only been offering insurance since October, but it, too, offers the full range of transgender medical services.
"It was really an early and clear statement about our values," Dr. Jack Westfall, the nonprofit's chief medical officer, explains.
Westfall says that while the surgery is expensive, relatively few patients want it. And he notes that more common procedures, like open heart surgery, are also expensive for health insurance companies.
Westfall says that not only will Colorado HealthOP continue to cover trans services, it hopes to lead the way in creating a virtual center of excellence for transgender health in Colorado — essentially, a group of top doctors who can meet every transgender health need. It would include people like Jacklin, and ideally a surgeon who specializes in gender confirmation surgery.
Those surgeons are in short supply; none currently live in Colorado. But Westfall is working with Dr. Curtis Crane of California, who says he wants to work out an arrangement whereby he would work in Colorado three months of the year.
Contacted between operations, Crane says he's hopeful the arrangement could be ironed out late this year or in early 2015.