Transgender women worry about access to surgery

Dawn Ennis, a transgender woman who recently underwent gender-affirmation surgery. Dawn Ennis, a transgender woman who recently underwent gender-affirmation surgery. Photo: Contributed Photo / Dawn Ennis Photo: Contributed Photo / Dawn Ennis Image 1 of / 1 Caption Close Transgender women worry about access to surgery 1 / 1 Back to Gallery

Dawn Ennis’ body and gender identity finally are in sync.

On May 15, Dr. Jess Ting, a surgeon at the Mount Sinai Center for Transgender Medicine and Surgery in New York City, performed the radical, delicate gender-affirmation surgery on Ennis, a transgender woman, changing her genitals from male to female.

“The surgery went particularly beautifully,” Ting said. “There’s a lot of aesthetics in these operations. It’s not just make a vagina. We try to make it beautiful as well.”

And last week Ennis said her recovery was going well. “The pain is manageable,” she said. “It’s mostly discomfort. I still can’t sit upright.” That makes it difficult to travel to New York from her West Hartford home for follow-up appointments.

“I’m used to being the caretaker, not the person who needs to be taken care of,” said Ennis, who has three children.

But Rebecca Callaghan, of Waterbury, a transgender woman and Ennis’ friend, apparently won’t get the same life-changing opportunity.

Connecticut has one surgeon who performs vaginoplasties, but Ennis and Callaghan said that they felt he was inappropriate and insensitive when they met with him. They said he told them he had taught himself how to turn a penis into a vagina.

Two out-of-state surgeons are enrolled in Connecticut’s Medicaid program, Husky Health, in addition to Ting. But the hospitals where they have privileges either refuse to accept Husky patients or are negotiating with Connecticut over reimbursement rates.

Husky, also known as the Connecticut Medical Assistance Program, has told Callaghan she is no longer eligible to receive the surgery. On Thursday, Callaghan received a letter from Husky Health.

Signed by registered nurse Deborah Cruz, the letter stated, “Thank you for participating in the voluntary HUSKY Health Program Intensive Care Management (ICM) program. At this time, we are closing your case at your request.”

Callaghan said she did not request to be taken out of the Intensive Care Management program, in which she must be enrolled to receive gender-affirmation surgery.

“We have been arguing and the last time I argued with them I told them … ‘Don’t call me back until you have your legal issues worked out and you’re ready to proceed with my treatment,’” Callaghan said.

Callaghan’s argued she should be approved to have an out-of-state surgeon perform the gender-affirmation surgery that Ennis underwent.

Later that day she received an email from Mount Sinai. According to Zil Goldstein, program director of the transgender center, “We’re not currently scheduling new HUSKY patients as we’re in negotiations with HUSKY right now to be able to see their patients.”

“It’s despicable and aggravating and typical of what I experienced for the last year,” Ennis said of the Connecticut Medicaid program. “Their first response is denial and delay. … Persistent is what it means to be trans. If you’re not persistent, you’ll never make it.”

David Dearborn, spokesman for the state Department of Social Services, when asked whether there would be any reason not to approve Ting for another patient, wrote in an email, “We can’t engage in media discussion about individual Medicaid enrollees. But, in general, Dr. Ting and Mount Sinai are enrolled in CMAP, so Connecticut Medicaid enrollees can be cared for by these providers under CMAP reimbursement.”

That was before Callaghan received the email from Goldstein.

When informed about the letter sent to Callaghan, Dearborn wrote, “We can’t discuss individual patients in the news media. We recommend to patients that they stay in touch with the program with questions and concerns.”

Hearst Connecticut Media is not naming the Connecticut surgeon or his hospital affiliation because he has no complaints filed against him. Callaghan has had a hearing with the state Commission on Human Rights and Opportunities about his treatment of her but has not filed a formal complaint, although a CHRO staff member said, “We’re working on getting that accomplished.”

Ennis said that when she met with the doctor, “He asked me the following questions: ‘How long have you been wearing women’s clothes?’ That’s the kind of question you would ask if you didn’t think transgender women were women. … I’m not wearing ‘women’s clothes,’ I’m wearing my clothes.”

He then asked Ennis, “‘Are you straight or gay?’ In what world would it matter to this doctor whether I’m straight or gay?” she said. When Ennis said she was a straight woman who was attracted to men, she said he told her, “‘I’m never going to be able to make it so you can please a man.’ He said, ‘I think you’re going to have to change your sexual orientation.’ I said, ‘Well, that’s not an option for me.’

Ennis said the meeting was so traumatic that it was another year before she would consider undergoing the surgery. She said she reported the doctor to the hospital, to the state Medicaid program and the state medical board. Both the hospital and state Medicaid officials said, “We stand by our doctors,” Ennis said.

In a written statement that she read at her CHRO hearing, Callaghan reported a similar interaction.

But despite Ting’s willingness to enroll in Connecticut Husky, which he called “quite a laborious process,” he has not gotten authorization to see Callaghan, who also has sent a complaint to Attorney General George Jepsen.

For Husky to approve an out-of-state surgeon, both the doctor and the hospital must be enrolled in Connecticut’s Medicaid program. The two other enrolled surgeons who perform vaginoplasties are Dr. Sherman Leis of Bala Cynwyd, Pa., who is affiliated with two hospitals — Roxborough Memorial in Philadelphia and Lower Bucks in Bristol — and Dr. Kathy Rumer of Ardmore, Pa., who has privileges at Hahnemann University Hospita, Philadelphia.

However, Roxborough Memorial Hospital, while enrolled in Husky, is “not accepting fees,” according to information from the Connecticut Department of Social Services; Lower Bucks Hospital is not enrolled. Both are for-profit hospitals owned by Prime Healthcare, based in Ontario, Calif. A call to Prime Healthcare was not returned.

“The hospitals where Dr. Leis does his surgeries refuse to participate in CMAP,” Dearborn said via email. “Consequently, we cannot approve a surgery with him unless the patient chooses to pay the hospital out of pocket (which is, of course, not tenable or possible, as Medicaid enrollees by eligibility definition have low financial resources).”

Hahnemann was sold in January to American Academic Health System. Hahnemann spokesman Phil Ellingsworth Jr. wrote in an email, “At this time, there is not a contract in place with the Connecticut Medical Assistance Program. Hahnemann has an ongoing effort to negotiate with as many existing providers to establish new contracts, including the Connecticut Medical Assistance Program.”

Concerns about surgeon

Several sources involved in transgender medicine, both in Connecticut and out of state, confirmed the in-state surgeon is neither experienced in vaginoplasty (a term originally used to refer to a procedure on a natural vagina) nor sensitive to the fraught emotional issues transgender people deal with. A 2014 survey conducted by the National Gay and Lesbian Task Force and National Center for Transgender Equality found that 41 percent of transgender persons attempt suicide.

Callaghan’s primary care physician, Dr. A.C. Demidont, who practices in Stamford and New Haven, said she has expressed concerns about the Connecticut surgeon with officials of the state Public Health and Social Services departments, including Dr. Lawrence Magras, senior vice president and chief medical officer at Community Health Network of Connecticut. The network is a nonprofit managed-care organization that administrates the state’s Medicaid program.

“Dr. Magras reached out to me,” Demidont said. She said Magras told her, “We think there’s a problem. What providers should we reach out to?”

“We, as people who take care of hundreds of transgender patients, have been arguing with top leaders of DSS and the department of health in order to have this changed,” she said.

“This is life or death for people, which is why I continue to fight to make sure people get appropriate care, because this is a huge, huge vacuum that needs to be filled,” Demidont said.

“My concern has always been that if you only give transgender women one option for that surgery that is not fair, especially when there are better surgeons out there that will create a better outcome,” she said.

She said the surgery “needs both a urologist to create the vagina and a plastic surgeon to create the labia or the outside of the vagina so it looks like it would on a cisgender woman.” “Cisgender” refers to a person who identifies with the gender they were assigned at birth, a non-transgender person.

Demidont said the in-state surgeon is “a competent surgeon but in these procedures he does not have the same experience as surgeons outside of Connecticut have.”

A spokeswoman for the surgeon’s employer said he “performs approximately one gender-affirming surgery per month in addition to other kinds of reconstructive urology surgeries. He has lectured on the topic and has taught other urologists this advanced surgical technique and has also educated them and the clinical and administrative staff on how to be culturally sensitive to these patients.”

Callaghan, 38, said she self-identified as female at 4 years old. She said the state is resisting approving out-of-state surgeons because the Connecticut doctor charges only $4,000, and that people who work for both Mount Sinai and Leis have confirmed that figure as Connecticut Husky’s reimbursement rate for vaginoplasty.

That term traditionally refers to a procedure to tighten a natural vagina, and Ennis said she thought $4,000 might be the rate for the traditional procedure. She said, in her case, Community Health Network and Mount Sinai negotiated “a middle ground” rate for her surgery.

Dearborn said Connecticut Medicaid would not pay as low a rate as $4,000 for gender-affirmation surgery. In an email, he wrote that Medicaid reimbursement rates are based on surveys of providers and that any doctor would be paid the same rate for a particular procedure. “We are in the process of re-examining our fees in this field of practice,” he wrote.

Demidont also said she doubted a doctor or hospital would charge that low a fee for such a complex surgery.

Demidont said both Mount Sinai and Hahnemann have training programs for vaginoplasty, and more than 20 procedures a month are performed at Hahnemann.

Ting said since he gave up his general plastic surgery practice in March 2016, he has performed 150 to 200 vaginoplasties. He uses “a relatively new innovation” in which “the deepest portion of the vagina is lined with peritoneum” rather than skin, he said.

The peritoneum, a thin membrane that lines the inner abdomen and bodily organs, does not grow hair, as skin does, and produces lubrication.

“In order to do Dawn’s case, I did enroll in Husky Medicaid and it was quite a laborious process,” Ting said. “I give Husky Medicaid a lot of credit” for approving the surgery at Mount Sinai. “I don’t think it’s too much of a stretch to say we’re a center of excellence,” he said.

Ting said that once he began doing gender-affirming surgery, “I very quickly decided to do nothing else because there’s such an unmet need for doctors who can do these operations and care for transgender patients.

“Historically, transgender people have been marginalized by not just the general population but by the health care system,” Ting said. “Until March of 2016, you couldn’t get gender-affirmation surgery in New York City.”

Ennis is pleased with the results of her surgery. “I can’t say I feel different as much as I feel relieved,” she said. “I’m finally, finally done. There’s a long road ahead in terms of self-care and I feel like I’ve accomplished something personally.”

A friend struggles

Callaghan said after sending her to Leis, the state DSS, which oversees Connecticut’s Medicaid program, canceled the contract with Leis’ hospital “so they wouldn’t have to give me a denial. Dr. Leis had handled many other patients before me but all of a sudden it was a big deal.

“The doctor may be enrolled, but the only thing they’re cleared for is basic consultations and not all of the things they need to actually perform a surgery,” Callaghan said. Doctors “need a surgical contract and they need a hospital.”

According to information from DSS, Leis accepts Connecticut Medicaid referrals on a case-by-case basis, as does Ting. Dearborn said Rumer also is enrolled. But negotiations between the hospitals and Husky Health appear to be preventing the doctors from taking on Connecticut Medicaid patients.

A medical professional who asked to remain anonymous but who is familiar with Leis’ practice said Leis performed many vaginoplasties for Connecticut Medicaid patients until about two years ago. But changes in hospital ownership and administration have led to an impasse between them and Husky.

According to DSS data, Medicaid began paying for “gender-reassignment surgery” in Connecticut in 2015. Since then, there have been 20 patients who have undergone male-to-female surgery and three who have had female-to-male surgery.

“Connecticut was one of the first states to cover reassignment services under Medicaid,” Dearborn wrote in an email. “Finding endocrinologists, dermatologists, psychiatrists and other providers for transgender services has been difficult, and surgery services are more difficult to locate and enroll.”

Coming out, losing a job

Ennis, who was named after her father, Donald, works as a freelance journalist. (While many transgender people do not want to talk about their identities before they came out, Ennis said she’s “somewhat infamous,” has gotten a lot of press and is too well known to try to erase her life as a male.)

She came out as transgender in 2013 and was fired from ABC News the next year (she settled with the network and is not allowed to talk about it). She then worked for The Advocate, the LGBTQ publication, but when her wife died, she left the West Coast to be with her children, Sean, now 19, Sophie, 15, and Liam, 11. “I call them my strength, my heart and my soul,” she said.

They still call her “Dad.” “We lost their mom to cancer and there’s no way of replacing her,” she said.

Ennis, who will be on the lead float in New York’s Pride Parade on June 24, worries about transgender women and men losing protections they’ve gained. “Connecticut was ahead of the United States in terms of providing state Medicaid coverage for transgender people like me,” she said. However, under President Donald Trump, “they’ve removed protections for transgender Americans. … He’s stripped schools from having to offer equal accommodations for transgender students” and barred transgender people from serving in the military.

“I don’t think most people know that you can still be fired in America for being LGBT,” Ennis said. “We do have state laws to prevent that. The problem is there are no federal laws.