E. Tammy Kim is a writer in New York.

A few years ago, Stephan Rivera, a 31-year-old native of the Bronx, New York, consulted two doctors about his prospects for “top surgery,” a double mastectomy. “I was like, I really just want to cut them off,” he recalls. Although he was generally content—working as a teacher’s aide in a public school and living with his fiancée, Tanisha Burgess—he felt increasingly estranged from his body, especially his chest. He avoided the mirror after his morning shower; trips to the beach made him anxious. His best friend, Aiden, who had recently transitioned himself, told Rivera to seek out the Callen-Lorde Community Health Center in Manhattan.

At the time, it was becoming easier, at least in theory, for trans people to get treatment, and more of them were seeking care. Medical coverage was improving under the Affordable Care Act, queer identities were more widely accepted and anti-discrimination rules put into effect by the Obama administration had recently pushed a handful of states, including New York, California, Colorado and Illinois, to make “medically necessary” mastectomies available to trans men. Rivera lived in a progressive city, had good insurance from his public-sector job, and was seeking care at a clinic named after two LGBT pioneers.


Rivera felt welcomed when he arrived for his first appointment at Callen-Lorde, in the fall of 2015. Stickers and sharpies for notating one’s gender preference were on offer at the front desk; ads for patient support groups played on a flat-screen TV. He wanted to start hormone treatment but hadn’t shared his plans with Burgess, who identified as a lesbian. A doctor asked Rivera questions, and explained the effects and side effects of injectable testosterone. “There wasn’t any questioning about who I was or how I felt. No extensive, ‘You gotta do that before we can diagnose you as trans,’” he told me. He learned to give himself the injections, and, over time, decided he was ready for top surgery. Doctors at Callen-Lorde wrote letters establishing his severe gender dysphoria and asserting chest surgery as a cure.

Yet even in those favorable circumstances, Rivera could not get the care he was after. EmblemHealth, his insurance company, denied his request based on “insufficient … medical necessity.” It said he had failed to establish “true transsexualism,” which the company defined to include: finding “one’s own biological sex … repulsive,” “a desire to eradicate one’s own genitals” and an “inability to achieve arousal from cross-dressing.” The criteria were a baroque departure from those prescribed by the World Professional Association for Transgender Health, which deems “sex reassignment surgery” appropriate for any fully informed, healthy adult suffering persistent gender dysphoria. D’hana Perry, Callen-Lorde’s transgender health care coordinator, recalled, “I’d never seen anything like it before.” (Emblem would not comment about Rivera’s case.)

If ever there were a trans tipping point in the United States, it hinged not solely, but crucially, on the health care apparatus—the means by which many trans people become fully themselves. And the barriers Rivera faced, despite the apparent trend toward inclusion and equal access, prove how difficult it still was for trans people to get treatment.

Now, under the Trump administration, that difficulty is only likely to grow.

In January, the Department of Health and Human Services’ Office of Civil Rights proposed a new regulation meant to address “a culture of hostility to conscience concerns in health care.” During Barack Obama’s presidency, the same office had prioritized the rights of LGBT patients, but, under President Donald Trump, it would focus on the rights of health providers, allowing them to opt out of procedures and tasks on religious or moral grounds. The regulation specifically highlights abortion, sterilization and assisted suicide, but the language is broad, giving the entire universe of health care workers—not just doctors and nurses, but also insurance claims agents, dental hygienists, research-grant managers, social-services clerks, pharmacy assistants and X-ray technicians—permission to deny virtually any kind of care due to their beliefs.

Roger Severino, who leads the civil rights office at HHS and formerly led a center for religion at the Heritage Foundation, said in an emailed statement that the current proposed rule simply restates existing protections for health care workers, such as those in the Religious Freedom Restoration Act, and that, in the past half-century, “not a single case has arisen where [state and federal] conscience protection laws have been used for objections based on a patient’s identity.” Yet the draft regulation cites several pending cases in which trans patients sued after being denied services, on what the providers said were moral grounds—cases that could be thrown out under the new HHS rule. All this followed the decision of a federal judge, just after Trump’s election, to block a 2016 rule defending transgender patients against health care discrimination.

The latest HHS regulation is not yet final; the public had until March 27 to submit comments, and it could take weeks or months for the agency to make a determination. But trans people like Rivera believe that the proposed rule has sent a discouraging message, and that the final version could undermine hard-won progress for their community. Over the year and a half that Rivera fought the denial of his top surgery, and as he continues to navigate the world of trans medicine, the federal government’s retreat leaves him—and many others—with fewer tools to access care.



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Trans people, who make up less than 1 percent of the U.S. population, have been implicated in multiple policies since Trump took office. His administration has imposed restrictions on trans people in the military, opposed or rolled back protections for trans employees, nominated judges with “deep histories of anti-LGBT advocacy,” according to the LGBT civil rights group Lambda Legal, and signed a tax bill that’s expected to trigger devastating cuts to Medicaid and Medicare. Meanwhile, the trans community continues to face disproportionately high rates of extreme poverty (four times that of the general population), assault, bullying, job discrimination and attempted suicide.

Add to all this the acute challenge of health care. Thirty-one percent of transgender Americans lack regular access to a medical provider, even as their community suffers from high rates of depression, exposure to violence and HIV infection. It’s hard to overstate the dread induced by an unfamiliar doctor’s office or emergency room for trans and gender nonconforming people, even those with insurance. I’ve heard stories of cold sweats and ulcerative stomach pain, or self-medicating to avoid treatment altogether.

Advocates fear that the Trump administration’s emphasis on religious freedom gives providers and insurers yet another reason to rebuff trans patients. Elizabeth Gill, an attorney at the American Civil Liberties Union of Northern California, offers an example. In 2016, her client Evan Minton was scheduled for a hysterectomy at a Catholic hospital in California; only when a nurse learned that he was transgender did the facility cancel. In legal pleadings, the hospital has denied intentional discrimination and claimed the right to refuse service on religious grounds. “Providers who are already uncomfortable now will feel they have license to discriminate outright, and will allow people to be shamed and refused,” says Flor Bermudez, legal director at Transgender Law Center.

In less populous areas, trans people—but also people with HIV, gays, lesbians and straight unmarried couples—may be left without medical options, Bermudez says. Teo Drake, a lapsed Catholic and trans man with HIV in rural Massachusetts, told me about an incident from 2015. After having genital surgery out of state, he noticed that a scar was failing to heal, and rushed to Baystate Medical Center, the hospital nearest to his home. When the doctor on duty refused to make eye contact or properly examine his incision, Drake had to drive to another emergency room almost an hour away. (Representatives of Baystate declined to comment.)

Like Drake, Rivera was denied transition-related medical care even without HHS’ new proposed rule. His request for top surgery, submitted and denied in 2016, became stuck in a long, bureaucratic appeals process that stretched into 2017.

In the meantime, his body took well to testosterone, and he attended to the mileposts of his transition. Burgess, his fiancee, tried to adjust to how they were seen in public: as a heterosexual couple. “In the end, we have a great relationship, and to give that up for something that makes me uncomfortable—I felt that was selfish,” Burgess told me.

Rivera also got a new job, working with troubled girls and boys in the Bronx, and looked forward to starting the job fresh, as “Stephan.” To avoid any confusion, he called human resources in advance, and asked that his personnel file be updated with the correct name and gender. But as he found out on his first day of work, his request had been ignored. “They’re assigning us lockers, and they’re like, this is your locker number, and walking me toward the ladies’ room,” Rivera said. He found himself having to disclose and defend his trans identity to a room full of strangers. In the men’s locker room, he felt self-conscious about his chest, unable to dress and undress in the open. “You’re never comfortable. You always feel like someone can tell.”

In the spring of 2017, just a few weeks before his wedding, Rivera finally resolved to explain his transition to his mother, a devout Jehovah’s Witness. Though they saw each other often, they had not spoken of the changes in his appearance or the deepening of his voice. He told her everything, then asked her to come to the wedding; she reacted hesitantly. A week later, she sent a long email to him and Burgess, saying that, because marriage is a sacrament, she would not attend. “I get it Steph, I understand what you have been feeling over the years and I just want you to know that I will continue to treat you the way I have before this was made known. … Understand that my not being there does not mean I don’t support you,” she wrote.

On a rainy May afternoon, Rivera and Burgess were married in a simple ceremony at City Hall, she in a form-fitting white lace dress, he in a blue-and-flower-print tuxedo. His best friend, Aiden, was there, as were Burgess’ aunt and a few old friends. After the ceremony, they drove back to the Bronx, for a dinner and reception, during which Burgess’ aunt mistakenly referred to Rivera as “she,” and apologized profusely. At the end of the night, Rivera’s mother surprised everyone by showing up, and embraced her son.

Rivera felt that everything had come together—except for his top surgery. With the help of an attorney at the Legal Aid Society, he appealed the denial by EmblemHealth, and waited for a decision. When the company, at last, responded in February 2017, it promised to overhaul its policy on “gender-reassignment surgery,” eliminating the concept of “true transsexualism” and the criteria of repulsion and cross-dressing. Rivera’s appeal had led to a significant change, yet his own request for surgery was rejected once again for lack of medical necessity.

As his attorney handled a second appeal, Rivera fell into despairing grooves of thought. In early June, he took a last-minute flight to Charlotte, North Carolina—to see a surgeon who was recommended online. Rivera had lost patience with his insurer and decided to pay out of pocket, but he couldn’t afford the services of Dr. Paul Weiss, his Callen-Lorde-approved surgeon in New York. “I came to the point of saying that I’m just not going to go through it anymore,” Rivera told me. He scheduled an operation with the doctor in Charlotte, and planned to pay the $6,500 fee with a medical credit card that charges 20 percent in interest—a common strategy in the trans community. Aiden, who was also insured by Emblem, had resorted to paying $7,000 for his own top surgery in 2015.

Burgess was concerned, but she gave Rivera her support and made plans to take time off work. Just before Rivera’s operation, however, he canceled the trip. “When I did the math, I would literally take everything I earned every month to pay this thing,” Rivera explained. His cancellation turned out to be prudent. A few days later, he got a call from his attorney. The private monitor reviewing the second appeal had found that, “The insurer did not act with sound judgment in the best interest of the patient.” Rivera’s chest surgery was finally approved.

In September, Rivera was operated on by Weiss, a specialist in trans medicine. (He performed his first top surgery nearly three decades ago, and today, he told me, “I’m doing 10 times the amount of transgender surgery I was doing three years ago. Twelve to 15 surgeries per month.”) Within a week of the procedure, Rivera texted me a shirtless selfie. The curved incisions were still red and raw, but “I was able to shower. I’m HAPPY,” he wrote.



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If Callen-Lorde’s statistics are any indication, the demand for LGBT-friendly care increased dramatically after Trump’s election, and again after his inauguration. The same has been true in other parts of the country: Patients’ anxiety was “at a fever pitch,” a Los Angeles insurance manager told STAT News in September; Harper’s reported in February that the Equitas clinic in Ohio was swamped with requests for help. By 2017, Callen-Lorde was maxed out—18,000 patients, 26 percent trans-identified, making 110,000 visits a year—and expanding to satellite offices in the Bronx and Brooklyn. Perry, the transgender health care coordinator, arranged a series of weekend legal clinics for people who needed to change the “male” or “female” marker on their birth certificates and IDs. “There’s no telling what can happen, so people are just trying to shore up themselves, just to make sure they have documents that align. I had to do that for myself as well,” he told me. Multiple doctors and mental health providers at Callen-Lorde complained to me of overwork; shortly after Rivera’s first visit, the clinic had stopped taking new patients.

After the proposed conscience rule was announced, Kimberleigh Smith, Callen-Lorde’s policy director, collected patients’ stories about previous denials of care—to shape an official comment the clinic submitted to HHS. The National Center for Transgender Equality, a nonprofit advocacy group, launched a comment portal for trans people and allies to “tell HHS just how bad this new regulation would be.” And Gill of the ACLU promised that, “if the final rule looks like the proposed rule, then we’ll see the administration in court.”

As for Rivera, his left side took some time to heal, but life, post-surgery, has otherwise returned to normal. He and Burgess were making plans, finally, to have a baby, and had asked Callen-Lorde to recommend a few fertility specialists. “I’ve never planned on carrying, unless I had to, unless my wife couldn’t,” Rivera told me. He wasn’t thinking too much about politics in general, or the proposed religious-exemption rule in particular, but he did wonder, what “if I had to carry and someone didn’t want to assist me because of their beliefs?” In the many Facebook groups and chat rooms where he meets other trans Americans, he has observed a recent urgency—a feeling of “being in a rush” to get health care. Rivera and Burgess are trying to pace themselves, though. For the two of them to start a family, and for Rivera to continue being himself, they’re going to need a lot of medical help.