The price of a gender transition
About four years ago, I decided to finally come out as transgender. And it was hardly impulsive. I’d spent decades drowning in self loathing taught to me by a transphobic movies and television. I’d thought about coming out for more than two decades, but always withdrew in fear of what it might cost me. It wasn’t until I realized I couldn’t live any longer that I realized that coming out was the only way to save my life. And so I did. And with that came love and support, an overwhelming amount of transition labor such as name changes, voice work, research on surgery, surgery planning, actual surgery, working through old photos and documents, the regular trauma of having my civil rights debated, the advocating for their restoration, and the inevitable sexist and transmysogynist discrimination. On top of all of that was a pandemic, which isolated me, slowed my social transition, challenged so many of my assumptions about what I wanted my transition to mean, and brought me dangerously close back to self harm.
Despite all of these challenges, four years later, I feel like I’m on the other side of transition. And for the first time, I feel like I can take stock of what I’ve gained and what I’ve lost. What I’ve gained is is easy: I saved myself, with the help of so many, and my body and my self are no longer a daily source of depression, dysphoria, and despair. In fact, on many days they are a source of joy and empowerment! I didn’t know that life could feel so peaceful.
What it cost is harder to judge. I could write at length about the trauma of transition, and how most of it wasn’t inherent to being trans, but being trans in a world that doesn’t make room for trans people. All of that has taken a toll, and will continue to until I can feel safe just being me anywhere I happen to travel. Perhaps the most urgent of those are the health risks I’ve taken on to find peace: the sparse medical literature that gives doctors little to know insight about my risks and medical future, the lack of providers who understand my anatomy and physiology, and the general risks of being confident that I’ll find gender affirming care in any place but the most trans-inclusive of places, such as my home of Seattle. None of these have to be, but the world generally ignores trans health and wellness, so this is what it is.
But there is one cost that is quite easy to judge: the monetary cost of transition. This is something that trans people don’t often talk about, partly because Americans don’t talk about their finances, but also because it’s quite depressing. Everything about transition costs so much, and is so infrequently covered by insurance, that the majority of trans people — who tend to be near the poverty line already—simply can’t access the care they need. The result is that many just have to learn to live with dysphoria, with constant misgendering from strangers, with the risk of physical or sexual violence, or simply staying in the closet out of fear of these things. In the capitalist U.S., in which everyone has to fight for basic needs, liberation has a price, and it is paid not by the people who create these harms—cis people who built and maintain the oppressive structures of a binary gendered, anti-queer world—but by trans people themselves.
So what I’d like to do here is catalog the price of my transition. I want everyone who reads this to see what I’ve spent, what was covered, what was not, and why I had to spend that money. Perhaps by seeing this, you might see your own role in creating these costs, your opportunities to share in them by advocating for gender affirming care, and just how necessary such care is to make a gender transition like mine remotely possible.
So here is what my transition cost:
- Four years of therapy. I have a wonderful therapist whom I’ve seen every other week since I hit rock bottom in 2017. For a long time, she was the only person in my life I’d confided in, and the only person I felt safe sharing my feelings. I wouldn’t be alive without her. My Kaiser Permanente insurance plan has covered every one of these visits, and so I’ve only had an out of pocket copay of $30 per visit, which is $3,120. Had they not been covered, my cost would have been $120 per visit, $12,480.
- Four years of laser and electrolysis. Perhaps my greatest source of dysphoria has been facial hair, since it’s the single strongest signal of gender. Fortunately, I never had much of it, and my hair is dark, so I was able to save some money by starting with laser, and then moving to electrolysis for grey hairs, smaller hairs, and more stubborn hairs that required more precise removal. Electrolysis was the only viable option for genital hair removal, required for bottom surgery. Overall, I’ve spent about 90 hours doing hair removal over the past four years, at an average hourly rate of $120/hour (less for laser, more for electrolysis), at a total cost of about $10,800. Only about $1,500 of genital hair removal was covered by insurance, because 1) I needed a letter from my surgeon but didn’t have one when starting removal, 2) my hormone levels had to be below a certain level for it to be covered and they weren’t, and 3) insurance only covered about half the cost. (Under most insurance plans, hair removal isn’t covered at all).
- Bottom surgery. There were two major expenses: the surgery itself and living in Spokane, Washington for 2.5 weeks post recovery, mandated by my surgeon. The surgery cost $27,300, but I only paid $500 out of pocket because Washington state mandates trans-inclusive coverage. My stay in Spokane was not covered at all, unfortunately, because apparently Kaiser apparently thinks that 300 miles is close enough to home that there are no travel expenses associated with surgery. My expenses for food, lodging, and supplies came out to about $4,000 for 2.5 weeks.
- Hormones. I’ve taken estrogen and progesterone for several years, also essential to my medical transition. The cost is about $90 a month, but these are covered by my insurance, and so I only pay about $30 a month in copays, or about $1,440 over the past few years.
- Name changes. Federal and state governments in the U.S. like to charge for every little change to government records. The result was that I spent about $1,200 overall to correct all of my official documents with the federal government, with Washington for driver’s licenses, with California for my wedding license, and with Oregon for my birth certificate.
- Clothing. I replaced my entire wardrobe. And then I realized my tastes weren’t what I thought they were, and so I slowly replaced it again. And then I realized I’d outgrown everything because my chest and bottom got bigger, so I had to replace it again. I estimate that I’ve spent about $5,000 trying to get my wardrobe right.
Of course, all of these are just the direct transition-related costs. There were also opportunity costs: for all of the time I spent on all of the above, I could have been doing the normal consulting I do, which generally brings in about $6,000 a year, so that was about $24,000 I didn’t make in the last four years. And of course, there is the pink tax: I rely on makeup to address some dysphoria with my face, I have more hair care costs I didn’t have before, and there seem to be so many other little things—more expensive razors, pads, more frequent doctor’s appointments. That all seems to add up to about $1,000 extra a year, though most of these are costs most other women pay. And of course, many of the costs above will continue, including hormones, possible further surgeries, and continued therapy.
If you add up all of these costs over the past 4 years, and include lost income, my gender transition cost over $40,000, and this is with some of the most gender-affirming health insurance in the world. How could I possibly find an extra $10,000 a year to pay for all of this? In my case, the answer is easy: I’m paid relatively well as a professor, I only have one child, I’m a compulsive saver, and I’m quite frugal. For someone in the upper-middle class like me, what that $40K meant was just having $40K less in savings (and had that been invested for retirement in 30 years, $500K less in retirement savings). Therefore, the price of my transition was about $0.5 million in retirement income. And what it bought me was my life.
Every trans and non-binary person has different costs. Some don’t medically or socially transition at all, meaning that most of their costs are existential and hard to price. Others have significantly more surgery than me, with no coverage at all. Some people have complications with surgery and end up having additional health care costs to find their way back to health and wellness. And so the range can be anything from $0 to more than $100,000.
Cis people don’t have those costs. They will be wealthier when they retire; they will have more in savings (or be more likely to save at all); and they will have more time to do things other than fighting insurance companies and brittle health care systems. In contrast, trans people have even greater costs and even less money. Many have no insurance at all, or insurance that does not cover any trans-related care. And trans young adults, those most likely to be seeking care before the permanent effects of puberty lock in, are not likely at all to have income to cover any of this. Had I been without gender affirming insurance, my costs would have been more like $80,000. When you only make $14,500 on federal minimum wage, or you’re unemployed because businesses in your community refuse to hire trans people, how can you possibly pay $20,000 a year in transition costs? You can’t, and so you don’t.
Because of this, I feel immense privilege for having the transition I’ve had. And I also feel immense guilt, since I know how many in my community just can’t access the care and coverage that I’ve had. And this is fundamentally because the world sees some life saving health care as essential — a bypass for heart disease, appendix removal, cancer treatment—and live saving health care for trans people as optional. The dramatically higher rates of death by suicide amongst trans people are therefore no accident: they are the willful choice of the majority cis public to view trans health, wellness, and lives as optional.
So when you see a photo of me smiling, happy, and glowing, I don’t want you to think, “Wow, she’s so pretty; her transformation is amazing!” I want you to think instead, “Wow, that must have cost so much. Why doesn’t every trans person have the same gender-affirming care that she had?”
Then, I want you to see what the laws are in your state or country, and who’s fighting for rights gender affirming health care. For the U.S., check the list at the National Center for Transgender Equality. And then call your representatives and demand that your states and governments fully cover gender-affirming care, just like we cover every other life saving treatment. Anything less is an injustice.