Hawaii to expand gender-affirming care for trans residents

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In 2016, Hawaii took a seemingly small but significant step forward for its transgender and non-binary residents: the state passed a law prohibiting insurance companies from discriminating against residents because of their gender identity. But in the years after the anti-discrimination law, trans residents, advocates and lawmakers found it hadn’t done enough — people were still denied coverage for gender-affirming care. .

Hawaii Gov. David Ige (D) signed a bill on Thursday that clarifies certain treatments that insurers had deemed “cosmetic” — such as laser hair removal, voice therapy and facial feminization surgery — should be covered as long as a doctor provider deems it medically necessary. The legislation, HB 2405, would also require insurers to give patients clear information about which gender transition services are covered.

“The bill is essential to protect people from discrimination in accessing gender-affirming treatment,” Ige said at a signing ceremony, Honolulu Civil Beat reported. The governor also signed two other bills expanding LGBTQ protections in the state: one that bars people from being barred from juries because of their gender identity and expression, and another establishing a commission. which will examine the status of LBGTQ residents of Hawaii.

The health care bill, which was developed with input from health care providers, trans rights advocates and insurers, passed with overwhelming support in both houses of the legislature from Hawaii. The law went into effect immediately Thursday.

The coverage issue highlights how difficult it is for transgender people to access medically necessary and potentially life-saving health care, even in areas that embrace and support them, the agency representative said. Hawaii State Bill Champion Aaron Ling Johanson (D). and Chairman of the State Commerce and Consumer Protection Committee.

Johanson said the policy change had been a “passionate project” for him.

“One of the things we found was that… ‘cosmetic’ treatments are a very essential part of accomplishing gender-affirming care for the patient,” Johanson said. But “fights” have persisted between trans Hawaiian residents and insurance companies, he said, because some insurers have ruled the care was not medically necessary, even if a patient’s doctor recommended them. (Hawaii Medical Service Association, the state’s largest insurer, declined to comment.)

“It’s just heartbreaking to hear from a lot of these people who have higher rates of depression or suicidal thoughts because they’re just stuck in a system that’s not helping them,” Johanson added.

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Fan Liang, medical director of the Johns Hopkins Center for Transgender Health, said that when it comes to gender-affirming surgeries, insurers tend to cover both “upper” and “lower” surgeries (thoracic and genital surgeries). , but not procedures such as facial or voice surgeries. That’s a big oversight, Liang said, given how important these features are in everyday life.

“When you engage with someone, the first thing they really appreciate is your face and your facial expressions,” Liang said, adding that many of his patients have also shared stories of sexual abuse. on the phone. Some fear that their voice is “an indicator” of their transition. (Noninvasive procedures, such as laser hair removal and voice therapy, are also more likely to be declined by insurers.)

Generally, Liang said, gender-affirming care, which includes psychosocial and educational resources as well as medical interventions, helps transgender people live more freely, whether to alleviate their gender dysphoria or to reduce the probability that they will be distinguished or discriminated against.

“It’s really a medical necessity,” Liang said. “These patients live with an incongruity that permeates every aspect of their lives.”

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In passing its new gender-affirming care bill, Hawaii has joined a handful of states, including Washington and Colorado, that have attempted to expand access to transitional care.

Trans people and their advocates have long noted the structural barriers to seeking care. Fighting to get treatments covered can be an expensive, overwhelming and time-consuming process, experts said. And even when patients can get their treatments approved and covered, there aren’t many providers capable of performing these procedures, and it’s not uncommon for patients to travel out of state or be put on long waiting lists to receive them.

That’s true even in “progressive” places like Hawaii, where some residents have traveled to California — a five-hour flight — to get the transitional care they need, advocates say.

Jenn Jenkins, a policy advocate who worked on the health care bill in Hawaii, said that in their view the law simply clarified what was intended in the state’s non-discrimination policy. of 2016.

“It’s already the law. It just wasn’t as clearly written as we made it [now]”, Jenkins said. Still, this clarification could significantly expand access to gender transition for Hawaii residents, especially trans women who had been particularly likely to have their applications denied, Jenkins added.

Hawaii advocates and lawmakers agree the bill is an important step forward at a time when other states seek to limit access to transitional care for trans youth and adults. Conservative lawmakers who have introduced bills limiting minors’ access to gender-affirming care say the policies are aimed at protecting children.

For Johanson, the lawmaker, Hawaii’s emphasis on community care — “the aloha spirit” — helped ease the bill’s passage. deeply rooted in Hawaiian culture.

Native Hawaiians have long recognized a third gender identity, “mahu”. Historically, trans and non-binary Hawaiians have taken on roles as teachers and leaders in their communities, explained Maddalynn “Maddie” Sesepasara, a trans lawyer who runs the Kua’ana Project, a transgender support organization.

That cultural reverence became evident in 2019, Sesepasara said, when Native elders protesting a billion-dollar telescope atop Mauna Kea mountain called on Hawaii’s Mahu community to join them.

“We know we have a place. We know we are respected,” added Sesepasara.

That doesn’t mean trans people in Hawaii haven’t faced the same systemic barriers, discrimination and violence that trans people face elsewhere, advocates say. After Christian missionaries arrived on the islands, “mahu” became a pejorative term, Sesepasara said, although that has slowly changed over the past few decades.

Medical transitions are a personal choice – a choice that not all trans and non-binary people are able to make or willing to pursue. But for people in Hawaii who need medical treatment to affirm their gender identity, these procedures could mean the difference between being targeted and being able to “blend in” and be comfortable in society, said Sesepasara.

And at a time when the cost of living has skyrocketed on the islands, some residents have become increasingly desperate to complete their transitions.

“These are not cosmetic surgeries,” Sesepasara said. “These are operations that will save transgender people in Hawaii.”

Jenkins hopes Hawaii’s new law could be a “little bulb of light” for trans communities in other parts of the country, where vitriol and attacks on trans people and other LGBTQ people have increased.

“It’s our contribution to the possibility that we can change things for the better,” they said.

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