Posted By Florence Paré
Every time I looked in a mirror, I saw someone else. I was what I was not. But unlike Lindsay Lohan in Freaky Friday, I had no one else to be. It was not until I had taken estrogen and anti-androgens for a few months that my face started changing and I started recognising myself in the mirror. To this day, it varies: on worse days, I feel the dread of self-misrecognition. On better days, I am relieved to see myself as I am. Well-being is unavoidably hampered if you cannot ever feel at home anywhere. Through our bodies, our consciousness is embodied. People typically feel at home in their body, but for many of us it does not feel like home.
Far from being a caprice, hormone replacement therapy, for those of us who wish to receive it, is often a lifesaver. Amongst trans people who have considered medical transition, those on hormone replacement therapy were about half as likely to have seriously considered suicide in the last year. In total, around 35% of all trans people have seriously considered suicide in the last year. Of those who desired to medically transition but had not begun hormone replacement therapy, 53% have seriously considered suicide in the last year.
To this day, it varies: on worse days, I feel the dread of self-misrecognition. On better days, I am relieved to see myself as I am.
Apart from alleviating dysphoria by creating changes in our body which we desire as ends in themselves, those changes also participate in our well-being because of their relationship with what we call “passing as cisgender”.
A person is cisgender if they are of the same gender as they were assigned at their birth; in other words, a person who is not transgender. Someone is said to pass as cisgender if they are read as cisgender. For example, if someone were to believe that I am a cisgender woman rather than a trans woman, I would be said to pass as a cisgender woman. Passing is not a yes or no feature: people may pass in some contexts and not in others, and may pass or not in the same contexts at different times or to different people. Not every trans person wishes to pass, nor can everyone pass; non-binary people cannot pass as cisgender as there are no cisgender non-binary people, and some people’s anatomy puts passing out of reach.
By changing a person’s appearance, hormones help trans people to pass as cisgender. This can alleviate some of the difficulties trans people face: it curtails misgendering, can reduce social anxiety, and decreases the number of opportunities for transphobic violence, discrimination, and harassment. Insurance coverage for hormone replacement therapy across Canada varies by province. My considerations will focus on the situation in the province of Québec, as it is the jurisdiction I am most familiar with. However, many of my comments will also apply to other provinces.
Passing is not a yes or no feature: people may pass in some contexts and not in others, and may pass or not in the same contexts at different times or to different people.
In Québec, hormone replacement therapy is covered under the basic plan established by An Act Respecting Drug Insurance, C.Q.L.R. c. A-29.01. The person is covered either through a private insurer or, if ineligible for private coverage, through the RAMQ’s Prescription Drug Insurance. Under the Act, the person’s coverage through a private insurer must be at least equivalent to the basic plan coverage. Thus, in Québec, hormone replacement therapy is, in theory, covered by insurance. In my case, I am lucky to have a private plan which covers the totality of my hormone replacement therapy costs.
Even when hormone replacement therapy is covered by insurance, other factors work to limit its access by trans people. First, it can often be difficult to obtain a prescription. Only a handful of doctors prescribe hormones on an informed consent basis, meaning without a letter from a psychologist. The waitlist to see those doctors (there seem to be around four in all of Montreal, based on anecdotal evidence) is often between six months to a year, and to this is added the weeks to months it takes between the first consultation and the writing of the prescription.
In the case of doctors who follow the World Professional Association for Transgender Health (WPATH) standards (who can also be fairly difficult to find), the individual must find a therapist ready to write a letter of referral. Those therapists are too few (though not as few as doctors prescribing hormones on an informed consent basis), have long waitlists, and often charge a substantial sum of money for consultations. Those costs can be prohibitive given the prevalence of poverty within the trans community. Trans individuals are more than four times as likely as the general population to have a household income of under $10,000 per year; 15% of trans people live under that household income, and 27% of trans people report a household income below $20,000 per year, a situation that is even worse amongst trans people of colour and trans people living with disabilities.
In addition to global hormone shortages, the prohibitive costs involved in seeking hormone replacement therapy threaten to deny access to trans Canadians who choose this treatment. || (Source: Teen Health Source)
Under An Act Respecting Drug Insurance, a coinsurance payment of 34% of the cost of the drug can be asked of trans people filling their prescription, up to a yearly total of $1,029 (sections 11, 13, and 27). Although in exceptional situations the coinsurance payment can be waived, coinsurance payments are the norm, and can be prohibitive to trans people in precarious economic situations. On the other hand, private plans which are frequently unavailable to less privileged trans people regularly cover the complete costs of hormones.
Many trans people fear that hormones themselves will be unavailable in the future. In the last few years, some forms of injectable oestrogen and testosterone have been in shortage. People I know have an extra vial of hormones reserved for them at their pharmacy, “just in case”, and many people report being unable to obtain injectable hormones. Different forms of hormones have different primary and side effects, and are not interchangeable, and switching to a different form is not possible or desirable for many due to potential adverse health effects. This constantly looming threat remains at the background of many of our minds, and contributes to a state of perpetual anxiety seldom absent from trans subjectivities.
Despite the presence of public prescription drug insurance in Québec, a number of barriers confront trans people who seek to obtain life-saving hormone replacement therapy. In this article, I have considered extra-legal barriers. In the companion article to this piece, I will consider the threat of delisting hormone replacement therapy from drug insurance under human rights law.