In the first year of the pandemic, Liam Magan, 28, decided it was finally time to get gender-affirming surgery. Magan researched medical centers, made appointments with doctors and surgeons and got authorization from his health insurance company. But over a year later, he’s still waiting for a hospital bed to open up.
Transgender people in New Hampshire have long faced delays in getting gender-affirming care. But the standstill in many non-emergency surgeries for the last two years means the wait times are growing even longer.
How the pandemic has affected trans health
Not all transgender people turn to hormones or gender-affirming surgery to medically transition. But for those who do, access to gender-affirming providers and outpatient and inpatient services are essential.
Hormone therapy – estrogen or testosterone – helps people's bodies align more with their gender identity. Because this is administered at home after initial doctors' visits, hormone therapy is largely still available during the pandemic.
Top surgery – removal or augmentation of breast tissue – has faced some delays during COVID surges, but many people are still able to access them as one-day procedures. At Boston Medical Center, the number of these procedures has risen incrementally, even during the pandemic.
But more complex gender affirmation surgeries – such a vaginoplasty, the construction of a vagina, or phalloplasty, the construction of a penis – require multiple stages and can involve overnight stays.
And there are only a few New England medical centers offering comprehensive care – including surgeries – for trans people. Both Boston Medical Center and Dartmouth Hitchcock Medical Center report seeing interest that outstrips their capacity during the pandemic.
Palana Hunt-Hawkins, a trans activist in Rochester, suspects the demand for gender-affirming care is a product both of growing acceptance and visibility of trans people, and of a shift for some trans people during the pandemic.
The isolation and stakes of the pandemic, Hunt-Hawkins said, clarified the urgency of medically transitioning for some trans people.
That’s what happened for Liam Magan.
“I always thought: ‘Okay, I'm not going to really deal with the dysphoria I have in that region until it becomes a disrupting issue,” he said.
But stuck at home, Magan and his spouse began talking about his options more. He started researching options and connecting with other transmasculine people on TikTok and Reddit.
When he decided to move forward with surgery, the first step was getting a hysterectomy. But when the omicron variant ripped through New England, the first step of Magan’s process got indefinitely delayed.
Mental health consequences of delayed care
Health insurance companies and hospitals often view aspects of these surgeries as elective or cosmetic, in spite of evidence that delaying gender-affirming care can have profound mental health consequences for patients.
Dr. Oakland Walters, who works at Dartmouth-Hitchcock’s Transgender Health Clinic, says these delays can lead to increased anxiety, depression, substance use disorder and suicidal ideation for transgender people and those living with gender dysphoria.
Walters says that New Hampshire’s mental health care shortage, which predates the pandemic, means many of his patients don’t have access to gender-affirming mental health providers in general. And that's even tougher when they're having to cope with disruptions to their medical transition.
When delays reach a certain length, health insurance approval for surgeries that require prior authorization can lapse, Dr. Walters said. And patients have to start the process all over again.
“As a psychiatrist, practicing and seeing lots of transgender and gender diverse people - in my mind, the [surgeries] are more of medical necessity,” he said.
Magan says life after gender affirmation surgery could be the first time he’s able to live in and be aware of his body without profound discomfort.
“To call something like this elective makes it seem like I'm just laying around like ‘What do I feel like doing tomorrow? I feel like getting a penis,’ No. I've been thinking about this for probably my entire life,” he said. “It's a big deal.”
Online and in-person resources expanding in New Hampshire
During the delays, many have turned to Zoom and other online resources to connect.
Liam Magan has joined a Facebook group of others who are in line for a phalloplasty at Massachusetts General Hospital. The group offers advice on preparation and recovery from the procedure and support when procedures get delayed.
He also posts videos and information about medical transitioning on TikTok, where some of his videos have received over a million views.
The Center for Transgender Medicine and Surgery at Boston Medical Center, which use to facilitate support groups in person, has resorted to Zoom.
A new group, the Gender Diverse Care Coalition NH is developing resources for providers and for people who are seeking gender-affirming medical and mental health care.
And the Transgender Health Clinic at Dartmouth-Hitchcock is expanding outreach and support services for patients in New Hampshire and Vermont. Program manager Emmett LeBlanc is connecting patients who are waiting for a first appointment or facing delays in surgery to Facebook groups and local PFLAG chapters and gender-affirming mental health providers.
LeBlanc says connection online has been essential for people in the pandemic, especially those living in rural areas or far from other trans and gender non-conforming people.
The conversations range from specifics about surgery to what businesses in New Hampshire are trans-friendly.
“Maybe they're just looking for somewhere where they can go and get their hair done where they're going to feel affirmed and respected,” he explained. “Even things that may not necessarily be directly related to surgery – they're going there to find information about experiences others have had to support other aspects of their transition while they're kind of in this waiting period.”
