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I’ve been thinking a lot about what it means to live in the US and witness the blanket ban on puberty blockers for trans young people in England and Wales. Thread….
In the US, where medicine is deregulated, no-one can imagine a blanket, national ban on doctors prescribing a medication. Some of us might think that means a privatized, deregulated health system is a better alternative – that it offers a way to sidestep anti-trans institutions.
(Someone tweeted this take recently and I was kind of aghast, which is why this thread. Now I can't find the tweet though!)
Please know that the US system is no better. We access that "freedom" because of the structural violence of having an underfunded and punitive public health care system. Because trans people are more likely to be under the poverty threshold, a LOT of us are on Medicaid.
Until very recently, trans health care was routinely denied by private insurance companies and Medicaid alike. The ACA builds in protection for coverage of trans health care by including an anti-discrimination clause (Section 1557) and defining gender identity under “gender”.
Before that, it was routine to have hormone therapy denied by insurance (it still is, and people just fight it). Very few people got surgical procedures covered by insurance at all. If you did, the gate-keeping procedures were legion: real life test, many surgery letters, etc.
But ACA non-discrimination doesn’t necessarily apply to Medicaid! States control Medicaid funds, and some states specifically exclude Medicaid funds from being used for trans affirming care. Many states exclude Medicaid coverage of trans affirming care for anyone under 18.
Also, in many states Medicaid-funded systems are deliberately underfunded and have long waiting lists. Like all US health care, publicly funded hospitals and clinics are rife with medical racism and punitive or regulatory treatment for poor people and BIPOC people.
So how does anyone poor get care at all? Enter Part 3 of the health care system: free and low-cost clinics. These have a long history: the Black Panthers and Young Lords’ free clinics, Indigenous health clinics, women’s health centers, HIV/AIDS clinics, sexual health, etc.
Free and low-cost clinics are great, but they aren’t universal. Because orgs like Planned Parenthood provide services like abortion and contraception, the far Right targets them. And free/low-cost clinics depend on donors or liberal states’ funds. So they're not everywhere.
TLDR: if you’re poor and trans in the US, you may not have many options available. Or you may have none. You may have to move to a different city to access health care. This especially applies to young people, Black, Indigenous and trans people of color, poor folks, sex workers.
Trans kids in the US can maybe access puberty blockers if their parents get them to a clinic that provides such care, and IF it is covered by insurance. That is, IF THEY HAVE MONEY AND TIME.
So if you live in the US, please do not heave a sigh of relief and think, "This can't happen here!" I haven't even begun to talk about the GOP waging war on all of these provisions: Medicaid, the ACA, Planned Parenthood, trans health care specifically.
Those wars will not go away. But we can fight for low-cost, universal health care for everyone, and build universal trans affirming care into that model. Universal health care does not necessarily mean trans exclusion. Historically, it has meant that -- but times are changing.
We lose something when we only look at the losses. The UK case is yet to be appealed. And I think we are also limited by looking exclusively at the UK and North America. We need to envision the dreamiest, most universal trans health care models possible.
I think a lot of this is preaching to the choir, but maybe it's useful as a history lesson. Also the US health care system is so complicated! It took a long time for me to understand it for real, as an immigrant experiencing it and as a health care scholar.
