Rochester, NY: When Alexandra Chelf, her family, and their young son relocated in 2018, Alexandra could begin living as her true self.
“I tried to live as myself in Tennessee almost 15 years ago, and there were some horrible experiences,” said Chelf, who is a transgender woman. “Enough so that it forced me to stay in the closet for my safety and sanity, and it wasn’t until I arrived that I realized that life could be different.”
Four years ago, Chelf requested maintenance from the Transgender and Intersex Specialty Care Clinic at Mayo Clinic. For both of her rhinoplasty and visual feminization, which were performed five months off, she had back-to-back sessions.
Finally, in the summer of 2022, Chelf was informed that her vaginoplasty would likely be performed nine months in advance.
“My partner and I, we took that to the bank,” Chelf said. “That would have taken place in March of last year.”
Chelf called the TISCC to inquire about her scheduled operation in January 2023 because March was rapidly approaching and she had not been given a date for the procedure. She was then informed that she would have to wait nearly a year.
“They told me in January that it would be by the end of the year, by November, December,” Chelf said. “Everything came to a halt; for years there was a feeling of so much anxiety.”
Chelf worked to control her melancholy and met with her doctor twice weekly. Her vaginoplasty was finally scheduled, and completed, in December 2023.
“Recovery is going extremely with my clinics,” Chelf said.
The Transgender and Intersex Specialty Care Clinic at Mayo Clinic was founded in January 2015. Two years later, Mayo performed its second vaginoplasty. According to the Post Bulletin at the time, it was one of the primary methods of its kind to be performed in Minnesota. As of 2022, the TISCC had served near to 2,000 patients.
However, companies in states like Minnesota are facing higher patient load as many U.S. states enact legislation that restrict or ban gender-affirming care, especially for children. The river result: longer wait times for visits and therapies.
“I do love the people that I’ve been able to work with,” Chelf said. “They are just some of the best citizens at Mayo,” the statement read. “I think they’re really horribly understaffed.”
Increased need and access to transgender health maintenance
Gender-affirming wellness attention, as defined by the World Health Organization, encompasses the physician, emotional, social, and behavioral interventions used to recognize a victim’s gender identity. This might include hormone treatment, voice training, as well as procedures like top surgery (removing breast tissue to create a chest that looks more masculine) and vaginoplasty (creating a vagina).
A research published in JAMA Network Open final year found that there are more people receiving gender-affirming care than there are globally. In 2019, it increased from 4,552 surgeries to 13,011 in 2019. Moreover, the “overall number of health method encounters for gender identity problem rose from 13,855 in 2016 to 38,470 in 2020,” the researchers wrote.
According to the study, the rise in gender-affirming surgeries “is likely due in part to federal and state laws requiring transition-related attention, although exact insurance protection of certain procedures is adjustable.”
Throughout his 25 years of advocacy and community engagement for transgender health care, Phil Duran, director of advocacy and community engagement for Minneapolis-based Rainbow Health, has observed this.
“If a person was, typically, looking at something that was cost-prohibitive… if it’s going to cost you a million dollars, you’re not going to get it done,” Duran said. “However, if your insurance coverage is present, then you can go into the market to try to find it.”
With the rise in insurance coverage, particularly in the wake of the passage of the Affordable Care Act, “more clinics (that) opened up as a result, and more training programs are acknowledging the need to provide specialized education and experience for clinicians,” said Dr. Carl Streed Jr., a Massachusetts-based primary care physician and president of the United States Professional Association for Transgender Health.
Contributed/Dr. Carl Streed, Jr.
There are more people requesting services, but I believe it to be people who have already done so, according to Streed. “But now the services are actually available, so there is a bit of supply improvement, and therefore there is a demand to match the supply.”
According to the PFund Foundation, an estimated 30 hospitals and clinics in Minnesota currently provide at least some gender-affirming care. The majority of these providers are located in the Twin Cities area.
But, Duran said, there are even fewer institutions that offer surgical procedures.
“If you’re looking for surgery, you’re really limited to the U (M Health Fairview), Mayo, and, I think, Park Nicollet,” Duran said.
In the past few years, several U.S. states have implemented laws restricting access to gender-affirming care, particularly for minors. 23 states have passed laws that restrict access to gender-affirming care, according to the Kaiser Family Foundation. Among these states are Nebraska and Missouri, which are close to Minnesota and border North Dakota, South Dakota, and Iowa.
Some people have moved to states like Minnesota as a result of those restrictions, particularly after the state’s Trans Refuge law, which forbids other states from preventing people from receiving or providing gender-affirming care there.
At least 192 people and families have relocated to Minnesota or intend to relocate there for “trans refuge purposes,” according to a recent survey from Twin Cities Pride and the PFund Foundation. The majority of those moving to Minnesota are from Florida, Texas, Missouri, and Iowa, and 89% of those who asked said their top need was gender-affirming healthcare.
“As a result of these bans, people do move, and therefore we have a higher demand despite no change in the number of clinicians,” Streed said. “So that’s affecting wait times for a number of people.”
In a hearing before the Minnesota Senate Committee earlier this month, Dr. Angela Kade Goepferd, the program’s medical director, told lawmakers that the gender health program at Children’s Minnesota saw a 30% increase in new patients over the past year.
“These families are eyeing, hopeful that we’ll be ready to welcome them with open arms and provide them with the care they need,” Goepferd said during the hearing. “Unfortunately, our hands are already incredibly full.”
Waiting for gender-affirming care
A Mayo Clinic spokesperson said the hospital was unable to hold interviews with TISCC team members before the deadline when asked about appointment and procedure wait times at the TISCC.
“Our teams work together to develop personalized solutions that address each of our patients’ unique needs,” according to a statement from Mayo Clinic. “The best way to make a patient and the care team a decision is to make one.”
Other transgender community members who are young adults just starting their care journey have heard from Chelf as a member of a local queer support group.
“Some of them were recommending five to seven months at the TISCC clinic just to be seen and the process started,” Chelf said. “Then (see an) endocrinologist and blood work, and it’s two to four months before you’re starting any medication.”
Chelf has also heard from her fellow patients that the waitlists for gender-affirming facial surgery could last as long as four to six years.
“It made me feel very strongly about how some others were having to wait even longer than I did,” Chelf said. “I suppose, to some extent, I got a little lucky with my timing of getting into the clinic, (but) it still can take about three to five months to get in with a social worker if I need to do follow-ups or catch-ups.”
When it comes to the expected wait time for surgery, Streed said a year is “fairly standard”.
“It’s all about managing expectations,” Streed said. “And I’m never able to predict that it’ll occur as quickly as anyone wants. It’s not as fast as I want, it’s not as fast as the surgeon wants, and it’s not as fast as the patient wants.”
Training medical providers
Although there is a pressing need for more gender-affirming care providers, it is not unusual in the US healthcare system, according to Streed.
“I would argue that there is no form of care that is currently sufficiently provided in the states,” said Streed. “We also have a significant shortage of primary care physicians and a significant shortage of those who have received training and feel comfortable providing transgender people with medically necessary care.
Surgeons who want to specialize in genital surgery or other gender-affirming procedures frequently have to look for additional training outside of medical school and residency programs to learn how to carry out those procedures. These specific surgeries can be different for trans patients, even if there’s a similar procedure used in another context, Streed said.
“For example, a double mastectomy is not the same as doing chest contouring for a transmasculine individual,” Streed said. “There are various surgical strategies and objectives that involve the removal of breast tissue and chest shaping to make it appear more masculine. It’s not the same as what happens, for example, for a lot of surgeons who have received training to do mastectomies with regards to oncology.”
Streed claimed that there are efforts being made to increase the number of providers providing gender-affirming care in the United States, but “that’s a very slow and long game.”
In order to expand Minnesota’s gender-affirming healthcare workforce, some state lawmakers have proposed allocating money for training. If passed, companion bills SF 3502 and HF 3386 would provide $1 million to the PFund Foundation to be distributed as grants to medical institutions to train seven doctors in gender-affirming care.
“We’re trying to get funding so these hospitals and clinics that have this expertise of care can start imparting that knowledge on other providers, doctors, etcetera around the state,” said Aaron Zimmerman, executive director of the PFund Foundation.
Additionally, the foundation is attempting to create a system navigator for patients who are looking for this particular kind of medical care.
“That can help say, ‘Hey, Children’s has a really long waitlist, why don’t you try getting on the waitlist at North Memorial? They’ve got a much shorter wait time to see a doctor,'” Zimmerman said. “More of that coordination and mapping the constellation of different providers and what kinds of needs might someone have.”
