[J]essica Oski’s 15-year-old son did not formally begin to live as a boy until 2018 — but “as soon as he could communicate,” his mom said, he identified as male.
In response, the Oskis have spent the past decade navigating Vermont’s support network for transgender youth. Their son got counseling from an early age. He saw all the appropriate doctors. The family joined support groups. When the time came, the Oskis travelled to Springfield, Massachusetts, to get their son a mastectomy.
Throughout the transition process, the Oskis faced a handful of high-frequency roadblocks. Jessica recalls the parents in her support group bonding over familiar themes: the difficulty of finding clothes, for one. There’s the lack of gender neutral underwear, especially for families who can’t afford Hanna Andersson’s organic $6-a-pair offerings. And of course, there are the problems around public bathrooms.
“Every parent of a trans kid, or a gender nonconforming kid, has the most horrendous stories about using public restrooms,” Oski said with a laugh.
But there was one common challenge — one discouraging, frustrating, normal part of transitioning — that the Oskis didn’t face.
“Blue Cross and Blue Shield of Vermont was incredible,” Oski said. “The first time I was on the phone with this woman, Colleen Sanford, at the end of the conversation, she said, ‘How are you doing with all of this?’ I was like, what? Are you kidding me? My insurance person is asking me how I’m doing with all this? It was just really a different experience than you normally have when you’re talking to your health insurance company.”
According to Oski, the family had no issues getting coverage for their son’s medical transition. Sanford is BCBSVT’s dedicated specialist for transgender people seeking treatment, and she worked with the Oskis every step of the way.
Other insurance companies, however, do not share BCBSVT’s approach.
“There are some other private insurance agencies who I’ve heard not such great things about, where there’s constant struggles,” Dana Kaplan, executive director of the LGBTQ youth advocacy group Outright Vermont, said.
In recent months, the state has increased its emphasis on combating those coverage inequities. In the 2019 legislative session, 59 Vermont representatives co-sponsored a bill that would have barred age minimums for receiving care. The bill never made it out of the House — but two proposed changes to state rules could pave the way for expanded coverage.
The first proposed change is to Medicaid, which may soon cover surgery for youth under 21.
The second change is an update to state bulletin 174, which clarifies the purview of a Vermont anti-discrimination law. The bulletin now specifies that private insurers cannot refuse to cover gender affirming surgery on the basis of age.
Between the two updates, it may be easier than ever for teens to access affirmative medical procedures. The advance will move Vermont’s trans community one step closer to full access to gender-related health care.
The updates aren’t an end to the effort — but advocates say that they’re a help.
“I’m just thankful that Vermont is willing to set aside fear and misinformation in order to do what’s right for kids,” Oski said.
State rules
Vermont’s earliest gender-based anti-discrimination law dates to 2007, when Vermont added “gender identity” to its list of protected categories. The rule states that gender is not a legal basis for unfair differential treatment from employers, landlords, or schools.
Six years later, the Department of Financial Regulation published bulletin 174, a document that clarifies that Vermont’s anti-discrimination law applies to private health insurance. In mid-June, the department updated the bulletin to specify that coverage cannot be restricted on the basis of age.
The announcement came less than a month after the Scott administration proposed the elimination of a minimum age for gender affirming surgery under Medicaid. The change will be open for public comment until July 17, after which point it will be revised and voted upon.
Department of Financial Regulation Commissioner Michael Pieciak said that, while the timing “dovetails nicely,” his department did not update the bulletin because of the proposed Medicaid change. Instead, two recent complaints from trans youth and their parents spurred the department to clarify its position.
“Once we received these complaints, it was clear to us that there was some confusion within the industry,” Pieciak said.
Dr. Erica Gibson, a pediatrician at UVM Children’s Hospital and the medical director of the hospital’s Transgender Youth Program, said she and her colleagues advocated for the Medicaid updates because they felt the old policies were not based on advice from clinical professionals.
“We felt that we had very productive meetings with Medicaid,” Gibson wrote in an email. “They have been responsive and we are happy with many of the adjustments they have made to their policy.”
According to Pieciak, around 53% of Vermonters use private insurance, placing them under the bulletin’s jurisdiction. Another third use Medicaid. It appears likely that updates to both groups will soon go into effect — granting most Vermonters guaranteed coverage for affirmative surgeries.
State resources
While the updates will increase trans youth’s access to coverage, the availability of medical interventions does not mean that surgery is the only — or primary — option. Instead, doctors and advocates say that the new rules render surgery one more possibility for teens experiencing dysphoria.
According to Kaplan, it is important to “debunk the myth” that all trans youth follow the same process. Surgery is the right answer for some, while others may benefit first from a social transition or hormone therapy; trans people come out at different ages, and in different situations, and within different social circles.
“We think about things like, do they have an accepting family? Or do they have a supportive adult? Are they connected to other resources? Do they live rurally or not?” Kaplan said. “So it’s really a case by case basis in terms of what that process looks like.”
Gibson, too, spoke about the complexity of caring for transgender youth and their families. But she added that there are some best practices — derived from the Endocrine Society of America and the World Professional Association for Transgender Health — that the Vermont medical community generally follows.
The first step for children who have not yet gone through puberty, Gibson wrote, is often a “social transition.” Transitioning socially frequently entails coming out as transgender, changing a name or pronouns, and dressing as the gender that one identifies as.
Jessica Oski asked that her son’s name not be used in this story. However, in a text message shared with VTDigger, he said he was fine with the use of photos of him.
For the Oskis, Outright Vermont helped facilitate their son’s gender exploration as a young child — well before he began any medical interventions. Jessica brought her son to the program’s Gender Creative Kids group starting when he was 6 or 7, and she said that she appreciated the community it brought to the family.
“It was great,” she said. “It was so great to be with other families and to hear other families’ stories.”
But for many trans youth, social support systems can only go so far. For people experiencing “consistent, insistent, and persistent” gender dysphoria, hormones and surgery are a medically necessary next step.
Gibson clarified that young people are not eligible to begin medical transitions until they have started puberty.
“The first option available for a young person who is just entering puberty is a blocker that can pause puberty,” Gibson wrote. “This is helpful for a young person who might be traumatized by further anatomic development that does not fit their gender identity.”
The proposals the state is considering to eliminate age minimums do not mean that kids would begin medical interventions earlier than Gibson’s best practices suggest.
Medicaid still does not cover surgeries for youth — or anyone else — until they have gone through some of the steps that the Transgender Youth Program outlines. Prospective surgery recipients must have a diagnosis of gender dysphoria, written evaluations from mental health professionals, one year of living as the gender they identify with, and documented consent from parents for minors.
Under Medicaid, genital surgeries also require at least one year of hormone therapy. Because children are not prescribed hormones, the requirement functionally prohibits prepubescent youth from getting certain surgeries.
Gibson added that hormones and surgery are a step that doctors take carefully, and only after extensive conversation and several consent forms. She wrote that a patient and their family may start gender affirming hormone therapy as early as age 14, “if the full support team feels that is an appropriate next step.”
Pieciak said that eliminating an age minimum will allow doctors like Gibson to freely determine what is best for their patients.
“I do think that our bulletin makes it clear that we’ve leaving it to … medical professionals,” Pieciak said. But once doctors have fully evaluated the youth in their care, he added, “there cannot be an arbitrary age limitation as to who qualifies for care.”
The impact
According to Jessica Oski, a lobbyist, the family was lucky. They had good insurance. Living in Burlington, they had access to a community. Gibson, whom Jessica called “fabulous,” was their pediatrician.
But others have had problems accessing similar care. The new updates are a response to past failures — and an attempt, advocates say, to keep those failures from repeating themselves.
According to Gibson, before the Transgender Youth Program began in 2016, “young people and their families had to travel to Boston Children’s Hospital for transgender care.” But even with today’s increased in-state awareness, the Oskis still traveled to Massachusetts for their son’s mastectomy.
They tried to get treatment in Vermont, but they were told that the doctor to whom they had been recommended would not help people under 21. And for the providers that do operate in Vermont, insurance has posed a consistent problem: Oski and Kaplan alluded to issues that, they said, seem endemic to certain companies.
The updates may ameliorate some of that problem, but it is hard to predict their exact impact. According to Department of Vermont Health Access communications director Nissa James, less than 1% of Medicaid members have a diagnosis of gender dysphoria in any given year. In the past five years, seven to 23 Medicaid members annually have had claims for gender affirmation surgery.
“Estimates for increased utilization remain variable as they are dependent upon a number of factors,” James wrote in an email.
But if even a few teenagers utilize the new coverage, then the number of people receiving gender affirming surgery in Vermont will increase — an opportunity that Oski said is very literally a matter of life and death.
“The data is that trans kids have a dramatically higher rate of attempted suicide, and suicide, and depression,” Oski said. “Access to treatment for the medical condition of gender dysphoria, to prevent self harm or other negative outcomes, is really important. It’s medically recognized as a treatment.”
As for her son? His mastectomy went well. Right now, he’s visiting Vietnam and “very confident.” He made the trip with a female passport, which made his mother nervous, but everything appeared to go fine.
“He got there, and he’s now living there as a boy, a young man,” Jessica said. “But yeah, he’s great. His surgery was fabulous. We had great care.”
And with policy changes, advocates hope that others will soon have similar success stories.
