For Transgender Women, an Extra Dose of Fear

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Abbie Paige began transitioning from male to female seven years ago. Since then, she has had electrolysis, hormone therapy, a neck lift and breast augmentation.

In April, she had an orchiectomy or the removal of her testes, which stops the production of testosterone, which makes hormone management easier and curbs the growth of body and facial hair. She also had a vaginoplasty, changing her genitalia from male to female

The surgeries were important for both her psychological well-being and physical safety, she said.

“The political climate is a catalyst to our danger,” said Ms. Paige, 58, who lives in Lake Worth, Fla., and is a buyer for a company that manufactures ventilation systems for ships. “Generally, people want to see you as male or female. Nothing in-between seems to be acceptable.”

Her partner Eveline Carr, also a transgender woman, feels similarly. “All it takes is one guy to be attracted to you, and feel embarrassed because of it, and you can be assaulted or killed for ‘tricking’ him,” said Ms. Carr, 59, a tech writer in Lake Worth, Fla. “I can’t deny that presenting female is important to my safety.”

In an era in which protections allowing transgender students to use the restrooms they prefer have been rescinded and 14 transgender people have been murdered so far this year, according to the Human Rights Campaign, an L.G.B.T. rights advocacy group, many transgender people say they feel increasingly unsafe, and that “passing” is necessary for survival.

So far, 19 states and the District of Columbia have put strong nondiscrimination policies in place for transgender people. But “now we’re seeing this pushback,” said Jaclyn White Hughto, a research fellow at the Yale School of Public Health who specializes in transgender health. “It’s the belief that the violence is a response to the more progressive agenda to protect transgender people.”

A 2015 report from the National Center for Transgender Equality that surveyed nearly 28,000 transgender adults from across the United States found that one in 10 reported being physically or sexually assaulted, and 46 percent had been verbally harassed in the past year.

“These experiences are not just restricted to transgender individuals living in more conservative areas of the U.S.,” Ms. Hughto said.

In 2016, advocates tracked at least 22 murders of transgender people in the United States, the highest number ever recorded, though numbers on transgender violence tend to be unreliable since many cases go unrecorded. “We lack systematic data collection within the U.S.,” said Jody L. Herman, a scholar of public policy at the Williams Institute, a research center at the U.C.L.A. School of Law.

“I’ve met many transgender patients who have faced horrific challenges to societal acceptance, from discrimination to violence,” said Dr. Rian Maercks, the Miami plastic surgeon who performed some of Ms. Paige’s and Ms. Carr’s surgeries. “When their femininity or masculinity is natural in appearance, it protects them from the traumas they may otherwise experience.”

A possible repeal of the Affordable Care Act also adds to the urgency for many transgender people. The act made it illegal for health insurance companies to refuse coverage to patients with pre-existing conditions, and before it took effect, many carriers denied insurance to transgender people, citing “gender dysphoria” as a pre-existing condition.

Still, the Affordable Care Act has not been without its problems for transgender people, who have “all sort of related health issues that are exacerbated by discrimination,” said Kellan Baker, a senior fellow at the Center for American Progress.

In a perspective piece in the New England Journal of Medicine, Mr. Baker noted that while the Affordable Care Act made it illegal to discriminate on the basis of sex or gender identity, it does not require health plans to cover any particular service. Rather, “it prohibits plans from excluding a service related to gender transition for transgender people when the same service is covered for non-transgender people,” he said. So, for example, a carrier could not deny coverage for a mastectomy or hormone therapy for a transgender person if it would cover the service for a non-transgender individual with breast cancer or an endocrine disorder.

Insurance companies often refuse to provide coverage for many surgeries, like facial reconstructive procedures or breast augmentation, because they are thought to be cosmetic and not medically necessary. The 2015 transgender equality report found that 25 percent of the nearly 28,000 respondents had experienced a problem with their health insurance, including being denied transition-related coverage or routine care because they were transgender. Fifty-five percent of those who sought coverage for transition-related surgery and 25 percent of those who sought coverage for hormones were denied — a much higher rate than the typical rate of all claim denials, said Mr. Baker.

“Transition-related health care is not consistently covered in health care plans,” said Dr. Herman of the Williams Institute. “Health insurance is a bit of a patchwork in the U.S., and the states have control over regulating private plans that are sold within the state, as well as their own Medicaid plans.”

Karissa Sanbonmatsu, a transgender woman and structural biologist at Los Alamos National Laboratory, saved for 10 years to have a variety of procedures, including gender reassignment and breast augmentation surgeries as well as laser hair removal. She also had facial feminization surgery with Dr. Toby Mayer, a facial plastic surgeon in Beverly Hills, which encompasses everything from rhinoplasty to a tracheal shave, which reduced the size of her Adam’s apple.

The treatments cost about $100,000, and insurance did not cover it. “It’s not about vanity,” Ms. Sanbonmatsu said. “It’s about passing, and in some cases it can be for physical safety. It’s the same reason 90 percent of trans women I know won’t leave the house without hair and makeup.”

Jordan Bell, a 31-year-old technology director at a film studio in West Hollywood, began transitioning in February 2014. In November, she underwent a series of procedures, including brow contouring, a lip lift and chin augmentation with Dr. Mayer. It cost about $29,000, which she paid out of pocket.

“The uncertainty of the current political climate played a large part in my decision to have facial feminization surgery,” she said in an email. “Since my surgery, I have felt an enormous weight lifted off of my shoulders.”