Why Medically Transitioning Is a Privilege of Location

For many trans folks, medical care is just too far away.

Thinkstock / megaflopp

When I realized that I was trans earlier this year, I understood that I had two choices: transition or don’t transition.

For some people, the latter option is totally viable. They can live their whole lives knowing that they are transgender without feeling fussed to present as the gender that they identify as. For other people, like me, the real choice that has to be made is much more macabre: transition to some degree socially and medically, or die. Only problem is, the ability to make that life-saving choice depends heavily on where you live.

Dysphoria, which is the felt-incongruence between immutable gender identity and anatomical configuration or aesthetic, had quietly plagued me for all of my 23 years. It was the source of my depression and anxiety. It fed my toxic masculinity, pushing me to double down on my manhood in an attempt to fulfill the role that I was assigned at birth. Once I understood what transitioning entailed, I knew that I had no choice but to pursue the process, because the alternative—living as a man, hating myself and feeling devoid of identity and purpose—would be the end of me.

I was living in West Virginia when I realized I was trans, and whatever you know about West Virginia, I can promise you one thing: It is not an ideal location to transition. I feared my family might face violent persecution if I were to attempt it, so for a number of months I pretended to be a man’s man to protect the people that I love—and it was extremely distressing.

Even if West Virginia’s intolerant culture wasn’t a factor, though, the resources available in the area are just shy of nonexistent. I lived nearly two-and-a-half hours from Charleston, the only place that I might be able to see a therapist to discuss my dysphoria. If I committed to six to 12 months of weekly five-hour roundtrip visits to a therapist, they might write a note affirming my dysphoria that I could then take to an endocrinologist to begin hormone therapy—after being put on a months-long wait list.

I had finally discovered who I was, and what was wrong with me, and yet I could do nothing to fix it. I despaired at the notion of not being able to transition for the foreseeable future, and in my anguish I even considered purchasing the necessary medication illegally on the internet. I decided against this, but there are many trans people who are left with no other options because of the lack of resources available where they live.

Owen, a 20-year-old trans man who lives in West Virginia, encountered the same scarcity of resources that I did.

“When I first started questioning my gender identity, I was already in Charleston for the summer,” he said. “I couldn’t find any therapists in Charleston that would take on people with gender identity issues. I drove two-and-a-half hours to Morgantown to see someone a few times over the course of a month … [but] I had to stop seeing her after my Morgantown lease ended, and I’ve been in Charleston since.”

Owen has been pursuing the first step of transitioning—hormone replacement therapy—for over three months. Due to the limited local options, however, he hasn’t had a lot of luck: Since May, he’s been on the waiting list of the only endocrinologist nearby that will treat transgender patients and won’t be seen until the end of the summer.

Still, like me, Owen knew right away that transitioning was the only course of action for him.

“My main goal was to be out and hopefully on hormones by the time that the semester started … it was very difficult because, although I know that this happens all the time for doctors, I didn’t think it would be such a long time-period of just waiting. I felt like I had nothing I could do during this time-period.”

Alice, a 23-year-old trans woman living in Tennessee, had a similar experience.

“Being the only trans person I knew in my area at the time, it was pretty difficult. There were no real local resources I could find, aside from some iffy, outdated information online, and a lot of the people I talked to—including my therapist then—had no real clue what being trans was or meant. I had to do a lot of legwork figuring everything out basically on my own, and with the help of online friends who lived pretty far away.”

Once she realized that she could transition, Alice felt that she had no other choice.

“As soon as I understood that I was trans, and that transition was an option open to me, I knew there was no going back. Honestly, I didn’t even consider the alternative until much later.”

Alice also had to pursue transitioning away from home, necessitating a two-and-a-half hour drive to a clinic in Nashville, Tennessee, that operates on an informed consent model.

Informed consent is exactly what it sounds like: The patient reads documents about the medication that they’ll be prescribed, signs a liability waiver, and is written a script. This is the easiest means of starting hormone replacement therapy, given that it does not require the often lengthy process of obtaining a therapist’s recommendation.

Alice, Owen, and I were fortunate enough to have some resources with which to pursue our transition. Unfortunately, there are many trans men and women that don’t have any of these opportunities—and for those people, the absolute need to transition and the inability to do so due to their location can be unbelievably distressing.

If we’re going to reduce the staggeringly high suicide rate of trans people, increasing the availability of transitional resources nationwide is an absolute must. Doctors and mental health professionals need to be taught to adequately care for trans patients, and gatekeeping needs to become a thing of the past—it’s the only way we’re going to move forward.