More Breast Reconstruction Thoughts

insurance, flashy TikTok surgeons vs serious pro surgeons, weird physical feelings

photo credit: The Met. Mrs. Grace Dalrymple Elliott, Thomas Gainsborough

As I posted in last week’s essay, I got breast reconstruction surgery last week. A combination of recovering from surgery and also my toddler’s morning school ceasing for the summer (my precious writing time!!!) has meant that I struggled to put together something very coherent this week! Whoops! I hope you won’t begrudge me a chattier, more informal post this week.

Recovery Is Weird

Part of what was so terrifying about trying to get surgery is, of course, that you can’t get your old body back. You can get a new experience: implants! It’s been weird to adjust to. I got under-the-muscle implants, under the muscle because there’s no breast tissue to keep the implants from sliding around. They feel extremely bizarre, like little… stress balls, or squishy dinner bowls, under my skin. My chest feels very tight and weird (this part, I’m told, will get better as the muscles relax and stretch for their new reality). When I’m showering, the sensation of the water on the skin over the muscles over the implants is very alien.

But this isn’t my first shocking change of physical state. I’ve been through this rodeo before in a certain sense. I know that I’ll adjust to some extent.

And there’s one good thing that struck me right away: I like how I look in clothes! I feel like the old me, which is weird. I think I’ve lived longer post-top-surgery than I had post-puberty. But I guess I never stopped feeling bad when I looked in the mirror, like that chapter of my life was still haunting me. And now I don’t have that painful visual reminder.

So that’s good.

But if there’s a horrible complication, I will certainly be kicking myself.

I will write out a more comprehensive analysis later, when I have really lived with it. I don’t want to declare it a success, or a failure, or anything until a lot more time has passed. So right now, let’s just call it weird, but cautiously: good, I think.

Insurance thoughts
The first time I called my insurance to see if they would cover breast reconstruction, it was not long after the initial surgery. I described my situation to the phone operator. She sounded unhappy with me. As I remember it, I tried to ask her, and, in a bored and unhappy tone, she told me they couldn’t cover trans reversal surgeries. I started to ask if that was really right, or something like that, and she actually said “No” and hung up the phone.

I was very shaken up by this. Maybe this makes me sound kind of like a weenie, but I didn’t bother trying again for many years. I just felt so stupid. The “no” was so definitive. And it was a big change from the first go-round, where there were clinics set up with soothing, affirmative clinicians, where everyone’s responded to your Gender Journey in hushed tones. Where all the insurance went through without a hitch. And it’s not that I blame them. We were all in it together, back in 2017 or whatever - everyone was excited to be affirming and were working stuff out.

Well, things have changed a lot since then. I remember when I posted about this on twitter, some people were like “healthcare costs are already THIS HIGH and now you want to add insurance for surgeries BACK AND FORTH?”

And look, I get it. But also, it really fills me with some rage. You think I’m doing this for funsies? And also, more selfishly: so much of insurance spending is for things that are, at least partially, due to lifestyle choices. If you break your leg skiing, they don’t say, “Okay, no insurance for you, skiing is known to be dangerous.” Why draw the line at detransition?

I think it would be reasonable that, if transition surgery continues to be considered medically necessary, detransition and reparative surgery does too. I also think it would be reasonable to establish some gatekeeping on either side.

Good Surgeons Vs Bad Surgeons

One thing I liked about my surgeon is he wasn’t much of a salesman. The woman who did my first surgery, was super flashy, always making TikTok’s of herself flouncing around in dresses and joking about cutting boobs off and such. My new surgeon was a serious guy, very no-nonsense, kinda gruff. Yet his walls were encrusted with awards and professional accolades. I’m not some surgery connossier, but I felt like I was in more serious hands. He didn’t hit me up afterwards to ask to use me for promotional material on his instagram, either, unlike my top surgeon. I liked him. If you’re a detrans women in the NYC area looking for a recommendation, hit me up for details. I’m not going to post his name because I don’t want him to be punished for his good deed of helping me out.

Breast Reconstruction Coverage Is Weird

The Women’s Health and Cancer Rights Act, or WHCRA, put into law that any insurance company that covers mastectomy must also cover reconstruction. As the name suggested, the law was created to ensure women who get mastectomies for cancer prevention can access reconstruction. Yet this document provided by the US Department of Labor specifies:

Despite the title, nothing in the law limits entitlement to WHCRA benefits to cancer patients. If an individual is receiving benefits in connection with a mastectomy and the group health plan covers mastectomies, then the individual is entitled to WHCRA benefits.

Also, despite the title, nothing in the law limits WHCRA entitlements to women.

What’s interesting to me about WHCRA is how it came about: A 32 year old woman had a mastectomy and her insurance refused to cover reconstruction. Her plastic surgeon did the procedure for free , but he was so outraged that he started a quest to make sure any insurance that covered a mastectomy would cover reconstruction.

It’s one of those questions. It’s not exactly medically necessary for like, basically survival, in the sense of like, your knee being replaced - right? But then I guess it’s just considered so psychologically important that it was made medically necessary.

So, in theory, this should be covered by insurance that covers mastectomies, and available to detransitioned women who are seeking reconstruction. In theory. In practice, that doesn’t always work out. But, as times change, it seems like it’s becoming possible again.

When I started talking to doctors again more recently, most of them expressed that they hadn’t seen as many cases for reconstruction and they would have to just submit the insurance pre-authorization and see what happened. And, as it turned out, we got the authorization.

I’ve been keeping my ear out on the topic. I’ve talked to some different detrans women who got reconstruction covered. I’ve also talked to some who were not able to get it covered, and paid out of pocket. These are just anecdotes, of course, but I think it shows how piecemeal and disconnected the landscape is for reversal surgeries for detransitioners. Could the surgery perhaps be billed as another sex-change surgery, once again, to combat gender dysphoria? Does the WHCRA law apply to it?

On the other hand, Medicaid in several states explicitly forbids reversal surgeries from coverage (12, as of 2022 according to this study). As another very anecdotal point: I remember hearing some women telling me their private insurance specifically forbid reversal surgery a few years ago. A lot might have changed since then, though, as detransition advocacy makes more of an impact.

As an additional note: I don’t really know much about other types of reversal surgeries, and if they might be covered by insurance. I think some recent bills have been introduced to try to ask insurance to cover them, but it’s a politically spicy topic and really varies by state and provider. Will electrolysis and shaving down the vocal cords be covered for detrans women looking to undo the physical changes of testosterone? From my informal knowledge of the field, I don’t think so, but please let me know if you’ve heard anything to the contrary.

Anyway

Sorry for being so informal and disorganized here. I’ve been running on fumes a little - partially from the surgery, which happened last Monday at 4am, but truthfully also because of the playoffs, which happen at 8:30pm which is a crime against parents everywhere. Anyway, go Knicks, and I’ll see you next week, hopefully with something a little more coherent.