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Hawaii just expanded gender-affirming care for trans residents

The new law clarifies that treatments insurers had deemed ‘cosmetic’ should be covered as long as a medical provider deems them medically necessary

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In 2016, Hawaii took a seemingly small but significant step forward for its transgender and nonbinary residents: The state passed a law barring insurance companies from discriminating against residents based on their gender identity. But in the years since the anti-discrimination law, trans residents, advocates and lawmakers found that it hadn’t done enough — people were still being denied coverage for gender-affirming care.

On Thursday, Hawaii Gov. David Ige (D) signed a bill into law that clarifies certain treatments insurers had deemed “cosmetic” — such as laser hair removal, voice therapy and facial feminization surgery — should be covered as long as a medical provider deems them medically necessary. The legislation, H.B. 2405, would also require insurers to give patients clear information about which gender transition services are covered.

“The bill is key to protecting people from discrimination in accessing gender-affirming treatment,” Ige said at a signing ceremony, Honolulu Civil Beat reported. The governor also signed two other bills expanding LGBTQ protections in state: one that bars people from being excluded from juries because of their gender identity and expression, and another establishing a commission that will examine the status of Hawaii’s LGBTQ residents.

The health-care bill, which was crafted with input from health-care providers, trans advocates and insurers, passed with overwhelming support in both chambers of Hawaii’s legislature. The law went into effect immediately on Thursday.

The coverage issue highlights how difficult it is for transgender people to access medically necessary and potentially lifesaving gender-affirming health care, even in areas that embrace and support them, said Hawaii state Rep. Aaron Ling Johanson (D), a champion of the bill and chair of the state’s Consumer Protection and Commerce Committee.

Johanson said the policy change had been a “passion project” for him.

“One of the things that we came to find was that … ‘cosmetic’ treatments are a very critical part of accomplishing gender-affirming care for the patient,” Johanson said. But “clashes” persisted between trans Hawaii residents and insurance companies, he said, because some insurers decided the care was not medically necessary, even if a patient’s medical provider had recommended it. (Hawaii Medical Service Association, the state’s largest insurer, declined to comment.)

“It’s just heartbreaking when you hear from a lot of these folks who have higher rates of depression or thoughts of suicide because they’re just stuck in a system that doesn’t help them,” Johanson added.

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Fan Liang, medical director of the Johns Hopkins Center for Transgender Health, said that when it comes to gender-affirming surgeries, insurers tend to cover “top” and “bottom” surgeries (chest and genital surgeries), but not procedures such as facial or vocal surgeries. That’s a big oversight, Liang said, considering how important these characteristics are in everyday life.

“When you engage with somebody, the first thing that they appreciate, really, is your face and facial expressions,” Liang said, adding that many of her patients have also shared stories of being misgendered over the phone. Some worry their voice is “a telltale giveaway” of their transition. (Non-invasive procedures, such as laser hair removal and voice therapy, are also more likely to be denied by insurers.)

Generally, Liang said, gender-affirming care, which includes psychosocial and educational resources as well as medical interventions, helps transgender people live more freely, whether that’s relieving their gender dysphoria or reducing the likelihood they’ll be singled out or discriminated against.

“It really is a medical necessity,” Liang said. “These patients are living with an incongruence that permeates all aspects of their lives.”

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In passing its new gender-affirming care bill, Hawaii has joined a handful of states, including Washington and Colorado, that have tried to expand access to transition care.

Trans people and their advocates have long noted the structural barriers to receiving care. Fighting to get treatments covered can be a costly, overwhelming and time-consuming process, experts said. And even when patients can get their treatments approved and covered, there are not many providers capable of performing these procedures, and it is not unusual for patients to travel out of state or to be put on lengthy waiting lists to receive it.

This is true even in “progressive” places like Hawaii, where some residents have traveled to California — a five-hour flight — to get the transition care they need, advocates say.

Jenn Jenkins, a policy advocate who worked on Hawaii’s health-care bill, said that in their eyes, the law simply clarifies what was intended in the state’s 2016 nondiscrimination policy.

“This is already the law. It was just not as plainly written as we’ve done it [now],” Jenkins said. Still, this clarification could greatly expand gender-transition access for Hawaii residents, particularly trans women who had been particularly susceptible to having their claims denied, Jenkins added.

Advocates and lawmakers in Hawaii agree the bill is a significant step forward at a time when other states are looking to limit access to transition care among trans youth and adults. Conservative lawmakers who have introduced bills curbing access to gender-affirming care for minors say the policies are meant to protect children.

For Johanson, the lawmaker, Hawaii’s emphasis on community care — the “aloha spirit” — helped facilitate the bill’s passage. Jenkins, meanwhile, noted that Hawaiians have been “much more open to the idea of a spectrum of gender” because those beliefs are deeply rooted in Hawaiian culture.

Native Hawaiians have long recognized a third gender identity, “mahu.” Historically, trans and nonbinary Hawaiians have taken roles as teachers and leaders in their communities, explained Maddalynn “Maddie” Sesepasara, a trans advocate who manages the Kua’ana Project, a transgender support organization.

This cultural reverence was made apparent in 2019, Sesepasara said, when indigenous elders protesting a billion-dollar telescope at the summit of Mauna Kea mountain called on Hawaii’s mahu community to join them.

“We know we have a place. We know we are respected,” Sesepasara added.

That doesn’t mean trans people in Hawaii have not faced the same systemic barriers, discrimination and violence trans people face elsewhere, advocates say. After Christian missionaries came to the islands, “mahu” became a derogatory term, Sesepasara said, though this has slowly changed over the last several decades.

Medical transitions are a personal choice — one that not all trans and nonbinary people are able to make or willing to seek. But for people in Hawaii who need medical treatments to affirm their gender identity, these procedures could mean the difference between being targeted and being able to “blend in” and be comfortable in society, Sesepasara said.

And a time when the cost of living has soared on the islands, some residents have become increasingly desperate to complete their transitions.

“These are not cosmetic surgeries,” Sesepasara said. “These are surgeries that are going to save transgender folks in Hawaii.”

Jenkins hopes Hawaii’s new law could be a “little bulb of light” for trans communities in other parts of the country, where vitriol and attacks against trans people and other LGBTQ individuals have spiked.

“It’s our contribution to the possibility that we can change things for the better,” they said.