Imagine you wake up on your fiftieth birthday, look in the mirror and see an aging male physique. Your hair is receding, you have more fat around your waistline, less muscle mass, and going to the gym regularly doesn’t produce the results it once did. If you’re popular podcaster Joe Rogan, you start hormone replacement therapy (HRT) to help you look and feel more masculine, and when you open up about it publicly, millions of fans around the world applaud you for your honesty.

Sloane wakes up every day and experiences much the same reaction to seeing herself in a mirror: the image reflected back doesn’t align with her gender identity. Sloane is a 33-year-old transgender woman diagnosed with gender dysphoria. Unlike Joe Rogan, or other cisgender celebrities, Sloane faces a gauntlet of social, financial, legal, and political hurdles to gender affirming care. 

Gender dysphoria, the distress caused when a person’s gender identity and their assigned sex don’t match up, is a mental health condition characterized by clinically significant anxiety, depression, and unease. Not all people who identify as transgender or gender-non conforming experience gender dysphoria, and some who do never seek treatment for it. Treatment guidelines continue to evolve as new methods are developed and patient outcomes are reported and studied. Some patients do well with supportive counseling to help them feel more comfortable in their gender expression. Others require HRT, hair removal, or gender transition surgeries. Unfortunately, many of these treatments are out of reach for those who need them due to lengthy insurance appeals processes, and discriminatory policies and practices. 

Sloane is insured through her employer, the University of Maine System, under a contract negotiated by her union and administered by Cigna Health and Life Insurance Company. It includes coverage for gender dysphoria, but Cigna has paid claims for some treatments and denied others. The line seemed arbitrary and out of compliance with standards of care, so Sloane enlisted the help of her union, the State of Maine, and the advocacy group Consumers for Affordable Healthcare to help her fight the denials. 

This isn’t the first time the University of Maine System has been in the hot seat over gatekeeping gender affirming care. In February of this year, the Maine Human Rights Commission found that there were reasonable grounds UMaine discriminated against a student on the basis of their gender and ordered them to seek conciliation to avoid trial. Students are insured under a different contract than Staff. 

So far Cigna has been unresponsive to Sloane’s appeal, and a legal battle could take years, so last week she launched a GoFundMe campaign to help her cover the cost of a scheduled surgery that her doctors say she needs, but her insurance won’t preauthorize. “I’m being forced to ask for charity because my insurance company has failed to authorize my treatment in a timely manner, but I don’t feel that I can wait.” Sloane said.  

The wait has been long enough even without this delay. Sloane has wanted to live as a woman for as long as she can remember. She describes having periods of depression, social withdrawal, and panic attacks that led to high-risk behaviors, and made her feel unable to help herself or others. “I couldn’t breathe, talk or think straight. I could remove myself from social situations, but no matter how much therapy I did, there was no permanent resolution,” Sloane said. She only began to feel lasting relief after starting HRT two years ago. “I have highs now, and I never had highs before,” she said. Counseling and breast augmentation surgery have also helped, but she still experiences significant dysphoria on a daily basis because of her facial features. “I have a very prominent chin, and I associate it with masculinity,” she said. Even talking about that association was enough to trigger an anxiety attack during which she couldn’t hear or respond to the questions I asked during our interview.

Humans are social animals. We get complex and subtle social cues from people’s faces that help us know what to say and how to interact. One of these cues is gender discernment. Facial Feminization Surgery (FFS) makes surgical adjustments to facial features that cue people to ascribe a masculine gender to a person. Those adjustments can include making a prominent jaw and chin more rounded, reducing a heavy browbone relative to the nose, lowering the hairline to reduce a high forehead, reducing the size of the Adams apple, and cheek implants. Not all patients require each piece. Using radiography to measure facial bone geometry and with decades of research into gender discernment, surgeons are able to determine which procedures will be most helpful for each individual patient. It’s one of the safest and most effective treatments for gender dysphoria in transwomen, but insurance companies and underwriters have been slow to catch up with the science. Cigna has denied Sloane’s claim as “cosmetic” though her doctors have written letters saying it is therapeutic and medically necessary.

The struggle for gender affirming care isn’t just a battle for insurance coverage, it’s also a political one in which allies are few and far between. The “T” in LGBTQ didn’t just appear there by itself, and still some feminists block trans rights by saying that women shouldn’t change themselves in order to fit a set of gender ideals dominated by the male gaze. But facial feminization surgery isn’t about beauty or objectification and, in Sloan’s case, it’s to treat a mental health condition. “It’s not about what other people think. It’s about what I see when I look in the mirror and how that makes me feel,” Sloan said, adding that she supports anyone’s choice to change their body, “and if Joe Rogan wants to pump testosterone into his body, that’s gender affirming care, too,” Sloan said.

Sloane is frequently misgendered, and the distress she experiences over this impacts her health, her finances, her ability to advance her career, even her freedom to move about. She can’t interview for jobs because she can’t know if she’ll be discriminated against. She wants to continue her academic career and has plans to apply for a PhD program in Ohio, where she has family and an affordable place to live, but Ohio is a red state where transgender protections are under attack and so are trans women. “Men can get angry when they clock you as trans,” Sloane said. In fact, transgender people are over 4 times more likely to be assaulted than cisgender people, and the ability to avoid being targeted makes so-called “cosmetic” surgery not only therapeutic, but potentially lifesaving. 

Recently, Sloane’s roommate has been taking her out to eat at the Cracker Barrel to cheer her up. “The servers there always correctly identify my gender. They call me sweetie and it makes me smile.” Sloane said. She looks forward to waking up after surgery, seeing herself in a mirror and feeling that kind of happiness every day. She calls it “gender euphoria.” You can help Sloane achieve this by donating to her GoFundMe.