Utilization Management and Trans Healthcare

This is a quick post – I posted the following comments in response to a post by Trans-Ponder on Facebook. They, in turn, posted an article by Alyssa Jackson for CNN, “The high cost of being transgender.” Since my comment was longish, I wanted to preserve it here on my blog (so, like some other recent posts, this is one of those “too long to just leave as a FB reply” posts).

Let me start by saying that I am unequivocally for a future (1) where a wide variety of trans experiences are embraced, and (2) where transition related healthcare (e.g., therapy, hormones or other medications, and surgical interventions) that some (not all) trans people choose is readily available to trans people irrespective of their socioeconomic status. My basis for a belief in a future of this kind is first, and foremost, because trans people are and have been around for a long time, and society needs to get used to it. Second, transition related healthcare is clearly safe and effective (viz. this and this and this and this and a million other reviews and studies, including the extensive data synthesized in WPATH’s position).

I am, for better or worse, also a healthcare expert, and I’ve been involved in discussions of making changes to reimbursability and enhancing access to services for underserved populations (in my day world of preschoolers with autism – I don’t provide trans healthcare). This doesn’t make me a leading expert in this conversation, although I know many of the leading experts, and I’ve talked with most of them about all this in some depth. It’s noteworthy, to me, as well, that none of them are quoted in this article, and that HRC, NCTE, and other leading voices that have done and synthesized the healthcare utilization research, are not quoted, either, in the context of cost, although relevant voices are quoted in the context of risk, e.g., with respect to suicide in our people.

The CNN article includes some real-world reports of trans people and their healthcare choices, although it only includes examples that appear to be significantly above the typical (e.g., +/- 1SD) spend for transition related healthcare.

The CNN article includes some real-world reports of trans people and their healthcare choices, although it only includes examples that appear to be significantly above the typical (e.g., +/- 1SD) spend for transition related healthcare.

From a healthcare utilization / healthcare sustainability standpoint, there’s a lot of problematic content in this article. The large (it quotes $140,450 for trans women and $124,400 for trans men) estimates cited in the article are for combinations of procedures that almost no patient ever chooses – note that the Philadelphia center cited for this data includes a wide variety of services, including blepharoplasty and rhinoplasty for trans men*. It appears to achieve its totals by literally adding every procedure together, even when these procedures cannot be done in conjunction. For instance, it adds the fee for an upper and lower blepharoplasty to the fee for a single, upper or lower blepharoplasty – this doesn’t make any sense – the second, lower fee is included in the list for someone who needs / chooses to only have one pair of eyelids, the upper or lower, done, and not the other. It likewise, for trans men, combines the costs of three different chest reconstructive procedures that all achieve the same outcome, and likewise, different, alternative bottom surgery procedures for trans men (that is, in each of these respective cases, any given man can do one of these things, but not all of them at the same time).

This is important because the figures cited in this work (which is on CNN, and thus has the potential to garner a lot of attention as well as remain part of the conversation over time) are starkly in contrast with data gathered in a rigorous manner by the people who’ve been most invested in moving us to the kind of future I want. Let’s start with San Francisco, the first US city to offer trans health care to all residents.

Note that the 2001-2006 San Francisco data had methodological limitations with respect to the per claimant spend (that is, they didn’t know how many unique claimants there were across the five year period, because they didn’t know how many claimants had also been a claimant in a prior year), but the reasonable median estimate was around $25k per claimant over five years, and the high estimate was $64k, well below the $75k cap imposed** in that model program. This is consistent with the long-term, multi-source data that converges on the result that the cost per covered life for an insurance plan (or employer) is very low (figures come out at in the neighborhood of $0.17 per covered life), as long as there is a medium or larger group of covered lives. The cost in San Francisco’s case, when they went through the first wave of making access available to the city’s own employees, was so low, that they famously stopped collecting an offset surcharge because they didn’t need the money.

We live in a world where, one way or another, care is utilization managed. I’m all for flexibility that allows for serving rare cases where transition related health costs are very high. More to the point, $25k is still out of reach for a large segment of the population – for instance the recent NYT article from a couple of days ago cites the median net worth of 18-34 year-olds as just $10,400, making the difference between $25,000 or $30,000 total costs and the unrealistic figures purported by CNN really irrelevant to an affordability conversation.

Similarly, when one looks at other successful attempts to systematically change access, such as the success we’ve had providing ABA therapy to children with autism (which I mentioned because I’ve been directly involved, in my small way), family costs of $25,000-50,000 are generally accepted by the public and by legislators as costs that “most Americans” cannot bear. So, we don’t need inflated estimates suggesting that trans people are commonly spending $80,000 or $150,000 on services, to win the coverage we want to see, both because people don’t have the smaller amounts of money, to begin with, and, importantly, everybody gets that.

The contrary risk is simple: the higher we make these costs out, especially when not borne out by data, the more reticent stakeholders will be to make these important changes.

With respect to reasonably feasible alternatives, outside of very large, high profit industries (the kind already scoring 100 on the CEI and already providing access to care), the alternative also, we have to consider, is an alternative that somehow tries to measure “objectively” the basis, e.g., on pre-procedure dysphoria level for the patient, and that kind of gatekeeping is deeply problematic for the trans community as well as for our providers. The last thing we want is a system where trans people have to be miserable (or pretend to be miserable if, like me, they are really happy) in order to access services. But if we walk into this argument citing astronomical cost bases, I am very concerned that this is where we might end up.

As the public, a lot of my friends believe firmly in a “no gatekeeping” model. But, the reality is that medical care provided in a congregate funding model – Medicaid, Medicare, insurance, universal health care systems like NHS, hybrid public/private systems – is gatekeeped in one way or another. Although the reality is that the biggest cost drivers, especially in the developed world, are not things like trans healthcare (or autism or any other area where we’re fighting for access), but “boring” things – note that in this review of nine drivers of increasing American healthcare costs, the only disease / problem / disorder / population centric things that even make the list are “lifestyle” diseases (being gay isn’t a lifestyle disease – this is talking about the effects of things like sedentary lifestyle, bad diet, smoking, etc.) and end-of-life care. Nonetheless, it’s flashier to pretend like extending healthcare to critical, impactful areas like trans healthcare (which can prevent the staggering loss to suicide in our population and which clearly provides improved quality of life) is the problem. And this is politics – it isn’t about what’s right, but about what’s perceived.

So let’s tell our story clearly, and not misrepresent our situation in a way that reduces our likelihood of getting the help we need.

*  I don’t even know an example of someone choosing those procedures as part of transition, for instance, as a trans man – I’m not saying it isn’t done, but I’ve never met a trans man who had these procedures done as part of transition, and I have been paying attention, both so that I am generally a better advocate and an ally, and of course because I am rather engaged to marry a trans man, myself.

** In fairness, it is worth noting that median and mean figures belie ranges. They are still important – because when you are looking at large groups of insured people, one must estimate actual costs in a given year across the entire population, and these costs can be used to effectively make these estimations. The range does vary, and this is important with respect to how these access policies are set up. And back to fairness, one should note at this point that San Francisco initially capped services at $50,000 and then moved the cap up to $75,000.

Authenticity as the Sine Qua Non of the Trans Success Story, and the Virtuous Cycle of Narratives Informing Lives

I’d like to try and draw together some thoughts that evolved during dinner with a friend at Philly Trans Health Conference, over the weekend. She and I are two very different, but similarly very happy trans women. This topic of happy trans people is established as one of importance to me. I want to move our happiness from a privilege, from luck, to birthright and expectation for our people*. Much like I want to make a world where people are proud to be autistic, where society recognizes the immense gift it is given in the form of the autism family, I want to make a world where LGBT (and particularly T) people aren’t just safe, but we are truly proud.

Proud as Proud Can Be... and you can click on the flag to buy trans pride stuff from randomflyingpidgeons!

Proud as proud can be… and you can click on the flag to buy trans pride stuff from randomflyingpidgeons!

In pursuit of this goal, I made my friend, Kelly, really think during dinner**. I wanted her to evaluate, critically, what it means to be a woman*** – beyond being addressed or seen correctly by others, and certainly beyond wearing a dress or heels, and granting that our identities as women are diverse, beautifully heterogenous, and ever evolving, what did it mean to her that she was a woman? She was a little surprised at how hard it was for her to answer this question.

I asked her a second critical question – not to push her or distress her, but because I think the answer is central to our cause. Why was she happy? And if the first question was hard, the second question was far more difficult.

One piece of extremely worrisome data I want to bring into this conversation is the subset of suicides, particularly of trans youth, that have arisen recently and that explicitly do not seem to look or functional like marginalization, lack of acceptance, or oppression stories. More than a few trans youth have killed themselves in the recent past (like Kyler from San Diego), who had parents who loved, accepted, and celebrated them. Who had solid, if not world-class access to transition-related medical services. Who had schools that celebrated them – one of them was Homecoming King – and who were in at least some cases pretty well-integrated into their communities. Who do not seem to have been experiencing a lot of traumatization by way of bullying or other victimization. I think we need to stop and question why these kids are dead, and how we failed to do anything about it. And we have to recognize that just acceptance – people recognizing one’s gender identity, people supporting one’s name or pronouns, access to school, employment, accommodations – doesn’t seem to always be enough.

This is Istanbul's 2011 Pride... the change is global! (Source: Wikimedia)

This is Istanbul’s 2011 Pride… the change is global! (Source: Wikimedia)

Moreover, trans acceptance, and LGBT acceptance more broadly, is not a static picture. It has changed dramatically just in the recent history – the stuff that happened since Stonewall – and it is changing at a breathtaking, accelerating rate every day. What is the quality of evidence that acceptance is reducing suicidality in our community?

I want to propose an answer to my own question. I cannot provide an evidence basis for it, but it is consistent with my base of anecdotal evidence. I’ve quickly had the privilege not just to become a happy trans person, but to get to know a lot of happy trans people, in fact many of the most influential ones, and even to share my very life with one. And I’d like to hypothesize based on my experience of them and myself. My hypothesis is that every happy trans person begins their process of authenticity with a sincere, internal step of self-acceptance. I mean real self-acceptance. They enter transition or coming out, knowing and deciding to learn to love, who they are. They do this first, and every subsequent decision in their authenticity process derives directly from this internal conviction – a conviction not just in the truth of their gender identity, but in the goodness and rightness of their gender identity. And, this is really important, they enter into coming out and transition happy. Really happy. Although they may gain confidence, surety, ease, from things like their name or pronouns, or from transition-related medical services, they neither seek nor obtain wholeness from them. They don’t, in fact, need to seek wholeness from anything, for they enter this process with it.

Marya is amazing. So thankful for sisters like this one. Source: Mark Trockman / trockstock.com

Marya is amazing. So thankful for sisters like this one. Source: Mark Trockman / trockstock.com

When I was in the throws of surviving anorexia, like many other anorectics, I found a lot in Marya Hornbacher’s words. Her Wasted has this phrase**** all the “ana’s” knew by heart: “If I eat this apple sandwich in precisely twenty bites, no more no less, I will be happy.” We repeat a similar mantra, over and over again, as trans people, and it’s sheer and utter nonsense. If I just have the facial features I think I want, I will be happy. If I just have a vagina, or I don’t have a uterus anymore or, …, I will be happy. If I have a beard, I will be happy. If I get pronouned correctly, I will be happy. If I “pass,” I will be happy. And we continually defer happiness to some future that never seems to come. Recovery from anorexia depended (for me) crucially on rejecting the idea that I would be happy if I just lost another one, two, ten pounds, and not just because I had gone far, far beyond the place where I had ten pounds to lose.

In Christianity, there is a rift between evangelistic and liberation theologies, in that the one is interested in finding deferred happiness in heaven, and the other is interested in helping people be well and whole. The rift is old, and deep, not just in Christianity, but far beyond it. The Christ who overturned tables, fed masses, cured the sick, and befriended the harlot, is alongside the apostle, in the same New Testament narrative, who cared less for what is good and what is evil, and cared more for what is right, and what is wrong. Before that, the God that demanded the Israelites strike down their enemies and leave no survivors was the same God that demanded grapes be left on the vine for the poor and the stateless, again, the one a question of rightness and the other a question of goodness. And on it goes back, turtles astride turtles, and we are forever, the serpent and the sons of Adam, at odds, the one striking at the other’s heel, and the other smashing one’s head*****. It plays out far beyond Christianity, and it is deeply enmeshed in the way we live.

And this is where I bring to the trans community not an answer, but the right framework to find that answer. We are failing these fallen siblings of ours, trans youth and trans adults, not just because we haven’t won complete acceptance and inclusion for our kind, but because we have not taught nor empowered each other to find our identities, to take that internal step of self-acceptance that allows for and necessarily precedes the pursuit of authenticity, and in so doing, we do more than just put the cart before the horse. We kill our own kind by selling them a dream that can never succeed.

So how do we stop? How on earth do we not just stop selling this absurdism that transition or coming out experiences, in themselves, can make anybody happy?

My thoughts from dinner that night, over margaritas and excellent Mexican food, link me back now to a video that I helped do for my beloved Actors Theatre, a couple of months ago. In it, I discussed a virtuous cycle between art and life, where life inspires ever greater, more true, more honest art, and art in turns drives us towards our own truths and our own authenticities, making us better people. This is the kind of art that Actors does, and I believe desperately that this is something of which people need far more.

I am far from done in figuring this puzzle out. But my first answer to this question is that we, as visible trans people, must think of our trans visibility, our stories, our narratives, as participating in a similar virtuous cycle with all the life experiences of the trans-gentry******. If we tell stories that are focused on how far we take transition, or how much external acceptance we gain or take, we will instead participate in a vicious cycle, in which we will press our own people ever farther from the thing that could save their lives. So rather, we must tell stories of authenticity, of identity, not because others could ever take on our identities*******, but because, as iron sharpens iron, as life and art lift each other up, our authenticity and identity stories will push our people higher and elevate them in their pursuit of the self-acceptance that presages being a happy trans person.

That’s my theory. I’m all for gathering supporting data, but I’m not going to wait, because this is life and death, and as one of that minority of really, truly, madly, deeply happy trans people, I’ve got to do something. While happiness remains a privilege, like any other privilege, I need to use it not just for me but for making the world a better place.

* Consider this also a shot across the bow of those people (you know who you are) who think that misery is at the heart of trans activism, and who reject any trans person who is happy. I view happiness like I view footnotes. I put it out there until you quite consider it over the top, and then I put it out there some more. The next shot will be between the eyes, my darlings, for I am out to get your worldview.

** I also made her change our plans and go to a place where I could get reservations, because you know, that process of walking around until you find a place to eat is what leads the world to eat at TGIFridays, and life is far too short. And excellent Mexican food came with Mexican revolution – there was a handwritten sign propped in the glass above the door calling for social justice in Mexico. Thank you for that, my darling Kelly.

*** Make no mistake… this ownership of what makes a woman is the principle bullet of exclusionary feminism movements. Although I respectfully agree with these women that women are a wonderfully diverse people who defy simple definition, and the seat of our definition is not in our cleavage, our hips, our dresses or makeup or any of those kinds of things, I continue to strongly reject their claim that only the cisgender early female life experience can be a gateway to womanhood, or that women of all kinds cannot coexist and build each other up and empower each other.

**** In fairness, none of us have any idea what an apple sandwich is, and if I had reached a greater place of sureness in myself when I got to meet Marya, I would have not just thanked her for what she did for me, which was a lot, but I would have pressed for an answer on this important question.

***** I’m with the serpent, and Ruth, and Mary Magdalene, and Jesus, and all of those seeking good over evil and not right over wrong, but you knew that.

****** A very cute term I am now borrowing from Kinky Boots.

******* The boom boom I have, that all the boys chase, and all the right junk I have, in all the right places, belongs to me and no one else. Just as I can never be any better than lousy at being someone I’m not, none of you will ever be a better me than I will.

Transgender Life: The Difficulties of Dating

Some artwork representing the dissonance many trans people feel between who they know they are and how they are seen by the world

Warning, this post is a bit of a blast from the past – I wrote this back in April, for Gays.com. Those of you who freelance know, sometimes, your posts get held in queue for the “right” time for an editor to publish them. This one finally dropped before Thanksgiving, and I never got around to posting it here. It’s interesting to read my mindset seven months ago (here on miracharlotte.com or elsewhere). Seven months on, I don’t just have “hope that there is room for us to find the love of our lives” – I know that I have, in fact, found just that. It’s funny, too, to think about being wound up about things like appearing feminine, or being out and about in public, which I now take, if not for granted, as like laws of the universe which I no longer question.

Dating and relationships is a really complicated business for transgender people, especially transsexual people who decide to transition. We’re all over the map – many of us found a long-term relationship or even a marital partner before coming out as trans, and sometimes (but not always), those relationships work out.

It seems for trans women, that more often was with another woman in a ‘heterosexual’ relationship (all of my significant relationships for example), but it could be all ranges of things. Those relationships have to change if they’re to survive – it’s common for a newly outed trans woman’s wife to express that she’s not a lesbian. That’s fair, maybe she’s not. For trans men and women who identified as gay or lesbian before transitioning, too, their partner might not be able to reconcile their own sexual orientation with the transition. On The L Word Jenny tells Max (whom she had been dating prior to transition), “you identify as a straight man. So there’s the mismatch, because you want me to be your straight girlfriend to your straight guy. And I identify as a lesbian, who likes to fuck girls. And you’re not a girl.” Sometimes, too, the relationship does survive, but not sexually or romantically.

Read the rest, over at Gays.com!

I Think I Passed

Okay, never one to shy from controversy, I think I had my first real experience being “stealth*.” To be fair, I’ve gone to the store many times, and I’m more or less stealth – outside that time I went late at night, about which I blogged previously, I’ve actually rarely felt very stared at, and most of the time I make direct contact with a few people in the process, and none of them do a double take, and the interactions are pleasant, except when someone honks at me, because I swear I looked in the rearview and they were not there when I started backing out. 

It’s often worse at inclusive spaces**, in a slightly ridiculous way, because other LGBT people read me more readily than straight people.  Also, more generally, the funny consequence of this is that only people who know me well ever misgender me, even though I’m just three months on hormones. You can argue the point if you want (people got catty when I suggested this was happening in a trans thread on Facebook). But it’s decently accurate, and no one is more surprised about it than I am.

I just met you, and this is crazy, but here’s my number, so call me Blackbird?

But, in the real, not officially inclusive world, the experiences have been stacking up. I do get compliments. They’re flattering, but I also admit that when I get compliments, going out, I assume people know exactly what I am, and they think I’m hideous, and they’re just being nice (because who could ever find me pretty?). So they compliment my bracelet or earrings to be pleasant without having to engage me on my appearance. This interacts a bit with the eating disorder history, too. I don’t have distorted body image so much, anymore, but at some level, those perceptions and those cognitions will always be with me. 

Anyway, little things challenge the pattern of cognition. I sat down at Starbucks the other day, and the woman on one side chatted friendly that she was envious that I could pull of a pant suit, because she can’t. This one I don’t think really had anything to do with recognizing I was transgender, but moreover, it caught me off guard, because I was a little scared to go with the pants over the skirt for fear that the outfit was just a little less clearly feminine, although, of course, with a frilly blouse, heels, and dangly earrings, the point comes across, honestly, well enough. But anyways, I was caught off guard, although the compliment felt genuine and really nice, actually. I quickly recovered with, “Thank you! I’m not always sure I can, either!” Which is actually the truth. My face doesn’t blush unless NARS has helped, but I would have blushed if my complexion allowed for it. The young women on the other side of me liked my earrings. Excellent power up before going into a big meeting, and I felt just plain like a woman all day***. 

But here’s the other, secret part. This is the part I haven’t heard very many trans people who “pass” (either as well as I do, or far better) talk about. Conceptually, I think it’s unlikely no one recognizes I’m, well, a different kind of woman. I also kind of know it’s unlikely that everyone thinks I look like a freak, and they are all simultaneously playing much better poker faces than I can muster, so that no one in the crowd shows it. I can also conceptually accept that some people probably do think I look a little … different … and may not much care for it, and are just being nice. What drives me crazy is not whether I pass, but that I don’t know what other people think of me. That drives me insane, because I’m that girl who wants everyone to like her, and can’t be terribly comfortable with the idea that there may be people who are faking liking me and I don’t know it. There. I said it.

People have written about how it’s hard to be pretty. I’m not going to try to convince you of some absurdity, like pretty people have it worse than ugly people or smart people have it worse than stupid people, or rich people have it worse than poor people, because by and large, the scientific evidence (which has addressed this) does not support the claim. But this is the dark side to … passing is the wrong word. Stealth is the wrong word, because, as I’ve already explained, I’ve made a  nuanced decision not to go stealth, even if I could. It’s the dark side to having a high degree of social acceptability (in a wide range of settings and among people who don’t know me) as a transitioning person, because like pretty people (dare I say other pretty people? It’s taken me a long time to wrap my head around the fact that I’m perceived as pretty, as much as I’ve longed for the moniker all my life), a lot of us hide insecurities, and just … there is a specific hell to not knowing what people think of me, even if the answer would turn out to be not so bad.

* Here I simply mean being in a cisgender space and being pretty sure most of the people with whom one interacts don’t know one is trans. As usual, I semi-facetiously court controversy. So, I don’t pass judgment on the choice of trans people who choose to go into a deep stealth, where they live in such a way that even many/most of their close/intimate friends and colleagues do not know they are trans. As I’ve said before, locally, that could never be an option for me, but were I to relocate somewhere where there isn’t a large neuropsychology presence or other network connections to my perceived-male days, it might be feasible. I don’t have the option globally, unless I were to leave my profession. I’ve also chosen not to do this, because, in my case, I believe I can work and thrive here, where many people know me, and by doing so open the door wider for our siblings. 

** Okay, so I wrote my post about Coolclusion, right? A couple weeks later, at church, one of the same people I mentioned, I kid you not, on the day that the sermon was about what it means to be an open and affirming church, told my girlfriend and me, “If we can accept you [laughter], we can accept anyone, can’t we?” Blithely. What does it really say about us, as a people, if I can go to expensive bars and fancy restaurants, and totally get treated well and feel welcome, and this is the standard to which we hold ourselves in making an inclusive church accepting? How did things come to be this way, and how do we right the apple cart?

*** And they don’t even know what coolclusion is, or who they’re trying to coolclude!

I Took My First Dose of Estrogen At A Laverne Cox Lecture

Mostly because it seemed like it’d make a good story. By way of background, when I started transition, I started seeing a therapist and going to a support group (through the fabulous Network) right away, but I didn’t really push for booking an endocrinology consult right away. There is someone decent here in town, but it turned out that I wouldn’t be able to see him until October. Also, he practices out of a diabetes group and trans health is not his primary calling. So, I did some digging and some emailing, and I settled on my second course of action, to seek care instead at the University of Michigan, which had the advantage of offering a comprehensive program. I don’t think speech therapy is my most pressing problem, but I’m going to get a consult from their SLP when I go back for my next appointment. Likewise I’m not sure it’s the surgical clinic I want, but still.

University of Michigan also maintains a great
community resource guide for trans* people

When I started support group, in hindsight somewhat foolishly, I didn’t know if I should come “en femme” the first time. I think, the second time, I wore foundation (and erm, a bra under my short trench) and went out for a drink like that after. One of the bartenders at the place we usually go to said to me, aside, when I was looking up front for someone, that he didn’t know who was what gender, but we were some of his nicest customers. After that I went to group in fairly clearly female form, and honestly, my “look” has only subtly evolved since then. Anyway, it seems in hindsight ridiculous for me to question whether it would be okay to go to a transgender support group in makeup. Mira won the same argument some four or five months later, when I had my endocrinology appointment, and I went in booties, a grey tweed skirt, white blouse, black velvet jacket (❤️ I do rather love clothes), and a faux fur bucket hat, since it was bitterly cold that day, and that hat is cuuuute. Anyway.

Endocrinology was great. The resident seemed like a nice fellow (sorry, medical joke), and the endocrinologist was excellent. They answered all my questions and got me going. Labs at the next building over confirm the testosterone in my blood (can’t wait to see the next numbers I post!). Okay, the Indian woman at the front desk, with whom I didn’t even have to communicate, really, since I got whisked back to a check in desk, was staring. I wondered if it was possibly because she hadn’t seen an Indian American trans woman, but she didn’t say anything, and she apparently stared at a trans man who came in later, and possibly also at my girlfriend (neither of whom are Indian Americans). Whatever, kind of odd, considering that a significant number of trans people come to see the doctor, and we rather pay her salary. But okay. I can tolerate staring, and I’ll be ready for her when I go back. In grad school, long before I took transition seriously, I got accused of working a room like a sorority girl, and forget you, if you think I make a timid woman.

If you haven’t met her, Laverne is radiant. Seriously.
And when anyone preaches bell hooks, I listen.

Anyway, this was a Monday, and I took the day off to drive across the state to the appointment. Tuesday I went into work, and GVSU was hosting Ms. Cox that night – it had been on my calendar for weeks. No time to go home and change (and the place was packed; I wouldn’t have had a seat if I had). A trans woman friend yelled, “Hey, Mira!” across the room, and I had a momentary panic, but the moment passed. I had been able to stop at the pharmacy on the way there, so I brought in my pills (in a baggie with cookies from Subway!), and I got to dose next to a fellow trans person, also taking their evening dose, and surrounded by tons of my own queer friends and literally hundreds of people out to embrace and support our sister Laverne.

And, damn, did that lecture not sound like sweetest symphony on estradiol? And, as she quoted Sojourner Truth, “Ain’t I a woman?” Nice way to start a chapter in my story.