Even with a cane for support and braces on both knees from injuries while working on diesel engines in the Army, Tabitha Emo walks briskly, hurrying to an appointment at the James J. Peters Veterans Affairs Medical Center in the Bronx.
When she was a boy of six, Emo was already helping around her family dairy farm in western New York, about an hour south of Rochester, where the Allegheny Mountains cradle a town less than three square miles large. Mending barbed-wire fences, flipping hay with the tractor, repairing machinery alongside her grandfather, she learned the family business. The work was fun—she didn’t see it as masculine or feminine—and it prepared her for her later career as an Army mechanic.
Now 37, Emo has lived as a woman for five years, though the stubble on her face and the depth of her voice never let her forget the male body she was assigned at birth. The Department of Veteran Affairs (VA) pays for Emo’s mental health care and hormone therapy of estrogen patches and a testosterone blocker. But Emo has yet to complete her transition, because the VA does not provide for sex reassignment surgeries.
“I’m ready right now,” she said of the surgeries, which can cost anywhere from $15,000 to more than $50,000, an amount she can’t afford as an unemployed, disabled Army veteran living in a halfway house.
So she waits, and makes plans, hoarding pills. For Emo, it’s a matter of which comes first, her full transition to a female body or her third suicide attempt.
The term “transgender” describes individuals whose internal sense of self as male or female, or gender identity, differs from the sex assigned to them at birth. The term “transsexual” more specifically refers to those who are transitioning or have transitioned from one gender to the other. But these terms are not listed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in May 2013 by the American Psychiatric Association (APA). The relevant diagnosis in DSM-5 is “gender dysphoria,” revised from the previously-used “gender identity disorder.”
“It makes an important point that identity is not what is disordered, but gender dysphoria is a set of treatable symptoms,” said Dr. George Brown, the program director of health care outcomes at the VA in Washington, D.C. and professor of psychiatry at East Tennessee State University.
A diagnosis of gender dysphoria applies to individuals who identify with a gender other than their own, desire to transition to that anatomical sex, and experience distress or disability from the incongruence between their body and gender identity.
Transgender veterans can get transition-related health care at medical centers and outpatient clinics run by the VA: Hormone therapy, mental health care, routine health screenings, pre-operative evaluation, and post-operative care — everything but the actual operations.
In June 2011, the Veterans Health Administration (VHA) clarified VA policy on transgender health care with a four-page directive. Although it didn’t create any new benefits, the directive affirmed that transgender patients would receive all care included in the VA’s medical benefits package, as do other veterans, without discrimination and “regardless of sex or sex reassignment status.” In February 2013, the VHA reiterated this directive and expanded the content to 13 pages.
“The goal of the directive is to ensure that we’re all working toward the same goal, which is to provide high-quality care to transgender vets, including cross-sex hormones, psychological evaluation, and post-surgical recovery,” said Dr. Jillian Shipherd, who helped draft the directive and is co-coordinator of lesbian, gay, bisexual, and transgender program for patient care services for the VA.
The directive states, “VA does not provide sex reassignment surgery or plastic reconstructive surgery for strictly cosmetic purposes.” It cites federal regulations that say medical benefits for veterans do not include “gender alterations” but does not explicitly define sex reassignment surgery as “cosmetic.”
This policy functions as an absolute ban. The Department of Health and Human Services has also banned Medicare and Medicaid coverage for sex reassignment surgery in a determination that came into force in 1981 and has not been reviewed in the 32 years since, though a recent administrative challenge calls it outdated and discriminatory.
Despite the unavailability of surgery, transgender veterans have access to more care today than was available in the past.
“I first started with the VA in my transitioning, or attempted to, back in 2007 when I was still living upstate,” Emo said. “And at that time, the VA employee was telling me that transgender veterans could not get health care unless they had already transitioned and gotten the surgery.”
But Emo needed hormones and psychotherapy before getting any surgery, as set out in the World Professional Association for Transgender Health’s (WPATH) “Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People.” Headquartered in Minneapolis, WPATH is widely recognized as a leading organization for understanding and treating gender identity disorders. WPATH’s Standards of Care promote gradual transition, progressing slowly from fully reversible steps (estrogen or testosterone suppression), to partially reversible (feminizing or masculinizing hormone therapy), and then irreversible (surgical procedures).
During her service, Emo came out only on weekends, away from the military base, so she could dress up, put on makeup, and feel comfortable with people she had met online. Once she almost got caught by her sergeant when she returned to base with traces of makeup on her face; she made up a lie about playing a game.
The clothes make her feel feminine, she said, but it’s not enough. “Until I can get rid of the male genitalia, until I can get some semblance of real breasts, until I can afford laser hair removal, I think I’m going to continue wondering or believing that people keep seeing me as male,” she said, “and I don’t like that.”
WPATH’s 2011 Standards of Care say that, based on current science and professional consensus, “sex reassignment surgery is effective and medically necessary” to treat gender dysphoria.
Left untreated, gender dysphoria can lead to psychological distress, dysfunction, and depression, according to the American Medical Association (AMA). And efforts to cope can further endanger a person’s health, if he or she engages in substance abuse or self-mutilation, comes down with stress-related physical illnesses, or even attempts suicide.
Emo, too, has tried to harm herself. She’d abuse her genitalia, hitting, punching, clamping down on it to stop the flow of urine by force, until she bled. After her military service and a marriage she describes as a “sham” — “Military and marriage, the two Ms, are like the two last ditch efforts at masculinity,” she said— Emo was incarcerated for more than 10 years in prisons for men, for a rape she claims she did not commit. While there, she was attacked numerous times. When it got to be too much, she swallowed an array of pills, whatever she had been able to procure from other inmates. She became violently ill and vomited, her first attempt at suicide unsuccessful. She was 26.