Accessing Competent Health Care as a Trans Woman

By Aurelie Richards

I'm prompted to have conversations every day that aren't the conversations I choose. That's truer now that I live abroad. Last year, I left the U.S. for Berlin and a new life, one hard won after my swift and costly gender transition. When I landed, the Customs agent scanned my passport, which has an F marker indicating finally that I am (according to my therapist, endocrinologist, gender-confirming surgeon, the State of California, and the U.S. Department of State) female.

Since arriving in Germany, my agency has been defined by my mastery of a foreign language, culture and law. I've found myself navigating systems where I don't feel in my personal power, where I have to make space for the multitudes I contain.

I constantly ask myself: How will I maintain my well-being and meet my medical needs while abroad? My wellness as a trans woman hinges on my ability to access competent care and have agency within the care that I access. But the systems around me demand that I reveal private information. I need letters from experts (listed above), written on my behalf, to say who and what I am, so I can pass through Customs undetected as the anomaly that I am.

The German health care system is an impressive accomplishment of its country's bureaucracy — organized, streamlined, algorithmic. As long as you know how to work the system, you can satisfy almost any medical need. The problem with a hyper-organized system is that it relies on categorization. Diagnosable or not. Male or female. German or non-German. If you fall into these categories, great. If not, you are an anomaly and the system is blinded by its own bureaucracy.

Read more about Health Care Access for Transgender Women.

When I first went to the Frauenarzt — the catch-all term here for "women's health practitioner" — I chose beforehand not to inform my doctor of my transsexual status. Though I was impressed with her inclusion of "Trans" on the intake form, I checked the "Female" box of my new patient questionnaire. Let me explain this choice.

I'm at a point in my gender confirmation journey where I'm largely self-medicating with hormones, checking in with an endocrinologist yearly to appease the gods of bureaucracy. My injectable estrogen prescription had run out slightly ahead of schedule, and I'd intended to visit my trans-affirming endocrinologist on a visit to the States in May. But then coronavirus regulations were put in place, suddenly and indefinitely.

I'd heard mixed stories about the German system for trans people. I knew the American system had problems. Trans girls joke about how the States are still the Wild West of trans-affirming care, and American doctors are cavalier about throwing prescriptions at trans women to make us go away.

At the Frauenarzt, the receptionist butchered my French-Canadian name. I remained quiet, so as not to give away my slightly less-than-fluent German and not to let my androgynous, testosterone-influenced voice expose my male past. I went through my exam and was asked about my last period.

"Actually, that's what brings me in," I said. "I haven't bled. I know I'm not pregnant. I'm wondering if you'd test my hormone levels." I'd rehearsed this in the mirror, in German, before leaving the house.

The doctor challenged me, but I smirked back: "Trust me. I'm definitely not pregnant." She ordered an estradiol test. I smirked when my levels came up low, and she prescribed me estrogen gel. I lied so I'd be free to choose the conversation myself.

When I seek health care, my in-between-ness is reduced to fit me into something the system can comprehend. My transness is reduced to conversations required by people who don't have my lived experience. This often takes the form of paperwork.

A letter from my therapist: "Yep, turns out after 12 sessions, she is trans after all." A referral from my endocrinologist: "Well, what do you know, give a person the right hormones and her symptoms of gender dysphoria are manageable. I think she might be a girl, even though she's been telling us this since she was 6 years old." A notarized affidavit from my gender-affirming surgeon: "This one has a vagina now. Is she a real woman to you, yet?"

These paper trails serve as bridges from my lived experience into the clinical and legal systems I need and also loathe — systems that try to serve me but at the same time find my body and mind suspect.

Early in my transition in the U.S., some stitches came loose from my newly reconstructed genitals. I was driven an hour to meet a gynecologist who said she had experience with trans patients. When I got to the appointment, legs up in the stirrups for the first time, she disclosed from behind her speculum, "Not to make you the poster child of trans care, but our clinic has never had a neo-vagina come through. I'd like to invite our head nurse to observe your exam."

I let my head drift up off the paper-covered pillow. The room was spinning a bit from the painkillers I needed steadily dosed to get through the day. I slurred, "Yeah sure. OK, I guess?"

Notice, I wasn't a female patient to them, not even a trans patient, but a neo-vagina with legs. They spoke to each other cheek-to-cheek. I remember their breath on my still hypersensitive labia. Two cisgender medical practitioners hunched over my transness, marveling at medical science.

After that day, I decided I would only have the conversations about me that I chose. I don't have to abandon myself because someone (or an entire system) deems my body or mind suspicious or threatening. Living abroad, I'm learning to feel comfortable being misunderstood all the time. Living my womanhood, I'm learning to accept my experience will always be doubted. Living my transness, I'm learning that I'm the only person who can take responsibility for my health. Containing multitudes may mean I'm not entirely in control of my well-being, but it's also the source of my authenticity, resilience and vibrant health.

Sometimes that means I'm out and proud. Other times, I'm the quiet expert of my own experience. I get to choose. And that's freedom.

Aurelie Richards is a writer, performer, body worker and coach. Born and raised in California, she's currently based in Leipzig, Germany. She has been an LGBT organizer for over 10 years; her recent trans activism focuses on developing rural/small-town queer and trans communities. Visit her website: www.aurelierichards.com