A surgery consultation I recently had was one of the most affirming doctor’s appointments I’ve had in a long time. If you read my previous post, We Need to Talk About Disability as a Reproductive Justice Issue, you know I have chronic pain and illness conditions and I go to the doctor regularly. I’ve had many bad appointments, experiences which likely resonate with other people in the disability community, so I was surprised when this one went so well. After about a decade of thinking about it, and 13 years of struggling with my large breasts, I finally decided to get a breast reduction.

Usually, when I mention considering this, people would question it. After all, in a society that places too much of a woman’s worth on her appearance and sexuality, why wouldn’t a woman want large breasts? What people don’t usually consider is the physical and emotional pain and strain they may cause. The surgeon I saw noted quite straightforwardly that I was a “classic case of breasts too large for the body.” He asked if he “waved a magic wand” and made me my ideal size, what would it be? I told him. He agreed and told me there would be no problem with my insurance company covering it. My surgery is scheduled for October – quick, respectful, and easy.

When I called my insurance company to look at my options before my appointment, they told me the requirements for a reduction to be medically necessary:

1. Severe neck and shoulder pain (check)
2. Permanent grooves in my shoulders from my bra straps (check)
3. Headaches (check and check – I’ve written about that here)
4. Irritated skin under the breasts (check)
5. Restriction of physical activates (check)
6. Nerve compression
7. Chronic breast pain due to weight (check)

Hanging up with my insurance company, I felt relieved. I check six out of seven boxes to deem this surgery medically necessary, and I could very likely get this reduction at little cost to me. The relief quickly dissolved into anger and guilt. Trans people close to me have struggled to have gender confirmation surgeries that are similar to my reduction, but different for some very key reasons.

Gender confirmation surgeries can be part of the medical transition process, which also includes hormone therapy. While not all trans people decide to transition medically, others have surgeries, including “top surgery” and “bottom surgery.” For trans masculine people, top surgery is when all of the breast tissue is removed from the body, using similar procedures to a breast reduction. For trans women, the surgery is typically a breast augmentation.

Some trans people experience dysphoria that stems from their physical appearance not matching their identity. What makes my breast reduction “medically necessary” is the pain and emotional distress my breasts cause me. This is no different, and probably less severe, than what many trans people experience when their body does not match their gender.

Trans people have to jump through an incredible number of hoops to have their top surgery approved, and even then it’s rarely paid for by insurance. Only in a few places can trans people have their surgery covered. In many states, their doctors need to prove that the surgery is necessary for them. Sometimes they can’t get it until they’ve been on hormones for a certain amount of time – and not all trans people want to take hormones. Sometimes people have to travel out of state to even find a good doctor who will do top surgery. And then there’s the money – the upwards of $8,000 that people may be forced to raise on their own to pay for a surgery they need.

Some people who have gender confirmation surgery turn to crowdfunding to pay for their procedure. This should not be a necessary step to accessing much needed healthcare. Furthermore, some people may be absolutely unsafe being open about their gender publicly. For them, crowd funding online isn’t an option. So how do you pay for a surgery you know you need when your insurance doesn’t deem it necessary and you can’t ask your friends and family for money? This is why some trans people seek hormones and other gender confirmation services from outside the medical community, where they may end up buying dangerous chemicals. (For more about this, I strongly recommend listening to the Heart episode Beauty Is Pain.)

For my part, I just waltzed into a doctor’s office, paid my copay, talked to the doctor, explained why I wanted the reduction, and scheduled the surgery. All I need is to hear back from my insurance company that it’s covered. While I should not need my insurance to approve something my doctor and I decided was the best choice for my health, it’s nothing compared to the barriers and indignities that trans individuals may face.

Making these types of medical care cost prohibitive is economic violence against the communities that need them. My breast reduction is medically necessary. My breasts cause me physical pain and anxiety. At times, I have felt unsafe in public because people feel that they can talk about, leer at, and grope my breasts simply because they’re big. I am so privileged that my insurance company will cover a surgery that I need to live my most fulfilling live possible.

Gender confirmation surgery also allows some trans people to live their most fulfilling lives. (That is, if they want them. Some trans people do not want surgery, and their identities are absolutely still valid and real). Medically necessary surgeries can help people to be comfortable in their bodies. They alleviate physical pain and anxiety, too. They are legitimate surgeries, and they should not be inaccessible to people that want and need them. They are medically necessary, always.