Ian Ayers says he has known he was a man since a young age. But he did not always present himself as a man out of concern for his safety.
Now that Ayers is comfortable being himself, the 50-year-old Las Vegas resident has chosen to take hormonal medication to induce masculine features. Soon, Ayers hopes to get gender confirmation surgery as well, which in his case, would involve a double mastectomy — the removal of breasts, also referred to as top surgery — and a metoidioplasty — the creation of a penis from existing genital tissue, also known as a type of bottom surgery.
For Ayers and many others in Nevada, the road to those surgeries is long and riddled with hurdles.
No medical providers in Nevada are equipped to perform bottom surgeries, with the exception of two Las Vegas doctors who only remove testicles, according to local experts on the subject. Ayers, who is on Medicaid, knows of two surgeons in the area who perform top surgery and accept Medicaid.
One of those surgeons repeatedly referred to him by the wrong gender during a recent consultation, Ayers said.
“You’re giving me a consult for top surgery, but you’re calling me ‘she.’ That’s one of the frustrations as well,” Ayers said.
Transgender people across the United States face difficulties and discrimination when it comes to accessing health care and insurance coverage. While not all transgender people require hormones or surgery, they can be medically necessary to treat gender dysphoria, a condition in which one experiences distress because their biological features do not match their gender identity.
“For some people, those gender affirmation surgeries are really empowering to support their journey of who they are and how they express themselves, and to support their health and mental health as well,” said Ray MacFarlane, the trans and gender diversity program manager at the Center in Las Vegas.
Unlike in many other states, Nevada Medicaid covers gender confirmation surgeries, but the lack of providers who offer them and understand transgender people’s needs creates a barrier to access, MacFarlane said. Nevada also requires those seeking top and bottom surgery to obtain two letters from health care professionals — one from a licensed psychiatrist or psychologist who has worked with the patient, and one from another professional who evaluated the patient.
Because Nevada faces a shortage of mental health services in general, the two-letter requirement makes it even more difficult for people seeking surgery, said Rob Phoenix, owner of the Huntridge Family Clinic in downtown.
“Trying to get a psychiatrist to see someone for gender care is really hard, and then getting them to write that letter is almost impossible sometimes,” Phoenix said. “I have patients who’ve been seeing their psychiatrist for years, and they’re like, ‘Yeah, I’m not writing that letter.’”
Ayers described Nevada’s two-letter rule as excessive and patronizing.
“Why do we have to do that? We’re adults and we’re making a consented choice,” he said.
The state requirement is based off the 2011 World Professional Association for Transgender Health standards of care, according to the Nevada Department of Health and Human Services’ guidelines for changing one’s gender in Nevada.
Most transgender people in Las Vegas who seek bottom surgery look to providers in California, Utah, Arizona or even farther away, MacFarlane said. That’s what Las Vegas resident Rachel Rogers did, who had top surgery last year in Las Vegas and bottom surgery this past week in San Francisco.
Because the supply of surgeons who specialize in the procedure in the United States is still relatively small, many providers have long wait times. Rogers was on the wait list to see Dr. Marci Bowers, a San Mateo-based surgeon who specializes in gender confirmation surgeries, for two years. Rogers was able to get off the wait list sooner by putting down an initial deposit, she said.
“I did a few interviews here and there until finally I found Dr. Bowers and talked with her,” the 52-year-old said. “She’s one of the best in the country. She’s a trans woman herself, so that tipped the scale for me.”
Rogers, who described herself as a “trans person of privilege,” was able to set aside time and money to travel to San Francisco for her surgery, which ultimately cost about $3,000 out-of-pocket with her private insurance. But not all transgender people, who experience disproportionate levels of poverty, have the means and ability to do that, said Dr. John Brosious, assistant professor of plastic surgery at UNLV School of Medicine.
Brosious specializes in reconstructive surgeries for patients who had cancer or experienced trauma, but he also works with many transgender patients and performs top surgeries. Recently, he has made it his mission to improve transgender health care in Las Vegas.
“About one year ago, my first transgender patient showed up for chest surgery,” Brosious said. “That’s when I realized, my mind was blown about how little access to health care, period, these people have.”
Already trained to perform bottom surgeries, Brosious explained that none of the hospitals in the region have the necessary equipment and team of specialists for the procedure. He also hopes to improve the state of insurance coverage for the surgery and for necessary pre- and post-operation procedures, such as electrolysis, the permanent removal of hair around the genitals. Electrolysis is rarely covered by insurance companies, which often classify the process as “cosmetic,” Brosious said.
“It’s really very much a logistical challenge,” Brosious said.
Bringing bottom surgery to Las Vegas and improving insurance coverage for the procedure will reduce some of the barriers to care that transgender people experience. It will also be beneficial for patients’ safety, as the complication rate for bottom surgeries is high and follow-up appointments are often necessary.
“I’ve had one transmasculine patient who got a phalloplasty and had complications, so every time he had a complications, he had to go out of town again because he couldn’t find anybody in town who would work on somebody else’s surgery,” Phoenix said.
To bring bottom surgeries to Las Vegas and improve overall care, Brosious is assembling a team of local medical professionals, including surgeons, therapists, psychiatrists and endocrinologists who are well-versed in the medical needs of transgender people. The Center, which receives calls daily from people seeking referrals for those professionals, is also involved.
“It’s down the road and it’s not guaranteed, but people are trying to coordinate to make improvements, because there are a lot of gaps right now,” MacFarlane said.
The ultimate goal of the quasi-coalition is to create a comprehensive resource for transgender health care in the form of a local medical center, Brosious said.
Ayers sees the coalition and the efforts of Brosious as the most promising route for him to get bottom surgery. He recently began the process of getting the necessary paperwork for top surgery with Brosious.
“I had a top surgery consult with him last week. He was very positive, very affirming,” Ayers said. “Come spring, when I get the other things handled, I can have my top surgery finally.”