Jake Ferruzzi keeps a picture of himself as a toddler on his desk at home.
In the photo, his younger self is dressed in an oversized turtleneck covered in purple hearts and pink flowers, his light blond hair cut into bangs.
“I never knew the life that I’m living today was possible — like that little kid never knew it was possible,” said Ferruzzi, 29. “I feel like I’m living my life today for him and giving him that joy.”
Even at 3 years old, roughly the age Ferruzzi is in the photo, he knew he was a boy. But he didn’t have a word for the disconnect between his mind and body — transgender — until he was 14. Since then, with support from his family, he’s gotten medical care to help him feel more at home in his body.
This medical treatment, known as gender-affirming care, is lifesaving, according to Ferruzzi and other trans Baltimoreans. It will become more accessible Jan. 1 to the estimated 94,000 trans and nonbinary people living in Maryland. That’s when the Trans Health Equity Act goes into effect, expanding the number and types of procedures that Medicaid will cover in the state.
Advocates celebrated the bill’s passage earlier this year, but it’s expected to put pressure on the state’s infrastructure for providing gender-affirming care. There already aren’t enough doctors trained to provide this type of care, advocates say, and providers are concentrated in cities.
In another stress on the system, other states have moved in the opposite direction, heavily restricting or banning access to such health care, especially for young people. With Maryland Gov. Wes Moore signing an executive order in June to protect gender-affirming care here, advocates say trans people are already arriving for treatment.
It’s like a “double-edged sword,” said M. Tica Torres Bolivar, care coordination manager for Planned Parenthood of Maryland.
“Yes, it’s beautiful,” he said, but “we don’t have the capacity. We already didn’t have the capacity, and now we’re just seeing more and more people coming to get care here.”
Currently, Maryland’s Medicaid program covers some gender-affirming care, such as hormone therapy and some surgeries, for patients 18 and older.
The Trans Health Equity Act adds procedures such as hair alteration, voice modification surgery and therapy, and fertility preservation services to those covered under Medicaid. The legislation said 98 people received gender-affirming care through Maryland Medicaid in 2022. That number was expected to rise by about 25 people per year starting in 2024.
Legislative analysts wrote that the bill will cost “an indeterminate but likely significant amount” because services can range from less than $800 for voice therapy to more than $25,000 for surgeries that change a person’s face to make it look more feminine or masculine.
Del. Anne Kaiser, a Democrat who represents Montgomery County and sponsored the House bill, said she wanted Maryland Medicaid to support procedures covered by private insurance.
The legislation arose from concerns within the transgender community over health care access, said Margo Quinlan, an organizer with the Trans Rights Advocacy Coalition, which formed in part to lobby for the bill. Trans people were denied services by insurers that their doctors deemed necessary, Quinlan said.
The new law will allow people to medically transition who otherwise wouldn’t have the option, she added.
Quinlan said each procedure she’s undergone has “significantly decreased” her depression and anxiety.
Besides mental health improvements, physical safety can be a benefit of transitioning, Quinlan said. While being visibly trans “is not a bad thing,” it can lead to job and housing discrimination, harassment on the street, and violence, she said.
“When trans people are affirmed, whether we’re 7 years old or 70, it is life-changing for all of us,” Quinlan said. “It helps keep us alive.”
The schedule of Dr. Gabriel Alfonso Del Corral — one of the only doctors in Maryland who takes insurance and is trained to provide the spectrum of gender-affirming surgeries — is booked until early 2024.
Del Corral sees an average of 25 patients per week and does more than 100 surgeries every month. His patients typically have to wait about six months for treatment, said Erin Maxwell, a trans care navigator who works for the Center for Gender Affirmation under Del Corral at MedStar Franklin Square Medical Center.
“Compared to surgeons in New York, who have a two-year waitlist, it’s certainly not as bad,” Maxwell said. “But for folks who have been waiting for these surgeries their entire lives, to be told that you have to wait more, it’s really heartbreaking sometimes.”
Maxwell, who goes by they and he pronouns, anticipates demand will climb for gender-affirming surgeries like facial feminization and body contouring. Since Del Corral’s practice at MedStar accepts Medicaid, patients are scheduling appointments for 2024, after the Trans Health Equity Act goes into effect.
Torres, the care coordinator at Planned Parenthood Maryland, said clinics have seen an increase in patients from out of state, with new patients having to wait months for a hormone therapy appointment. Planned Parenthood accepts Medicaid and most commercial insurance.
Most doctors who provide procedures like genitoplasty — surgical alteration to or the formation of new genitals — and chest masculinization work in the Baltimore area, although there are some in cities such as Annapolis. It can be difficult for those who live in more rural areas to get care.
Under Maryland Medicaid, patients being assessed for some gender-affirming surgeries — specifically operations to remove ovaries or testes, and genitoplasty — must be assessed by and receive letters of support from two mental health providers, at least one of whom must have a doctorate.
Nine times out of 10, Maxwell said, the patient requesting the letters isn’t seeing a therapist with a doctorate, which means they have to wait to get an appointment with one. Maxwell understands why the letters are required, but it can be frustrating to see trans and nonbinary patients face multiple obstacles.
“You’re telling someone that to want to align your body with your gender identity and live as authentically as you can, you have to go through all of these institutional hoops while having to be diagnosed with a mental health disorder — because to want to live authentically as a trans person is considered ‘disordered’ by insurance companies,” they said.
Many mental health providers don’t take commercial insurance, let alone Medicaid, and the session required to receive a letter of support could cost anywhere from $50 to $350, said Jennifer Blue, a therapist at Reclaim and Rise, a Baltimore-based mental health practice that specializes in providing therapy to LGBTQ people.
Some providers write letters for free, but “nowhere near enough to meet the demand,” Blue said.
According to a 2021 report from the Center for American Progress, a liberal think tank, 1 in 3 trans adults report an annual household income below $25,000.
“We’re not talking about CEOs and investment bankers,” Blue said. “We’re talking about people who work retail. Trans people, by and large, are not a wealthy population.”
Quinlan said while the passage of the Trans Health Equity Act may increase wait times, it’s worth it to reduce barriers to access.
Now the legislation is in place, the next step is securing funding and infrastructure — such as investment in rural hospitals and telehealth — so there’s support for a potential influx of patients who can’t be taken care of by merely stretching the existing resources, Quinlan said.
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“This isn’t a one and done,” she said.
Especially as more trans and nonbinary people migrate to Maryland, more education on how to care for this population — and more resources for the organizations that work with them — is sorely needed, advocates said.
Baltimore Safe Haven, a nonprofit offering transitional housing for LGBTQ+ people, reported an influx of calls after Maryland became a sanctuary state for gender-affirming health care.
Nearly half of transgender adults report having negative or discriminatory experiences with a health care provider, according to the 2021 report from the Center for American Progress.
When Chase Brexton Health Care, which provides gender-affirming care, hires a new health care worker, it trains them on the fundamentals of gender-affirming care and cultural humility, aspects that may have gotten little attention in medical school, said Sam McClure, executive director of The Center for LGBTQ Health Equity at Chase Brexton.
McClure used to say the health care system was “broken” for transgender people. Then one of her colleagues corrected her.
“Health care simply wasn’t designed for transgender people,” she said. “So we try to fully participate in the redesign.”