Monique Fontaine eyes her cellphone screen as she records a video from Mount Sinai Beth Israel hospital in New York City. Flanked by cords and containers and a copious amount of beige, she and her doctor have agreed to enlarge her breasts, so she can look more feminine, from a B cup to a C cup, with implants surgically placed above the pectoralis muscle and filled with 425cc's of saline. It's not her first such procedure, but it is the first one performed in a medical facility, a far departure from the other locations — a Times Square hotel room, someone's living room in Brooklyn — where she's had work done before.
"See ya on the flip side," Fontaine says to her social media followers before the video ends. Fontaine is transgender, and, thanks to recent changes in New York State law, her procedure is covered by Medicaid. Not only does her breast augmentation come at no cost to her, but it comes with the peace of mind of being done safely and by a medical professional.
Procedures that transgender individuals like Fontaine undergo as a part of their gender transition typically include hormone therapy (for trans women, a combination of estrogen and the testosterone blocker spironolactone, which helps with inhibiting hair growth, redistributing body fat, growing breasts and softening skin), cosmetic surgery, and, often, gender reassignment surgery. Male-to-female gender reassignment surgery consists of removal of the testicles and penis and the creation of a vagina made from the remaining skin. In female-to-male procedures, the uterus and ovaries are removed and a penis is created from tissue taken from the forearm or thigh.
Monique Fontaine gets dressed in her apartment | (Jessica Bal/Courtesy Narratively)
Insurance companies tend not to cover the expenses of gender reassignment surgery, which can cost anywhere from $40,000 to $100,000, depending on the type of surgery. They also generally do not cover facial feminization surgery, which can consist of forehead and jawbone shaving, and run between $12,000 and $40,000. New York Governor Andrew Cuomo introduced a regulation, enacted into law in 2015, that requires Medicaid, along with private insurance companies in the state, to cover hormone therapy for trans individuals over the age of 18, as well as gender reassignment surgery for individuals 18 or older, or 21 and older if the surgery includes a hysterectomy or otherwise results in sterilization.
While the law was hailed as revolutionary for the transgender community, some trans women took issue with the fact that the law prioritized gender reassignment surgery, while leaving out procedures such as breast augmentation and facial feminization, which are deemed cosmetic. For many transgender people, the ultimate step in transitioning is not reproductive organ surgery.
Fontaine, for one, is not interested in having a vagina. Fontaine, who works as a beauty consultant at a Manhattan drugstore, feels it is precisely her trans identity that makes her unique and more attractive to certain men, including her boyfriend of four years. Fontaine had her testicles removed so that she could scale back on the hormone treatments, but she plans on keeping her penis. For one thing, she believes gender reassignment surgery would jeopardize her relationship with live-in boyfriend David Green, a cisgender male. "Once I have gender reassignment surgery, I'm like any female, [except] I can't have kids," she points out. "In some ways, I stick out because I have male and female parts," she asserts — and she doesn't see that as a bad thing. "That's a huge reason for being with a trans woman. I honestly don't want to get gender reassignment surgery."
Many transgender advocates and psychotherapists argue that all transgender individuals are not created equal. Lourdes Hunter, co-founder and executive director of the TransWomen of Color Collective, believes the legal framework of providing medical coverage to transgender individuals does not quite go far enough. "Trans people are not a monolith," Hunter observes. "It's possible to feel trapped in the wrong body. It is possible to feel like I need to assimilate to this image that society and religion say I need to look like a women to be accepted. It is also possible to love your body the way it is and reject gender and be trans. It is possible to not take medication and not conform to gender performance and still be trans."
According to SJ Langer, psychotherapist and executive committee member of the Psychotherapy Center for Gender and Sexuality, Fontaine's decision is not an uncommon one among transgender individuals because of the diversity in gender identities. He worries that new laws might push people to go through surgery even if they're not ready for it. "Gender is so complicated we can't reduce it to one standardized set of traits," he said. He's also concerned that, as transition methods become standardized through Medicaid, that more people will feel as though they must undergo male or female surgeries.
"There is nowhere in medical science that you find a definition for what is 100 percent male and what is 100 percent female. Nobody knows how to define that," adds Dr. Jamison Green, former president of the World Professional Association for Transgender Health, a professional organization that promotes and sets medical standards for transgender health.