December 2007 Vol. 4, No. 4 Sexuality Research & Social Policy Journal of NSRC http://nsr c.sfsu.edu Unraveling Injustice: Race and Class Impact of Medicaid Exclusions of Transition-Related Health Care for Transgender People Pooja S. Gehi, Gabriel Arkles Abstract: This article explores how Medicaid policies excluding or limiting coverage for transition-related health care for transgender people reproduce hierarchies of race and class. In many legal contexts, a medical model informs views of transgender experience(s), often requiring proof of specific types of surgery prior to legal recognition of transgender people’s identity and rights. Simultaneously, state Medicaid programs disregard the medical evidence supporting the necessity of transition-related care when considering whether to cover it. In this article, the authors analyze the contradiction between the medicalization of trans experience(s) and government’s refusal to recognize the legitimacy and neces- sity of trans health care. The authors examine the social, economic, legal, political, medical, and men- tal health impact of these policies on low-income trans communities, paying particular attention to the disproportionate impact on communities of color. The authors conclude with recommendations for legal and health care systems to improve access to transition-related health care for low-income trans people. Key words: transsexual; gender identity; economic justice; sex reassignment; health care disparities This article explores how Medicaid policies that exclude or limit coverage for transition-related health care 1 for transgender people reproduce hierarchies of race and class. The authors examine Medicaid policies that exclude transition-related health care, looking at such policies through the lens of social, medical, and legal sys- tems. These systems are intimately intertwined not only in determining when transgender 2 people’s identities are Sexuality Research and Social Policy: Journal of NSRC, Vol. 4, Issue 4, pp. 7–35, electronic ISSN 1553-6610. © 2007 by the National Sexuality Research Center. All rights reserved. Please direct all requests for permissions to photocopy or reproduce article content through the University of California Press’s Rights and Permissions website, http://www .ucpressjournals.com/ reprintInfo.asp 7 Address correspondence concerning this article to Pooja S. Gehi, Sylvia Rivera Law Project, 322 8th Ave., 3rd Floor, New York, NY 10001. E-mail: pooja@srlp.org ; Gabriel Arkles, Sylvia Rivera Law Project, 322 8th Ave., 3rd Floor, New York, NY 10001. E-mail: gabriel@srlp.org 1 We use the term transition-related health care to broadly describe the medical care trans people seek in relation to their gender identity. The term may be used in specific instances to describe specific types of care. However, unless specified, we use it to encompass the supportive psychother- apy, hormonal therapies, surgical procedures, voice therapy, and electrolysis or laser hair removal that trans people seek in relation to their gender. In medical and legal literature, these treatments are also referred to as gender reassign- ment, sex reassignment, sex change, or sexual conversion. Some health care professionals have started shifting to using terms such as gender confirming or gender affirming to refer to these treatments. Transgender health care is another term used to refer generally to such treatments. Like other types of health care, transition-related health care is individualized. Some trans people want and need certain treatments, whereas other trans people want and need other treatments. Still other trans people do not want or need any health care specifically related to their gender— but their gender identity is still legitimate and should be recognized and respected. There is no single, universal transgender experience or narrative (Spade, 2003). or are not recognized in society but also in how these sys- tems support race and class hierarchies. Legal sources of authority often disregard the wealth of medical information that demonstrates the necessity of tran- sition-related health care for many transgender people. Many of these same legal systems rely heavily on medical information to the exclusion of virtually all else prior to recognition of the gender identities and civil rights of