This is the second story in a two-part series on transgender youth.
The process of physically becoming the gender a transgender person identifies with is called transitioning and requires years of work and tens of thousands of dollars.
Sometimes these services are covered by insurance, but, more than likely, the burden falls solely on the patient.
Drake Eilert is female to male transgender. He regularly wears a binder to compress chest tissue.
"Some are a little more halfway, so they're like a sports bra," Eilert says, identifying the different binders.
Drake wears a binder all the time to help him pass so people identify him as a male. But passing comes with a price - binders can cause physical pain and discomfort.
"There are a lot of risks to it over time," Eilert says. "They recommend 8 hours a day, less is better. It can be physically uncomfortable for breathing. You don't want to sleep with it, it can cause physical pain when you wake up."
Drake says many transgender youth, including a number of his friends, aren't out to their parents and can't afford binders.
So they use things such as duct tape or Ace bandages to suppress chest tissue.
"Those can actually lead to the breaking down of your ribs," Eilert says. "It's gonna reformat your ribs and break down your bone, and can really cause some damage later."
Drake has been lucky. His family supports his transition both emotionally and financially.
"He's my child," York says. "It's gonna bring me to tears. I'd throw myself in front of train for my kids. I'd give them my last breath. I want him to be complete – you know happy, whole, and this is who he's meant to be."
When Drake told his mother the truth about who he was the two came up with a plan. If Drake wanted to transition, Shelia wanted to make sure he did it safely.
The World Professional Association for Transgender Health publishes standards of care that provide best practices for transitioning.
The first step is counseling, so Drake and his mom went to Indianapolis therapist Becky Bickel.
"We want to make sure that our clients are ready that they have the coping skills they need," Bickel says. "That they really understand what this is going to do to their body social, legally. The primary role is to help them think through this and make sure everyone's on the same page and understand that they're doing the something that is potentially irreversible."
Once counselors establish a patient is transgendered, they recommend them to begin hormone therapy.
Drake began taking testosterone just before high school graduation, where his school let him wear a blue robe instead of the white ones girls had to wear.
After about a year and a half of living as his preferred gender, the next step now is top surgery, which Drake has scheduled later this month.
"It's definitely freeing," Eilert says. "I came out I think when I was 17, and after 17 years of keeping that inside, it was like, I can be who I am. It was freeing."
Without Financial Support, Some Turn To The Black Market
It's more difficult for males trying to make the transition to female. Testosterone adds masculine features to a body that can be hard to reverse.
Kayleigh Renner is an example. She's 26 and drives a cab in Bloomington.
She realized she wanted to transition three years ago, and she already felt like it was too late.
"You know, I feel like I'm too old. Maybe 26 doesn't seem old, but you're past puberty, testosterone has done things to your body," Renner says. "It always seems like it's too late, and you think you're never going to pass. But then again you have to think it's never too late, because longer you wait, the harder it will be."
Renner says she realized transitioning was the only way for her to beat depression and have a chance at a normal, happy life.
"Everything is just so much better," Renner says. "There's still those thoughts and that's something everyone has to deal with, but it's nowhere near as difficult as it was. The future in depression is just black. There's nothing there. You can't even contemplate tomorrow. But this is just something I need to do. I can see the end goal, and its something I'm really striving for."
So Renner began the process. She sought counseling, started taking hormones, and scheduled surgeries.
Dr. Gregory Chernoff is a cosmetic surgeon who has been operating on transgender patients for decades. A major part of transitioning from male to female is facial feminization surgeries.
"All the surgical – male to female – forehead lift, hairline advancements, hair transplants to give a more feminine hairline, as part of the brow lift often we'll do a bony reduction of the bossing of the forehead that many men have," Chernoff says. "Eyelid surgery, feminize the nose with rhinoplasty, very commonly we'll do cheek implants chin implants and then do a face and neck lift."
Facial feminization surgeries alone can cost between $30,000 and $70,000, depending on the doctor, and how many surgeries are needed.
Together, top and bottom surgeries for male to female cost about $30,000, so the total cost of transition for Renner could be upwards of $100,000.
As a young adult, Renner was covered under her parent's insurance plan.
But her family didn't welcome the transition for many reasons.
"To them it was this huge blow from left field," Renner says. "The old argument of ‘we didn't see evidence of this as a child, you're kind of making this up, this is a chosen lifestyle, this is not who you are.'"
So when Renner's parents found out she was using their insurance to pay for counseling, hormones and consultations, they dropped her from the plan just days before her scheduled surgeries.
"That was the complete breakdown. It went back to the depression I was in before, just worse because it was so real, it was about to happen, and then it was just gone," Renner says.
Renner was left to pay for services on her own. She also no longer had access to counseling and hormones, leaving her to purchase the drugs on the black market.
"You can't be sure of what you're getting, if what you're getting is the real thing," she says. "Or, if it's fresh and not past its expiration date. The sources – there are several different types of estrogen – there's the bioidentical, the horse mare, and then its like, is this really what it says it is? It's pretty risky."
Insurance's Role In The Transitioning Process
But for those who have insurance, their transitioning process is more likely to be covered than it was years ago.
"Ten years ago, zero people were covered by insurance," Cleveland-based plastic surgeon Dr. Daniel Medalie says. "Now I would say maybe one in five of my patients is covered by insurance. "
He says big companies including Microsoft and Google are starting to include transgender services in their insurance plans to attract more employees and the number of surgeries they actually have to pay for is extremely low.
"There's not a lot of transgender patients in the world," Medalie says. "There are more and more companies that are specifically bargaining out with the insurance companies to have this included."
For now, the one glimmer of hope Renner sees is the Affordable Care Act, which covers counseling and hormones, if she can afford the right plan.
But the Affordable Care Act still doesn't cover any transgender procedures because they are still considered elective, not medically necessary.
Renner hopes to raise money for her surgeries by working and applying for aid through various foundations.
