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Intermountain Health rethinks bottom surgeries for adult transgender patients

Amber Chevrier smiling outdoors on a sunny day, May 11, 2023. She was on track to undergo a vaginoplasty at Intermountain Health until the organization said it would not be offering the procedure.
Saige Miller
Amber Chevrier smiling outdoors on a sunny day, May 11, 2023. She was on track to undergo a vaginoplasty at Intermountain Health until the organization said it would not be offering the procedure.

Amber Chevrier has known something wasn’t right with her body since puberty. She didn’t have the words though to describe how she felt until she met a transgender woman in her mid-20s while playing a game online.

“I asked if she would be comfortable talking to me and answering some questions about what gender dysphoria was like. She explained it to me, and every word that she said started to hit harder and harder,” Chevrier said. “Everything that she described as being her before she came out was how I was feeling all of the time.”

Those conversations changed her world. Depression and anxiety started to consume her, “partly because of learning about dysphoria.” Chevrier moved back home with her parents in Florida but the feelings didn’t disappear. The depression, she said, prompted her to start transitioning.

Chevrier publicly came out as transgender in 2021 and soon started on hormones. Then came laser hair removal and voice training. And because she had a better support system in Utah, she moved back. Now, in her 30s, Chevrier was ready to take another big step in her medical transition – vaginoplasty surgery.

“A big aspect of my dysphoria was bottom dysphoria. It was something that's been a struggle for me,” she said. “And I genuinely want to be able to get to a point where I can have that part of my transition, get that surgery done, and just feel more true to myself, more as who I am.”

On Feb. 27, Chevrier received a call from Salt Lake City-based Intermountain Health that changed everything. She was no longer able to receive the vaginoplasty surgery she was working to prepare for.

“The best way to say it is that it was kind of crushing, like all of that excitement that I felt about the fact that I was cared for,” she said. “And then it came crashing down because they just made it clear that actually, no, they [Intermountain] don't really care for us.”

Nationwide — and in Utah — gender-affirming care is politically in the hot seat. The uncertainty left in the wake of the bans sweeping Republican-led states is creating both a rush to secure care and a grey zone for practicing providers and physicians.

A change of plans

Intermountain’s decision to not offer phalloplasty, metoidioplasty or vaginoplasty — also known as “bottom surgery” — to adult transgender patients diagnosed with gender dysphoria came after Dr. Nicholas Kim had already begun seeing patients as the provider’s gender care surgical director.

Kim, a plastic surgeon by training, specializes in gender-affirming care, specifically bottom surgeries. His expertise is discussed in a video from Intermountain Health’s Project Echo uploaded on Feb. 14. His license to practice medicine in Utah was issued in 2021.

Intermountain did not answer KUER’s questions about why they prohibit bottom surgeries for transgender adults diagnosed with gender dysphoria. In a statement, the health care nonprofit reaffirmed its commitment to LGBTQ patients but noted that bottom surgeries “have never been performed at Intermountain facilities for gender care.” They also stated that the procedures in question “are offered in the community by other providers.”

“Intermountain always has and continues to help patients navigate their gender care journey and is committed to helping these patients connect with the care they need, whether internal to Intermountain Health or through our community partners and referral resources,” their statement concluded.

In an internal frequently asked questions sheet about Intermountain’s gender-affirming care policies obtained by KUER, the answer as to why the company hired “a surgeon capable of specific procedures if there was not a plan to offer these to patients” did not provide any clarity.

“Intermountain aims to hire the best, most skilled surgeons. Some surgeons or providers have skills that we do not utilize in their current role,” the sheet read.

The FAQ also said the decision not to offer bottom surgeries “was carefully reviewed and made by a team of Intermountain leaders,” and that they have “determined not to add these surgical procedures for gender dysphoria at this time.”

Chevrier’s journey started in October 2022. Since she has SelectHealth insurance, which is accepted at Intermountain facilities, she scheduled a consultation with Dr. Kim and his team.

The initial process was “a bit scary,” but she was also excited about the opportunity to receive the surgery. Chevrier said she was walked through the surgery expectations and what she needed to do to prepare. But most importantly, Kim made her “feel very comfortable about the whole process” and it made her “trust him a lot because of it.”

The medical team was in regular contact with Chevrier up until six months before being able to schedule a surgery date, when she got the phone call from an Intermountain social worker about the change in policy.

“I wasn't expecting that type of news,” Chevrier said. “My mind kind of went blank for the rest of the conversation because it just was pretty crushing.”

She didn’t receive a reason why Intermountain decided to forgo bottom surgeries for only transgender patients. In email correspondence with a member of the surgeon’s team, they apologized to Chevrier for not being able to get the surgery and gave her options outside of Intermountain where she could pursue care. None were covered by her health insurance.

If Chevrier were to get the procedure at another facility, she would have to petition her insurance to pay for it. She would also get a whole new care team.

Chevrier isn’t confident Intermountain will ever offer bottom surgeries at its facilities. And she isn’t keen on starting the process over just for “some person in charge to say ‘We’re not doing this anymore.’”

Even though she’s pausing her surgery, it’s not going to stop her from getting it one day. It’s too important to her.

“I was born and raised being told that I was a boy. I am not. I am a woman and I deserve to have the care that allows me to express that,” she said. “It's what I want. It's what I need to be able to feel like the person that I truly am, so that I can look at myself in the mirror and actually like what I see.”

Orion Enceladus standing in front of a fireplace at the Legendarium, a bookstore he co-owns in Salt Lake City, May 11, 2023.
Saige Miller
Orion Enceladus standing in front of a fireplace at the Legendarium, a bookstore he co-owns in Salt Lake City, May 11, 2023.

Broken communications

Confusion with Intermountain’s gender-affirming care policies didn’t end with Chevrier. While bottom surgeries are a no-go, full mastectomy procedures, or “top surgery,” for adults are performed at Intermountain facilities.

Orion Enceladus has been grappling with his gender identity for the last 30 years. When he came out as nonbinary and began using he/they pronouns, Enceladus said he felt euphoric. It wasn’t until earlier this year that he made the decision to seek gender-affirming medical care.

“When I decided I needed top surgery, I was like, ‘Wow, this cannot happen soon enough.’ You know, like this should have happened yesterday,” he said with a slight giggle.

He also has SelectHealth insurance and called Intermountain to schedule a consult appointment. Even though the appointment was far out, in August 2023, Enceladus said it was a step in the right direction toward living his authentic life.

Then Enceladus received a May call from Intermountain staff.

“They said ‘we wanted to let you know that your appointment for top surgery consultation has been canceled. Dr. Kim will no longer be providing that care through Intermountain,’” Enceladus said.

He added that he was given no alternative options for care and didn’t get an answer as to why top surgery wouldn’t be performed any longer. He was taken aback by the news, especially because the surgeon was one of the only providers who could perform the surgery within the Intermountain network.

“I just felt like I had any sense of control over my body just ripped away from me,” he said, “because my insurance wouldn't cover anything else.”

Since Enceladus determined top surgery was absolutely vital for his mental and physical well-being, they opted to pay out-of-pocket and get the surgery done at University of Utah Health. The higher out-of-network cost is worth it to Enceladus, though, because he “just need[s] this care.”

As summer approached, Enceladus received a stack of paperwork from Intermountain to fill out ahead of the original August consultation. He was perplexed because he was under the impression that surgery through Intermountain was off the table. When Enceladus called, it was discovered that an error was made by someone on staff. Intermountain is still performing top surgeries, the surgeon is accepting new patients and Enceladus was supposed to be one of them.

In a phone conversation shared with KUER, the Intermountain employee told Enceladus “that is very strange” that he was told Kim was no longer performing top surgery and that his consultation was canceled.

The employee told Enceladus a new employee “probably just got her names crossed” and confused a social worker with the surgeon. Enceladus’ appointment with the social worker was canceled – not his surgery consultation.

“I'm so sorry that information was so butchered,” the employee said to Enceladus. “I apologize.”

Now, Enceladus is torn on what to do. Stick with the scheduled surgery at University of Utah Health and pay out of pocket? Or stay on track through Intermountain and wait nearly a year to get the top surgery in the network?

Either way, Enceladus is getting the surgery and it’s a day that could not come soon enough.

“Being queer and trans and when you feel dissociated from your body for like 38 years of your life and then you have this tangible like hope that you might actually connect with your body for once,” he said. “It's like, ‘Oh wow, this is how most people walk through life,’ and I've never had that. So yeah, it feels amazing.”

Saige is a politics reporter and co-host of KUER's State Street politics podcast
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