Too Little, Too Late

When the promise of detransition care doesn’t live up to the reality

I am a 31-year-old detransitioned man who transitioned in Oregon between the ages of 20–24. My transition, from 2015–2020, was one of the first to be prioritized by Oregon’s Medicaid program: it included four years of cross-sex hormones, breast implants, and a bilateral orchiectomy. My identity was further rewarded by non-profit organizations and social services which provided food, housing, education, recreation, and employment opportunities exclusively to homeless and at-risk LGBT youth.

On the other side of transgender ideology (and youth), I found myself systematically excluded. The Oregon Health Plan, which prioritized my transition, explicitly named “Reversal of Gender Affirming Care” as an excluded service; and the surgeries I desired (removal of breast implants and insertion of prosthetic testicles) were labeled as such.

At the time, I argued that the surgeries should be included in Gender Affirming Care, and to this day I hold that the exclusion of “detransition” services undermines the legitimacy of so-called Gender Affirming Care; if the same individual can be discriminated against because they no longer identify as a gender other than that of their native sex, it cannot be regarded as “Gender Affirming” in a holistic sense. If it only affirms an expressed identity contrary to that of the person’s natal sex, it can only be called “sex-negating.”

My arguments did me little good. Besides that, my political views and life philosophy were undergoing a radical transformation. An essay by Thomas Szasz, The Therapeutic State, shared on Gender Critical Twitter did more to change my opinion than any single document had before. Since my teenage years in the 2010s, I had assumed uncritically that “universal healthcare” was a human right. Now I questioned if such a system wasn’t tantamount to totalitarianism. So what if my detransition wasn’t covered by state healthcare? Isn’t that what cost me so dearly to begin with? In the words of my most hard-working uncle: “nothing is really free.”

I went to a small, local clinic to have the breast implants removed. I was still in recovery from my transition, which had ended in homelessness, drug abuse, castration, and a COVID infection. I had been employed for over a year, and state insurance wouldn’t cover the surgery.

The surgeon offered to remove the implants with only local anesthesia, leaving the scar capsules in place beneath the severed muscles to eliminate the need for a hospital stay and thus extra fees. It cost a mere $2,000. At the time, I couldn’t stomach the thought of any further operations— much less afford them. I continued my biweekly testosterone shots, went back to work, and deleted my Twitter. I tried (unsuccessfully) to sue my former doctors for restitution, but mostly stayed out of the public eye and politics.

For two and a half years, I worked at a cannery near my childhood home and had an excellent insurance plan. Since leaving that workplace and moving out-of-state (to a very red Midwestern town), I haven’t found an insurance plan that makes sense for me. None of them will cover the pre-existing condition, which makes me dependent on hormone replacement therapy to achieve the normal range of testosterone for a man of my age, nor will they cover the surgeries (removal of scar capsules, removal of breast growth, insertion of prosthetic testicles), at least not in full. In short, I would be tripling my monthly medical expenses without any progress toward the surgical goals. And six years after my detransition, I can firmly say that I want those surgeries.

The Clinic

In June 2026, the Department of Justice announced a settlement with the Cleveland Clinic resolving allegations that the hospital had submitted inaccurate insurance codes in connection with pediatric sex-rejecting procedures. The Clinic denied the allegations, which the Department resolved without a finding of liability, and characterized the matter as an unintentional coding issue involving a small number of patients. As part of the agreement, the Clinic committed $2 million to restorative care for individuals who underwent such procedures before age 19. From the perspective of detransitioners, it might have been better for the Department to litigate the allegations to a public finding rather than settle.

As soon as I heard about the settlement, I hoped it would include my detransition. I called in August and was immediately routed to the LGBT center. After years of icy rejection from medical clinic and insurance receptionists, I have begun to wonder which part of my experience was closer to the norm. Now I have my answer: it was the simpering, giddy, seductive affirmation which is unique to LGBT “healthcare.” I don’t doubt that the average patient in any other corner of the field is treated as contemptuously as they are or charged an arm and a leg, on top of whatever ailment they are suffering.

I am in the loop enough to know where the political tides are turning (around the age of consent), and in my first conversation with the Clinic I mentioned several times that I was over the age of 20 years when I began my transition. The woman from the LGBT center seemed a little too eager to soothe and reassure me that I had already been through so much, and that the settlement would take care of everything. We scheduled an in-person visit with Internal Medicine four weeks in advance. But a few minutes after I hung up, I received a notification for a $1,375 “pre-pay.”

And what exactly was I paying for?

I looked up the doctor I would be seeing, who specializes in internal medicine. She described herself as a guide, or driver, on the patient’s journey, beginning with a “meet-and-greet.” The drive from my current location to Cleveland, Ohio, is three and a half hours. Was it really worth it for a “meet-and-greet?”

For the next two months, I played phone tag with the Clinic’s LGBT center and financing.

Yes, they assured me, the settlement would cover everything. Don’t worry about the pre-pay; it was automatic. It was their fault for not being prepared. It was an unusual circumstance: strong feelings were involved, and I was the first person to request services through the settlement.

No, they told me, unfortunately, the internal medicine meeting couldn’t be avoided, and they couldn’t do it via telehealth. It would have to be in person. But she would reschedule with the head of the LGBT center himself, at his personal clinic.

Bait and Switch?

I planned to make the most of the trip, optimistic as always but taking it with a grain of salt. It was a friend who took a closer look at the DOJ settlement and told me it was exclusive to those who had transitioned before their 19th birthday. I called the Clinic, asked for clarification, and spent another week on hold.

Today, on October 19, 2026, I received the final word from the Clinic: the settlement would not cover my services, nor can financing help since I am out-of-state, besides the 35% discount applied to pre-pay, which would bring the cost of my intake down to $867.75 and any follow-ups down to $690.95.

Joan Didion declared it vulgar to write about money, and also that there is no greater interruption to life than medical expenses; here they combine. I can imagine how many “follow-ups” might be required based on my previous experiences: a consultation, a pre-op, a post-op. For two different surgeries, that would be six meetings which, including the intake, would cost $5,013.45 (not including the cost of gas, mileage, and lost hours of work). Good Lord, imagine the cost of the prosthetics, anesthesia, surgeries, hospital stay, and other fees!

The disappointment strikes portentously ahead of midterm elections. The current administration has made much fanfare about its achievements on this issue as well as others, and I too have been swept up in the excitement. I have seen the excellent work in its beginning. But another might say it is “too little, too late,” and they wouldn’t be wrong.

Forrest Smith spent five years living openly as a trans woman before detransitioning in the fall of 2020. Facing institutional resistance in Portland, Oregon, he turned toward family, faith, and writing to chart a path to recovery and reflection. He recently completed a memoir manuscript and writes long-form reflections on Substack.

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