German Trans Surgery Bureaucracy 101

Every now and then English speaking people ask about the way to get surgeries (especially SRS) paid by German public health insurance. So here is my 101. I will amend it when new questions or difficulties come up.

Basically you need to write an Antrag (application) to your public health insurance, and they need to decide about it within five weeks. The difficulty is in the documents that you need to send with your Antrag, because they are meant to prove that you fulfill all the requirements for SRS. These are especially:

  • 18 Months of psychotherapy
  • 18 Months of real life experience
  • 6 Months of HRT
  • Your genital configuration (in case of srs) needs to be „normal“ and surgery possible and with good prognosis

So the first thing is to fulfill those requirements.

To get psychotherapy you need to make an appointment for a Vorgespräch (preliminary appointment) with a therapist. It’s good to go to a therapist with trans experience (ask in the community for recommendations) so they don’t try to „heal the trans“ or are reluctant to give you the necessary papers. For payment you only need the Gesundheitskarte, it’s good for the first four appointments, in that time the therapist will apply for the therapy at your Krankenkasse, you don’t have to do anything for it.

The real life experience needs to be described in the report of the therapist. So it is good to discuss right away what would be the requirements that they write it in the report. If you are already full time, then that should be enough (the 18 months of real life experience are then just the 18 months of your therapy where you go about your normal life), it is jut important that they write it in the report.

In case you are not in HRT yet, after some time the therapist should write you an Indikation (recommendation letter) that you can then take to an endocrinologist who can then prescribe you hormones. For the first appointment at the endocrinologist there is usually a long waiting time, and usually they first want to make some tests before they write the prescription, so it is good to start the process early.

Then you need to look for a surgeon. There are a good handful in Germany, with different methods and different outcomes, so it is good to ask around in the community for recommendations. It is important to not care about geographical distance, because the good ones are seldom close by. Then you should make appointments for Vorgespräch for a few ones that you consider fitting for your needs. There often is a large waiting time for those appointments, so it is also good to start early. At the Vorgespräch you can ask your questions (it is good to write a list of questions beforehand, to not forget anything important) and they usually will also do a medical examination to assess whether surgery is possible and how and also to be able to write the necessary documentation.

You should get the following elements in the documentation from them:

  • Description of your medical condition (descended testes for example)
  • Confirmation that you have been informed about risks and limits of the procedure
  • Confirmation that surgery is possible and that there is a good prognosis for the outcome
  • Usually also date for surgery (kind of fictional, but necessary for the application)

If you don’t get that documentation, call them. Some also only give it to you if you provide a recommendation for surgery from your therapist. Best ask about that beforehand when you make the appointment. Then you need to decide for a surgeon.

For the Antrag best is to ask the insurance about the necessary documents and ask them to send you a list of them. This paper is very helpful in collecting the documents. The doctors can read what they need to write and also have a contact (in the letterhead) to ask if something is unclear and also to regulate the payment for their reports. Usually you need the following documents:

  • Verlaufsbericht of your psychotherapy, confirming the 18 months of therapy and 18 months of real life experience and detailing that surgery is necessary.
  • Current hormonal status from the endocrinologist, also mentioning the time when HRT has been started.
  • The documentation of the surgeon as described above.
  • Usually they will also ask for the letters from your name change. If you have them and they are positive, send them, but the insurance is not allowed to require them.
  • Sometimes an additional psychiatric evaluation is necessary, especially if your psychotherapist is not a doctor. Usually that should be doable in one or two sessions, ask around in the community or ask your psychotherapist for recommendations.
  • Then a „Persönliche Stellungnahme“ (personal statement) is asked for. There you should write personally why you want the surgery and also describe what other medical interventions you plan and why. If you have a „transssexueller Lebenslauf“, for example from your name change, you can send that as well.

When you have all the documents, you can send your Antrag to the Krankenkasse. Make sure you get a written confirmation of the reception of the Antrag, either by handing it personally and having it confirmed by signature on a copy, or by sending it via „Einschreiben mit Rückschein“.

Within three weeks the Krankenkasse needs to send a reply. Usually they will send something that they have send it to the MDK for evaluation.

Within five weeks after reception of the Antrag, the Krankenkasse needs to decide on it and send the answer to you.

If you haven’t received anything within six weeks (allowing some time for post), the Antrag is legally approved (§ 13 Patientenrechtegesetz). Then you write a letter to the Krankenkasse informing them about that fact and giving them notice to send you a Kostenübernahmeerklärung.

Otherwise they will either send you a Kostenübernahmeerklärung or will require some additional documents. Then you need to collect those and send them in.

If you have the Kostenübernahmeerklärung, you send a copy to your surgeon and ask them for a surgery date. Sometimes they will also put you on a „quick waiting list“ in case someone cancels and then you can jump in and get the surgery earlier. They will also give you the information when to show up where for surgery and what to bring. They might ask for the original copy of the Kostenübernahmeerklärung when you show up.

 

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Transgender terminology in German

I was asked to answer a few questions about transgender terminology in German, so I thought I might as well post it on my blog as well:

1) Do you remember the first time you had heard of a transgender person? About when was this? How were they described? What terms were used? Would you consider this a negative or positive?

I am not sure when was the first time I heard of a transgender person. I remember watching a documentary about a couple of a cis man and a trans woman, where the cis partner said that he sees her as a woman and that I couldn’t really believe him.

The documentary had a positive view of the trans person as far as I can tell and remember, but I had a (pre-formed) negative view.

2) What are typical terms you have heard in your community to describe “transgender” recently? (German/English)

The English word „transgender“ is considered an umbrella term. In German this has at least four distinct meanings:

  1. Umbrella term (used by people who mostly follow English language discourses about trans)
  2. A person who is only concerned about social transition, not physical transition (used mostly by people with old-school respectability politics to distance themselves)
  3. A person who only lives part time as „the opposite“ gender of the ones they were assigned, usually only socially (old-school, used mostly for AMABs, the switching is usually between the socially recognized binary genders)
  4. A person who lives „beyond gender“ (used mostly for afab enbies, but not that much anymore)

In general this word is not used much anymore, mostly because it has such a blurred meaning.

Other words that are used are

  • „transsexuell“ (transsexual) this word is used some times in the medical community, also in its form „Transsexualismus“ (transsexualism). Also it is used by people with old-school respectability politics to make it clear that they have a physical problem and not a mental one, and that their primary concern is physical transition and not social transition.
    This word is rejected by other parts of the trans community because it has the word part „sexuell“ in it, which in German usually refers to sexuality, not sex. So it evokes ideas of „transsexuality is the extreme form of homosexuality“ or transsexual people transition for sexual gratification, along with images that trans people are usually sex workers (with the corollary that they are usually trans feminine).
  • „transident“ (trans-identified) this was developed to avoid the confusion with sexuality of the word „transsexuell“, clarifying that it is about (gender) identity, not sexuality. For reasons unknown to me, it has been largely adopted by the medical community (if they want to appear progressive) and by factions of the trans community.  I don’t consider it very helpful, because there are many identities, not just gender, and the word does not clarify which identity it is referring to. Other parts of the trans reject it because it refers to identity, which is often (especially in feminist circles) considered as referring to only gender roles.
  • „trans*“ this was tried to establish as an umbrella term, but more or less failed. People who describe themselves as transsexual see it as referring only to identity and not body. For some reason it is mostly used to describe afab enbies.
  • „trans“, following the English language discourse why the asterisk is not good.
  • „transgeschlechtlich“, which would be a literal translation of either transgender or transsexual since Geschlecht in German means both sex as well as gender. So it can be used to avoid the distinction between sex and gender and make clear that it can be used for both. Many people who call themselves transsexual see this term as meaning „beyond gender/sex“, something like non-binary, and thus feel their own binary genders not respected when this term is used for them. See also Helena’s comment under this article for this term.

3) Are there any additional popular terms that you have heard people use besides transgender? Please list the most popular ones you know of. (For ex: non-binary, genderqueer, agender, etc.)

  • „Menschen mit geschlechtlicher Fehlzuweisungserfahrung“ (people with gender misassignment experience), basically to avoid using any words that contain trans, in a hope to avoid the connected stigma.
  • „Frauen mit vermännlichten Körpermerkmalen“ (women with masculinized physical attributes), used by people with old-school respectability politics , to stress that their true gender is the one they see themselves as. I have not seen a comparable word for transmasculine people, this type of politics is strongly transfeminine dominated.
  • „weder*noch*“ (neither*nor*), basically agender
  • „nicht-binär“ (non-binary), basically a translation of non-binary.
  • „genderfluid“, same as in English, mostly used for people whose gender presentation (and sometimes identification) varies.
  • „Transfrau“ / „Transmann“ (trans woman / trans man). The distinction between „trans woman“ / „trans man“ and „transwoman“ / „transman“ is lost in German and some people reject the terms for similar reasons the terms „transwoman“ / „transmen“ are rejected in the English language trans community.
  • „Transmensch“, „Transperson“ (trans person)
  • „tt(i)“ (short for transgender, transsexual (intersex)): an attempt to form an umbrella term while at the same time to accomodate the need for the transsexual community to be named separately. Mostly used in souther Germany.
  • NIBD (neurointersexual body disorder?) and its predecessors BdBds (?, body dysphoria, body discreprancy disorder?) and HBS (Harry Benjamin Syndrome), different ways to describe that trans is a physical and not a mental issue.

4) Do you find that terms for transgender identities are changing/evolving in your community? (German, specifically) How have they evolved, if you have seen this?

There seems to be a split in the community, which probably goes with the surrounding society the trans people live in. People who live in more conservative areas largely form binary, body oriented gender identities, often also connected with rather conforming gender presentations. People who live in more progressive areas or in progressive (for example leftist and/or queerfeminist) subcultures often have more fluid gender identities, choose only few physical transition steps and are more critical of gender roles.

The second group seems to become larger, however that might also be my personal bias driven by the communities I predominantly move in.

There has been a move from trans* to trans, and the term tt(i) has been newly introduced. The term transident is used less now. Also among the „transsexuell“ faction, neurosicence has become more important and thus terms that try to center that, like NIBD.

5) What do you find most confusing about the language used in the transgender community? Is there anything you wish either English/German had to compensate for something lost or not translated right?

There are a lot of terms floating around, and for basically any term you find a group of people who will be offended by it. These different terms reflect the different strategies trans people use to improve their situation, especially concerning social stigma.

The German language discussion about these issues seems to be five to ten years behind the English language discussion and misses some important terms and concepts, for example „respectability politics“. There is a continuous movement back and forth of trying to create an umbrella term that then will be used mostly by only a subgroup and then will be rejected by others because of its connection to that subgroup.

Those factions that are following a lot of English language discussions and/or are academics use terms that are often not really accessible to others, even if they are translated. English language terms have the tendency to sound high-brow when converted to German and/or get very different meanings when used within academia, for example most of the queer theory terms.

For some terms, the English name is used because a German one is missing, like „deadnaming“ and „misgendering“.

6) How do non-binary individuals navigate the gendered language of German? If you are not non-binary, what have you observed?

German has quite a few gender markers besides pronouns, for example most professions include a gender marker in their names. Within feminism different strategies have been developed to work around that, for example the Gender Gap. They are often used to not assign binary genders to non-binary people in language.

7) How have you seen people use pronouns (or lack, thereof). If you identify as such (non-binary, etc.) what pronouns do you use? How easy/hard is it to navigate pronoun systems in German?

There are no more or less recognized non-gendered pronouns in German. Some non-binaries ask to not use pronouns at all, and instead use their names. Often they choose very short names to make that easier. Others ask to use whatever pronouns or to switch. Theoretically there are some non-gendered pronouns available, but they are so little known that hardly anybody uses them.

8) Is there language used by the mainstream media (newspapers, tv, online, etc), or majority of people to describe transgender identities, that makes you upset? (German media specifically) If so, do you see any trans representatives working with/against the media to fix this at all?

Quite a few of such „fails“ happen often, like „Geschlechtsumwandlung“ (sex change) or „als Mann geboren“ (born a man). Also there is a lot of deadnaming or misgendering. Different organizations work against that and even publish media guides. Transinterqueer in Berlin does a lot in that regard. However, few media look up such guides before publishing things.

9) Do you see a generational difference with the words used to describe transgender people in your community, or navigating pronouns? If so, could you mention what those differences seem most often to be?

Younger people are usually more open to non-binary gender identities and thus also sometimes use ways to get around pronouns. Older people more often use essentialist descriptions and terms for their gender experience.

10) Do you see an ethnic difference of words or terms used to describe transgender people, or pronouns used? This may be information you have gathered on people you have met with/are friends with, or personal observations. For example, the observation of Native Americans currently using “two-spirit”.

I  don’t of know any specific words that ethnic minorities use in Germany.

What I do observe, however is, that people living in conservative areas use different language and different descriptions of their genders than people living in progressive areas or moving in the queer feminist subculture, as described in my answer to question four.

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Safer Sex mit Transmenschen

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Wenn eins wissen will, was zu beachten ist, damit Sex sicherer wird, ist es relativ einfach, Informationen darüber zu bekommen, wenn es um Sex geht, bei dem ein cis-männlicher Penis involviert ist. Für Sex ohne einen solchen wird es schon schwieriger, und bei Sex mit Transpersonen1 sind, gibt es fast nicht mehr, egal wer sonst bei dem Sex dabei ist und egal ob sie einen Penis haben oder nicht. Deswegen möchte ich dazu ein paar Hinweise geben.

Weiterlesen

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Offener Brief ans SchwuZ

Schon vor längerem wurde auf medium.com wegen rassistischen Vorfällen ein Open Letter to SchwuZ veröffentlicht. Ich vermute jedoch, dass er, vor allem wegen der Sprache, leider keine große Reichweite bekommen hat. Jetzt hat jemand den Brief auf deutsch übersetzt und deswegen möchte ich ihn hier teilen: Weiterlesen

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Kritiken zu Beißreflexe [update]

Im Moment habe ich keinen Nerv, mich zu dem gerade viel diskutierten Sammelband Beißreflexe zu äußern. Ich habe in der Debatte aber festgestellt, dass Texte, die das Buch kritisieren, schlechter auffindbar sind, als solche, die es loben. Das zeigt m.E. auch schon das ungleiche Machtverhältnis, bzw. die unterschiedliche Sichtbarkeit an, um die es in dem Buch, bzw. in den von dem Buch kritisierten Praxen geht. Deswegen möchte ich hier einmal die ein paar aus meiner Sicht wichtige Texte verlinken, mehr oder weniger in order of appearance: Weiterlesen

Veröffentlicht unter Feministisches, Trans | Verschlagwortet mit , , , , , , | 2 Kommentare

Bilder aus Bosnien

Vor ein paar Wochen war ich mit dem Friedenskreis Halle auf einer Besuchs- oder Studienfahrt in Bosnien. Da ich vor langer Zeit, nach dem Bosnienkrieg, dort knapp zwei Jahre als Freiwillige_r für Friedensarbeit gearbeitet hatte, und seit neun Jahren nicht mehr da war, war es sehr spannend für mich, alles wiederzusehen und auch zu sehen, was sich verändert hat und was gleich geblieben ist.

Hier mal ein paar bildliche Eindrücke. Und ja, sie sind tatsächlich alle aus Bosnien, die Hercegovina war leider nicht im Besuchsplan.

Jajce und Umgebung

Hier ein Eindruck von unserem Hostel und dem Stadtzentrum, wo es sich befand:

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Nicht sehr spannend, aber für mich gibt es einen guten Eindruck der Stimmung, die in meiner Erinnerung oft vorkam. Und ja, es hat mir trotzdem sehr gut gefallen!

Deswegen hier auch noch ein Bild vom wirklich schönen Park am Wasserfall:

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In der Nähe gibt es die Mlincici, kleine Mühlen, die früher verschiedenen Familien aus Jajce gehört haben, die dort ihr Mehl gemahlen haben:

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Und außerdem den Balkan-See, schon in der Republika Srpska:

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Und dort in der Nähe Zelenkovac, eine Kunstgalerie oder eine ökologische Bewegung oder so:

Sarajevo

Von Sarajevo habe ich dieses Bild gemacht, das wohl in den Kameras der meisten Tourist_innen landet:

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Und außerdem dieses, was für mich recht gut passt zu dem, wie ich Sarajevo erlebt habe:

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Sanski Most

Und dann waren wir noch im CIM’s Bašča Mogućnosti, einem sich entwickelnden Bauernhof (und vielleicht Ökotourismus-Ort?), das zum Center for Peacebuilding gehört:

So richtig auf dem Land zu sein, war eine willkommene Abwechslung (auf jeden Fall für mich) von Sarajevo.

Landschaften

Und zum Schluss noch ein paar Landschaftsbilder:

Wir hatten auch einfach eine gute Jahreszeit erwischt, es war wunderbar grün.

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Kommentar zum AWMF-Leitlinien-Entwurf, Kapitel 8

Die AWMF entwickelt gerade eine neue „S3-Leitlinie Geschlechtsinkongruenz, Geschlechtsdysphorie und Trans*-Gesundheit: Leitlinie zur Diagnostik, Beratung und Behandlung“. Jetzt gibt es die Möglichkeit, den aktuellen Entwurf öffentlich zu kommentieren. Damit mein Kommentar nicht nur in die Tiefen des Leitlinienentwicklungsprozesses gehen, veröffentliche ich sie auch noch hier. Die Hauptüberschriften dieses Artikels entsprechen dabei den Hauptüberschriften der Leitlinie.

Unter der Kommentier-Website ist die Leitlinie nicht mehr einzusehen, hier gibt es eine Version.

Da die Leitlinie lang ist, teile ich meine Kommentare in mehrere Posts auf. Dies ist der achte und letzte Teil, der siebte ist hier, der sechste hier, der fünfte hier, der vierte hier, der dritte hier, der zweite hier und der erste ist hier.
Weiterlesen

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