Culture, Medicine, and Psychiatry

, Volume 41, Issue 4, pp 590–608 | Cite as

Insuring Care: Paperwork, Insurance Rules, and Clinical Labor at a U.S. Transgender Clinic

  • Marieke van EijkEmail author
Original Paper


What is a clinician to do when people needing medical care do not have access to consistent or sufficient health insurance coverage and cannot pay for care privately? Analyzing ethnographically how clinicians at a university-based transgender clinic in the United States responded to this challenge, I examine the U.S. health insurance system, insurance paperwork, and administrative procedures that shape transgender care delivery. To buffer the impact of the system’s failure to provide sufficient health insurance coverage for transgender care, clinicians blended administrative routines with psychological therapy, counseled people’s minds and finances, and leveraged the prestige of their clinic in attempts to create space for gender nonconforming embodiments in gender conservative insurance policies. My analysis demonstrates that in a market-based health insurance system with multiple payers and gender binary insurance rules, health care may be unaffordable, or remain financially challenging, even for transgender people with health insurance. Moreover, insurance carriers’ “reliance” on clinicians’ insurance-related labor is problematic as it exacerbates existing insurance barriers to the accessibility and affordability of transgender care and obscures the workings of a financial payment model that prioritizes economic expediency over gender nonconforming health.


Transgender care Health insurance United states Utilization review Managed care 



My sincere gratitude is due to the clinicians, staff, and transgender people who generously donated their time and insight to this project. They are in no way responsible for any errors or shortcomings in my analysis. I want to say “thank you” to Anna Zogas, Janelle Taylor, Emily Yates-Doerr, Anna Harris, Rima Praspaliauskiene, Anick Vollebergh, and the anonymous reviewers of Culture, Medicine, and Psychiatry for their helpful comments on this and earlier versions of this article.


This study was funded by Netherlands Organisation for Scientific Research (Grant number 400-07-112).

Compliance with Ethical Standards

Conflict of interest

Author, Marieke van Eijk, declares that she has no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.


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Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  1. 1.Department of AnthropologyUniversity of WashingtonSeattleUSA

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