Translated from the German original, «Was die Kasse nicht sieht».

Every two weeks I lie down in the same chair to have the hair removed from my face, hair by hair. My health insurance doesn’t pay a cent for it. Chin, jaw, neck. The technician sets a fine needle, a small sting, a brief jolt of current, then the beep of the machine. It hurts, without numbing cream I couldn’t bear it. I can’t speak while it happens, so I listen to podcasts, from Meyer:Wermuth to *innenpolitik, the SP’s feminist podcast. After an hour I’m still lying there, counting in my head. Not the hairs disappearing one by one, but how many of the hundreds of hours are still left until they’re all gone.

In my first post I wrote about what no one had told me beforehand: that the civil registry office wasn’t the end of it. This is the sequel. Only this time it isn’t about forms, it’s about money. And about a question I had never asked myself. Who actually decides what about me is medicine and what is just vanity?

The answer is in the law. Basic insurance pays for gender-affirming treatment if it is effective, appropriate and economical (Art. 32 of the Swiss Health Insurance Act), meaning medically necessary. Whatever counts as purely aesthetic does not count as treatment, and is not paid for. That sounds reasonable. The only problem is who gets to apply the word aesthetic. Because almost everything I do to be read as a woman can also be dismissed as vanity. It depends on who is looking. And who gets to decide that could be changed.

It starts with body hair. My hair growth is the one I was born with, on the darker side, on the denser side. The insurance should actually pay for this. The Federal Supreme Court has held that typically male hair on visible parts of the body must be covered, and visible there even means what shows during sport, swimming or in a summer dress (ruling 9C_465/2010). I invoked that, applied for cost approval several times, argued with my insurer. Without success. The argument against it I now know by heart: women have that too. For most of them some fine down, a few hairs here and there, sure. But what grows back on me daily, dense and fast, is nothing like it. Still, that one line is enough to turn a treatment into cosmetics. In the end I pay for it myself. You learn early that your own body is a running bill.

With the face it gets strange. Needle epilation, killing off one by one the light and grey hairs no laser catches, is paid for by the insurance, but only if a doctor does it. At a beauty studio it isn’t (Federal Supreme Court, ruling 9C_183/2016). That’s the rule. Except I don’t know of a single medical practice that offers it. So I end up at a studio after all, and therefore paying myself. Not because the treatment isn’t mine to claim, but because there is no one from whom I can get it in a way the insurance will cover. A right that exists on paper but is never applied in reality.

At the next step it is no longer the insurer who decides, but in the end a court. With facial feminisation the question is whether a feature in my face is typically male and incompatible with a female face. People have genuinely argued over jaw angles. Over millimetres of bone. Whether my jaw is male enough to justify a treatment, or whether a woman could have it too. The Federal Supreme Court has narrowed the duty to cover facial feminisation: only where a feature is typically male and incompatible with a female face (ruling 9C_123/2022). In plain terms: whether I have a claim depends on how someone else reads my face. The Transgender Network calls this narrow reading incompatible with the current state of medicine.

I’m doing it anyway. Just not here. For this I go to France, because it costs a fraction there. Not because it would be faster. I have to wait there too, two years. The lists are that long because women come from half of Europe, from Switzerland, from Germany, from everywhere, even from overseas. One surgeon, one operating table, and in front of it a queue that reaches across borders. I am one of many, and that is the point. It isn’t my bad luck, it’s a pattern that looks the same everywhere. The insurance pays for treatment abroad only in exceptional cases anyway, and lower costs explicitly may play no part in that (BGE 145 V 170). You don’t leave the country to save time, but because you can’t afford your own face at home.

Finally the hair that goes. Male-pattern hair loss is exactly the thing that gives you away. The hairline that recedes. The crown that thins up top. From behind too, in passing too. A transplant can only be done while there’s still enough of my own hair to move. And that’s exactly when it counts as cosmetic. As if it were the same for me as for a man who is getting older. For me it is the remainder of a body that grew in the wrong direction.

The insurance does pay, mind you. Genital surgery is recognised once the conditions are met. Breast augmentation is covered too, if little breast tissue grew under hormones. But that little clause. If little grew. Whether that’s the case is not mine to decide. The insurer’s medical examiner decides it. That person judges whether enough is missing for it to count as necessary and not as a wish. The same authority as with the jaw, only further down. In the end there is always a stranger sitting there, estimating how male my body still is.

And to even get that far, I have to document my body. Photos of my beard growth, photos of my breasts, sent off to the insurer. For the beard photos I had to let the hair grow for days, exactly what I otherwise shave off every morning. In that time I barely looked in the mirror, and I hardly dared to leave the house. You do it because you have to. But in moments like that I’m not a person, I’m a case in a file.

When I take a step back, I see what’s behind it. What stays under the clothes, the insurance pays for reliably. What people see on the bus, in the office, on the street, gets difficult. And the face is, after all, what decides things for me day to day: whether I’m read correctly, whether I draw sideways looks, whether I feel safe, whether I have to endure hate or fall victim to it. Of all things, that is what most readily counts as vanity.

A year ago I became Alyssa in five minutes at a counter. That was easy, and I wrote back then that this ease was no accident, but fought for over years. With the costs you see the other side. An hour of electrolysis costs around 190 francs. All of it I pay myself. To manage it, I give up a lot, a small flat, no travel, every franc left over goes into the treatments. I’m not asking for anything for free. But someone who gives up that much to pay for a treatment doesn’t consider it a luxury.

The system, as it stands today, does not work. It has too many gaps. Some could be closed without much effort, for needle epilation, for instance, all it would take is a place where a doctor oversees it, and it would be covered. Others weigh heavier. But at its core it comes down to one sentence: it cannot be that my life depends on whether someone regards the treatments I need as aesthetic or not. Not only mine, but that of many others.

That is exactly why I’m writing about it. I want to name these gaps so they don’t simply stay. I’ve decided not to wait for someone else to fix it, but to take it on myself. To become more politically active. Or, here on this blog, to let my thoughts run free.

Next week I’ll be lying in the chair again. Chin, jaw, neck. Hair by hair. And in my head I keep counting the hours.