Transgender communities across the United States are celebrating an announcement made this week by Washington, D.C., Mayor Vincent C. Gray of an initiative to prohibit gender identity discrimination in the district’s health insurance plans, including Medicaid. 

“Today, the District takes a major step towards leveling the playing field for individuals diagnosed with gender dysphoria,” the mayor said in a press release. “These residents should not have to pay exorbitant out-of-pocket expenses for medically necessary treatment when those without gender dysphoria do not. Today’s actions bring us closer to being One City that values and protects the health of all of our residents.”

It’s a tremendous victory for local activists and organizations like the National Center for Transgender Equality (NCTE) that have invested tremendous energy in changing health-care policy in so symbolic a place as the nation’s capital.

For many transgender people, announcements of equal health-care access—particularly through state-funded services—are met with all the adulation and tearful glee that would attend a state announcing that it has legalized same-sex marriage. This says a lot about the needs and priorities of transgender people, many of whom are still fighting for the basic preconditions for life.

In the wake of a growing consensus around the inevitability of same-sex marriage—even as a spirited wave of anti-LGBTQ laws are being put forward nationwide—it is important to consider the meaning of this legal victory in Washington, D.C., and what it signals about the future direction of the “T” in LGBT. Equal marriage, while a civil right worthy of celebration, was only ever a painfully compromised goal for many in the broader community. The overlaps between queerness and economic injustice have been deep and abiding.

In a 2011 report on transgender people in the United States issued by the NCTE and the National Gay and Lesbian Task Force, the broader community was finally able to put into clear figures the lived experience they described: 16 percent of trans people worked in the underground economy (particularly sex work) in order to make ends meet, trans people were four times more likely to be making under $10,000 annually than the general population, trans people were unemployed at a rate twice the national average (and four times the national rate when considering just trans people of color), 19 percent had experienced homelessness at some point, and 26 percent said they lost their jobs due to being transgender.

What transgender political activism has revealed since the 1960s is the urgent necessity of ameliorating these biting, intersectional issues—and that no LGBT rights movement worthy of the name can afford not to address them.

At the keystone of all these issues—poverty, race, underground labor, the distinctions of transgender experience—lies health care.

Victories in this field occasion so much celebration precisely because of what health-care access can do; so many of the trans community’s immediate concerns are quite literally matters of life and death.

The NCTE/NGLTF study is the one that gave us the now chillingly familiar statistic that 41 percent of trans people have attempted suicide at some point in their lives. Access to public resources for transgender people is not a question of preference, cosmetics, or even identity, but of life itself.

Nineteen percent of trans people in the survey said they were outright turned away from health services because they were transgender; many more said they fear even trying because they worry about encountering a particularly humiliating form of discrimination.

Clearly, health-care access is important. But the interlocking realities of poverty and chronic under- and unemployment also make an urgent demand of public health-care access. There are many trans people like myself who would benefit from a more equitable policy in our private insurance plans (my own has a rather taciturn exclusion, printed in big friendly blue letters that read “No Sex Changes”), but changing the policies of private insurers alone would never be enough to address the full sweep of the problem. Public health care, too, in the form of Medicaid and Medicare, must meet trans people on equal, humane terms. Rather than dismissing transgender health care—up to and including various hormone treatments and surgeries—those who administer public plans must recognize what medical and psychiatric organizations the world over have recognized: The social condition “gender dysphoria” describes is real, and the health care we ask for does save our lives.

This is the reason the Sylvia Rivera Law Project (SRLP) in New York is campaigning for that state to review its Medicaid exclusion of transgender health care.

This past Valentine’s Day, armed only with placards, passion, and a gaggle of red heart-shaped balloons, SRLP staged a protest at the New York State Department of Health office as part of their “Hey Shah, Where’s The Love” campaign—named for the state health commissioner, Nirav R. Shah—to end the state Medicaid trans exclusion. Health care is, as I have argued, the keystone to full and equal access to our civil rights.

But a right that exists on paper, or in theory, is no guarantee at all—particularly if all your energy is spent surviving or barely existing on the margins of our society. American society is certainly plagued with health-care problems at all levels—millions remain uninsured, and public health care is under sustained assault—but health care represents a vertex upon which many problems unique to transgender people have converged. Coverage and the education of health-care providers, insurers, and workers would lay a peerless foundation for transgender citizenship.

Lacking access to a doctor who understands you, or to necessary surgical procedures, or to competent supervision of a hormone regimen, is tantamount to the prohibition of transgender bodily autonomy.

Rights are never invested in the individual alone, but are rather shared amongst members of a community; they gain meaning and tenacity only through the collective exercise of, and mutual stewardship of our common liberty. A right is only theoretical without affirmation from one’s fellows—and what this means for trans people is that our right to exist is meaningless without access to the health care that ensures that existence.

Although much ballyhooed in analysis by some in radical circles, rights have always retained their salience to those most keenly affected by their absence. The screaming silence of that cavernous non-presence is a sound one learns to live with out on the far ends of societal acceptance and concern; it is the sound all too many trans women of color are hearing right now, all too many sex working trans people, all too many trans people being turned away from homeless shelters. That silence is relentless in its capaciousness, as if it could hold every trans person in the world.

Time and again in talking to friends in my own community for whom even $5 for hormones are a burden, for whom a walk to a clinic is a risk that threatens to sire patriarchy’s wrath, for whom surgery is a desperate need but an impossible dream, I keep finding the relentless cavernousness of that silence to be all consuming: a pain they can neither speak of, nor hide, nor do anything about. No matter how many loving embraces I give, consoling words, olive branches of hope, or a few dollars to make ends meet, I find—again and again—that the solution, the balm for all this pain, can only be a collective one, and any liberation worthy of that lofty name must come in the form of a civil process that ensures an end to the suffering these exclusions have caused.

From the immediate physical harm caused by denial of equal health-care access, to the inescapable knowledge that society has taken the time to consciously exclude you and label you an outcast, the slings and arrows of health-care denial are legion wounds upon the transgender spirit.

Yet theoretical battles may yet be fought over whether the very notion of “rights” is a hamhanded liberal compromise, unequal to the task of a grander liberation.

“It is one thing,” wrote legal scholar Catharine MacKinnon, “for upper class white men to repudiate rights as intrinsically liberal and individualistic and useless and alienating; they have them in fact even as they purport to relinquish them in theory. It is another to reformulate the relation between life and law on the basis of the experience of the subordinated, the disadvantaged, the dispossessed, the silenced—in other words, to create a jurisprudence of change.”

The absence of a right to health care is not some chit in a theoretical argument about law or philosophy; it is, rather, about as concrete as these things get. The absence is a wound we are constantly aware of. That is the perspective, and the reality, that informs this foundational step in our jurisprudence of change—to amend our social contract in such a way that it includes our right to life. It begins with equal access to trans-affirming health care.

And that is why we celebrate when a ray through the gloom like D.C. lances forth.

Full Disclosure: Katherine Cross is on the board of the Sylvia Rivera Law Project.