It is widely known that insurance is meant to help cover major medical operations that keep you alive, in situations that present an urgent ‘medical necessity’ for the victim of an illness. Insurance covered operations are meant to fix a medical condition that is seen as critical. The common phraseology employed by insurance providers for defining a medical necessity as “health care services that a physician [provides]… for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease, or its symptoms” (WPATH, 2). With this definition in mind, as well as the question driving this debate: whether or not insurance companies should be required to cover services related to being transsexual or transgender, we must realize that by asking this question in the first place we are assuming that transgender and transsexuals’ expression of self is wrong. By requiring insurance coverage for transsexual and transgender services, we are required to consider them as victims of an illness, a classification that members of the transgender and transsexual communities are very likely to reject.
I, for one, am not comfortable with this classification. I am not comfortable with science and medicine being so overly powerful in their ability to define gender in such a constricting, dichotomous way. I am not comfortable with the negative connotations (and subsequent stereotypes) that are included with having to diagnose an individual who doesn’t conform to gender norms with a disorder. And I am not comfortable with requiring insurance companies to legally stigmatize those who are transgendered and transsexual as mentally disabled. Before I continue with my argument, I feel that it is important to note (and remember previously discussed) definitions of a few terms:
Gender, an identity socialized culturally, sexually, and biologically. Gender has evolved, and will continue to change throughout history as “the social organization of different kinds of bodies into different categories of people” (Stryker, 11).
Gender roles, the assumed and often stereotypical classification based on “social expectations of proper behavior and activities for a member of a particular gender” (Stryker, 12).
Transsexual or transgender related services, hormonal treatments; surgeries, such as Sex Reassignment Surgery (SRS); therapy, are all recommended services to be covered by insurance advocated for by the Transgender Law Center (TLC, 2).
Transgender, a personal identity that exemplifies movement away from (or variation of) an initially assigned gender position (Stryker, 19).
Transsexual, a person who feels “a strong desire to change their sexual morphology” in order to permanently associate with a gender other than the one assigned to them at birth (Stryker, 18).
Why define these terms you may ask? Because they clarify parts of my argument, present a recap of what we’ve discussed thus far in class, and fill in gaps left by some of the readings that assume the person absorbing the information provided is fully aware of all of the basic terms.
We have discussed at great lengths in class the difference between sex and gender, and also the tremendous amounts of discrimination that those who actively choose not to conform to the norms of gender and sexuality face. And while I agree that it shouldn’t be so difficult for transsexuals and transgender individuals to gain access to appropriate and necessary medical treatment, these individuals must not be required to meet the criteria for an illness. The underlying issue at hand is that transgender and transsexual individuals are viewed as having a mental disorder, commonly classified by doctors as Gender Identity Disorder (GID). The name of the illness itself suggests that transgender identity is deficient.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the widely accepted manual published by the American Psychiatric Association (APA) for defining what medically and socially constitutes a mental disorder. Not only does the DSM influence our country’s classifications, it “strongly influences the International Statistical Classification of Diseases and Related Health Problems published by the World Health Organization” (Winters1, 1). Homosexuality was classified as a mental illness, and wasn’t removed from the DSM until 1973, when the APA reached a “compromise between the view that preferential homosexuality is invariably a mental disorder and the view that it is merely a normal sexual variant” (Spitzer).
The fourth Edition of the DSM (released in the year 2000) employs specific criteria for diagnosing GID. One specific piece of the criterion refers to a “disturbance…manifested by symptoms such as…frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex” (Stryker, 14). This categorization involves a narrow, dualistic definition of gender. This simplification facilitates the “treatment” for the illness as calling for transgendered or transsexual individuals to ultimately choose to undergo a Female to Male surgery or vice-versa to solve all of their “problems”. And while many do view surgery as necessary, “not every patient will have a medical need for identical procedures” (WPATH, 3). It is thus apparent why stigmatizing those who are transgendered or transsexual “implicitly [promotes] cruel and harmful gender-reparative psychiatric “treatments” intended to enforce conformity to assigned birth sex and suppress gender variant identities and expressions” (Winters1, 1).
Within the World Professional Association for Transgender Health’s “Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A.,” the terms transsexualism and GID are interchangeable (WPATH, 1). Not only does WPATH refer to GID as a state of being that “requires a professional consensus on how to be psychiatrically, psychologically, medically and surgically managed,” it also completely avoids mentioning those who are transgendered who might not even express any need for SRS or medical procedures (WPATH,1). This interchangeability is wrong on so many levels. Not only is it generating an unfair social stigma about transsexuals as diseased and unfit to manage their own mental well-being, it is confusing definitions of those who are transsexual with those who are transgendered. Just as “the medical system only recognizes the existence of males and females,” much of transgender activism has wrongly catered to this claim and the narrow gender roles attached, forcing all gender variant individuals to pick a gender, and get the surgery necessary to treat their illness (TLC, 2). Just as activist, author, and founder of the organization GID Reform Advocates Kelley Winters, writes: “failing to distinguish gender diversity from gender distress, the APA has undermined the medical necessity of sex reassignment procedures” (Winters2, 2).
Opposing views may believe that it is better to falsely identify transsexuals and transgendered people as disordered in order for them to gain necessary and immediate medical treatment. That insurance coverage should come first and the underlying stigma and outside discrimination will sort itself out in time. This, to me, is similar to putting the band-aid on top and expecting all the hurt to instantly go away. While I agree that “health care injustice has life-long effects on people’s ability to learn, work, and care for themselves,” transgender discrimination in a broader realm also has long term effects, if not more serious ones to tackle.
I don’t agree with denying anyone their right to express themselves in whatever gender they feel and change their outward appearance to match it, and I agree that the “medical procedures and treatment protocols [for those transgendered or transsexual] are not experimental” as cosmetic surgery is, for example. But transgenderism and transsexualism simply cannot be classified as a disease in order to do so. Just as Kelley Winters states, “it is time for the medical professions to affirm that difference is not disease, nonconformity is not pathology, and uniqueness is not illness” (Winters1, 1). Health insurers must not be required to cover services related to being transsexual or transgender, and must not inflict a classification that denies transsexual and transgendered individuals their dignity and sanity. In order for full social change to occur we must not only reform the system, but reform those who are making the system the way it is. Eliminating discrimination toward transgendered and transsexual within the field of medicine calls for fully changing the system, as the phrase goes, “to a T.”
Spitzer, RL. “The diagnostic status of homosexuality in DSM-III: a reformulation of the issues” http://ajp.psychiatryonline.org/cgi/content/abstract/138/2/210
Stryker, Susan. “An Introduction to Transgender Terms and Concepts”
TLC: Transgender Law Center. “Recommendations for Transgender Health Care”
Winters 1: Winters, Kelley. “GID Reform Advocates.” http://gidreform.org/
Winters 2: Winters, Kelley. “Issues of GID Diagnosis for Transsexual Women and Men.” http://www.gidreform.org/gid30285.html
WPATH: The World Professional Association for Transgender Health, Inc. “WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in U.S.A.”
Rachel raises some interesting points and while I agree that transgender people should not be classified as “victims” or “diseased” I disagree with one of the last statements of her debate, “Health insurers must not be required to cover services related to being transsexual or transgender”. Services related to being transgender are essential for transgender people and in some cases necessary for their individual well-being. Should anyone be denied what is necessary for his or her survival? Irma did a good job of laying out the ways in which transgender lives have been jeopardized because of the lack of health insurance coverage, “Transgender individuals go through extreme measures to get their sex changed, most will resort to attempt performing their own surgeries which in most cases results in death”. Lives are at stake, and for this reason alone health insurance should be required for transgender people. They should be allowed the same right to health insurance like everyone else.
Again, Rachel makes strong arguments in regards to the injustices of qualifying transgender people as “disordered”. In her conclusion she emphasizes the necessity of reforming the system as well as reforming societal expectations. I think this idea is spot on; many of our class discussions have focused on the importance of doing something. Rachel’s suggestion of reform is one that could begin to create equality for transgender people in the medical field. While it is right to go back to the fundamental discriminations transgender and transsexual people are faced with on a daily basis and Rachel did just that. It is also important to keep the focus on the specific question of health insurance for transgender people. As I said in my comment on Irma’s post ultimately, transgender people are being denied coverage for services that have nothing to do with their transgender, “Without health insurance, many transgender people have no access to health care. Transgender people who develop health problems, break a leg, get an infection, etc., have nowhere to turn unless they pay for the services themselves” (TLC). This is something that must be remedied by requiring health insurance coverage for transgender people.
“Recommendations for Transgender Healthcare”; Transgender Law Center.
I really enjoyed reading Rachel’s debate due to the fact that it was not the typical argument for why transgender individuals should not receive equal medical care. Instead of laying out all of the reasons why including transgender individuals would be detrimental to insurance companies and to society, I liked that Rachel argues that we should wait until transsexuals are socially accepted as being the individuals they are before we cover their medical expenses under the idea that we are “treating a disease”.
However, I would like to point out that even though right now the only potential path for transgender individuals to receive coverage of medical care is being diagnosed with Gender Identity Disorder (a mental condition or “disease”), which Rachel argues is unjust and forces transsexuals to identify as either male or female, this approach to broadening medical coverage is an incremental approach. As we have discussed in class (specifically with the Ayres and Brown book) an incremental approach, no matter what the time frame may be, is still progressive action. Think about the fact that being left-handed was seen as abnormal and wrong for a long time. As perceptions changed, left-handedness became okay and today is not a big deal at all. But it took time.
I think what Rachel is suggesting is very true – that the pervasive opinion of transsexuals as abnormal needs to change. I also think that the best way for this to occur is for change to take place incrementally; I am not necessarily saying that I think it is okay for us to continue to marginalize transgender individuals and deny them equal medical coverage, but I do think that the best approach to changing society’s view as a whole is by taking baby steps, even if it means treating Gender Identity Disorder as a “condition” or “disease” in order to access needed medical care.
Rachel takes an unexpected stance of the debate over insurance for transgender individuals. She argues that insurance should not cover their surgeries, not because they are cosmetic or unnecessary, but because of the negative classification this would impose on transgender/ sexual people. These individuals are defined by the medical community as having a mental disorder, commonly classified as Gender Identity Disorder. Rachel accurately parallels this placement on the DSM to the long held notion that gays and lesbians were also suffering from a disease as reported by the DSM until 1973.
Rachel says (again focusing on the definition of transgender/sexual individuals as mentally diseased) that “This categorization involves a narrow, dualistic definition of gender. This simplification facilitates the “treatment” for the illness as calling for transgendered or transsexual individuals to ultimately choose to undergo a Female to Male surgery or vice-versa to solve all of their “problems”. This literal force to conform reminds me of attempts by parents to cure their afflicted (gay) children by taking them to counselors or through rigorous religious advisement.
The word “disease” is powerful. It is by definition harmful and abnormal. However, waiting for society to remove this label reminds me of the rock discussion we had in class today. As we wait for the transsexual to be accepted as an identity, individuals are waiting. They do not have access to insurance and they are still in a body that does not seem natural to them. Is it fair to make them wait if they could gain access to insurance coverage under the umbrella of ‘disease treatment’?
When I was beginning to read Rachel’s debate posting, I was certainly not expecting what she argued. Rachel raises some interesting points that I think have been ignored in the debate in class and on the national level. First, the description given by WPATH of medical necessity as “health care services that a physician [provides]… for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease, or its symptoms” causes Rachel to take the stance that we assume that “transgender and transsexuals’ expression of self is wrong.” Taken a back at first, I then pondered this statement and found it to be completely true. In the terms of health insurance companies in order for transgender and transsexual individuals to receive health insurance they must have a disorder. As Rachel says “I am not comfortable with the negative connotations (and subsequent stereotypes) that are included with having to diagnose an individual who doesn’t conform to gender norms with a disorder,” and neither am I!
I do see some flaws in Rachel’s argument, though. I feel as if she did not tackle the question head on, rather she created a new argument in itself. Throughout I get the idea that Rachel does believe that transgender and transsexual individuals should have access to medical treatment, which we have learned from Irma’s argument are very expensive. Due to the expense some sort of coverage is needed to cover the expenses that most transgenders and transsexuals cannot cover on their own. I believe Rachel’s final statement “Health insurers must not be required to cover services related to being transsexual or transgender” does not match her entire argument, only the portion of transgender and transsexual should not be classified as a diseased. So I would like Rachel to address how then coverage for transgender procedures can happen? Is it through the health care system but with different definitions? Or is there a separate entity that should be made to provide funds to cover these procedures?
Rachel, I immediately agreed with you, insurance should be cover “urgent ‘medical necessity’”. However, does this mean that you are okay with the “fatal blood clots and liver damage” that Batty and Irma quoted? (Batty 1) While the issues surrounding transgender, and the assumptions that exist of there only being two genders, people are dying due to lack of treatment. As you quoted, and WPATH states, insurance covers illness, injury, disease or its symptoms. (WPATH 2) As WPATH notes, “The DSM-IV descriptive criteria were developed to aid in diagnosis and treat to alleviate the clinically significant distress and impairment known as gender dysphoria that is often associated with transsexualism.” (WPATH 1) Because transsexualism is clinically significant distress and impairment, should not it qualify? What is the difference between impairment and injury? According to dictionary.com, injure is a synonym for impairment. Therefore, transgender services should be covered.
In your debate, I think you should have considered the second half of the common definition among insurers, specifically part c. Health care services are “(c) not primarily for the convenience of the patient, physician, or other health care providers, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.” This means that the patient, doctor, and health care provider come together to decide the best way to treat the patient. The insurance company agrees to reasonable treatment, and because impairment is the same as injury, they must agree to a treatment. However, if a patient decides that they want a more costly procedure, they at least have a basic coverage that they can choose as a backup.
I agree with you that we should not assume there are only two genders; I also agree that insurance should cover “urgent medical necessity.” However, I feel that the language used in common insurance policies allows for transgender people to be covered, and they should self medicate through the black market or struggle to pay for these services without help.