Sex, Power, and Politics Blog

I would like to address my thoughts about my lovely commenters’ comments first 🙂

Meghan/Kyle:

“The United States is currently deciding on a new health care plan that would extend coverage to over 36 million people currently without insurance and create a government health insurance program. What does this do to the issue of including trans-sexual and transgender benefits in health care?”

Transgender individuals would then benefit from this coverage as well, unless they are not included in this health care plan just like other insurance plans sometimes do.  Again, the issue here would probably not be about the inclusion of transgender individuals because according to ‘House Health Reform Bill Pleases Homosexual Transgender Lobby’ online article about Obama’s Health Care Bill it states that it,  “would help LGBT people in particular obtain the improved access to health care that the Act is designed to provide” (exposeobama.com).  The major concern is whether or not the plan would include transgender procedures.

**“Why, with the current health care debate, do transgenders deserve a more expedient health care coverage process than the millions upon millions without health care, who are struggling to survive as a result of their lack of coverage?”

The reason millions upon millions of Americans do not have health care is because they cannot afford it, in my debate I do not advocate that insurance companies cover transgender individuals who cannot afford to have insurance because that obviously would not be fair.  I am speaking about those transgender people who can afford to have health care in the first place.  I understand the reality that not everyone is going to be able to have health care, but for those who can afford it and are transgender, all I am suggesting is that they require to include transgender procedures.

Katie:

**“They are currently not owned by the state, and do not need to cover services just because someone wants a certain service.”

The problem with this is, and I stated this in my debate (second paragraph, last sentence), is that they are already covering transgender related procedures; however these are only allowed for non-transgender individuals.  Why then are transgender individuals not able to get these procedures covered for themselves?  Some of the services are already being done, however insurance companies discriminate against transgender by not allowing them to also use them.  Politically, if they are not owned by the state they could do this, but where do these exclusions end? And what good are they if some procedures are already being used?

Also, in my debate, I did not mention whether insurance companies should cover all the needs of transgender individuals.  I focused on the fact that they should at least be included and for insurance companies to require to fund transgender/transsexual necessities.  I understand that “You Can’t Always Get What You Want”, however asking to be included in the plan does not suggest that the plan will pay for everything, but to know that you are included in a plan and may have the opportunity to be partially covered is better than to not be at all.

Leigh Ann:

** “Even if transgender people were provided with health insurance, how can services be made fair and of the highest quality?”

I agree with the fact that there needs to be more work on how doctors and specialists treat transgender individuals and there obviously has to be more doctors that practice transgender procedures, but again this has to do with the fact that transgender are excluded from health care at times and/or that their procedures are not being covered therefore there are less people qualified to conduct them.  For the second part of this statement, how do you measure quality?  This could be argued for non-transgender procedures as well.  How does a patient know that they are getting the highest quality?  One just assumes that their doctor is going to the best job he can do.  This changes however if whoever is administrating care is discriminatory against transgender individuals, which you point out; but this is not only an issue that only transgender people deal with, other groups also deal with this.

Jamie:

** “In order for the individual to change his/her lifestyle and to be socially recognized as the opposite sex, it is not always necessary to undergo any sort of surgical procedure”

Yes this is very true.  Not every individuals needs to have a sex change, because ultimately this depends on the person.  As I mentioned before in my debate, not every individual is going to need or want the same procedure.  However, what it feels like you are trying to say is that because there are other ways to feel of the opposite sex that surgical procedures are not necessary, which is assuming that people can stand and deal with their biological sex.  For transgender individuals undergoing surgical procedures is a necessity, they are trapped in a body that they do not want to be in, this affects their lifestyles on a day to day basis.  Also, just because some do not need to undergo a surgical procedure does not mean that it would be fair to get rid of this option, because there are those who absolutely need it.

Ashley:

**“This argument seems a little shaky because it does conjure up a parallel to a person who was born with a less than desirable body (as portrayed by mainstream society: thin, muscular, curvy, white) and has always wanted the kind of body that would gain more attention, or one that would not be a subject of teasing or ridicule”

I understand the story about the women who get ridiculed for being flat chested.  Confession time, I too am self conscious about my breast; I have been made fun of as well, however I am comfortable with my biological sex and what it means to me to be a womyn.  I love the fact that I have what I have because my mind is also comfortable with it.  The women that you are describing are the ones that are self conscious about what she has, for transgender individuals it has to with more than that.

There is a difference between disliking your body for how it looks like and another for disliking your body for what it is, in other words most transgender individuals cannot stand their biological sex to the point that they want to completely change it, whereas breast augmentations deals with altering your body to make it look ‘better’.  I also do not believe that transgender change their bodies to get attention, most do it because it is necessary for themselves and not for what others may see it, which is what the women who is insecure about her breast is ultimately doing it for others.

Ashley/Jamie:

**“The bottom line is that the doctor is in no way kept from reaching his or her potential by insurance companies refusing to cover transsexuals’ surgeries.”

By looking at this in your perspective I agree, maybe what I was trying to say was the following: Insurance companies are keep doctors from potentially performing more surgeries than they otherwise would if insurance could cover these procedures.  But, because many transgender individuals cannot afford these procedures because without health insurance to cover at least part of the total cost, surgery becomes out of the question.

Now I would like to say a few things about my opposing side 🙂

Rachel, I really enjoyed reading your debate because you brought a new concept to the question.  I do agree with you when you state that transgender individuals should not be viewed as individuals with a mental disorder.  But I disagree with when you state that until the medical community changes this term that transgender individual should not be covered under health insurance.  My questions for you are the following ones: While you stand on this principle, what are people suppose to do in the meantime?  You cannot forget about the fact that transgender individuals are still going to be suffering inside their own bodies until they are able to obtain help to be able to pay for their transgender procedural needs.  According to ‘The National Coalition for LGBT Health’ article studies of transgender populations have reported, “suicidal ideation rates as high as 64% and suicide attempts rates ranging from 16% to 37% with most attributing their ideation or attempts to their gender identity issues” (2).  Though this term is not the best term to use interchangeably for transgender individuals, I believe that the movement to require insurance companies to provide cover should not be put to halt for this issue because it is a necessity that needs to be taken care of now rather than later.

Also, what are you proposing on doing to change this?  And how long is it going to take? Equality for transgender individuals is going to take a long time, time which some transgender people cannot wait for.  It reminds me about what we talked about in class today and of the individual with a rock on their head; is it fair for them to be waiting while they could be doing something to change it?  You say that insurance companies should not be require to cover because they are treating this like an illness and by doing so they are in a way prohibiting transgender equality; however I believe that including transgender procedures in health insurance is an important step that acknowledges transgender individuals rather than completely ignoring their necessities.  Lastly, I would like to comment on your analogy, “This, to me, is similar to putting the band-aid on top and expecting all the hurt to instantly go away”; to this I would like to say that though the bandage is not going to take the pain completely away, it is better to have the bandage then to have no bandage at all.  Though I do not agree with the terms used either, I would rather have transgender individuals get covered than excluding them altogether.

http://www.exposeobama.com/2009/11/09/house-health-reform-bill-pleases-homosexual-transgender-lobby/

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.”

The discrimination begins as soon as transgender individuals are required to check the ‘female’ or ‘male’ box as they apply for health insurance.  Unfortunately, it does not stop there, furthermore according to the Transgender Law Center; most transgender individuals are denied health insurance coverage not only from a group plan, but also from private health insurance companies because they are transgender.  So, even if a transgender were to need medical coverage to an issue non-transgender related (such as a broken arm), this individual would need to cover this cost themselves.  Even when transgender people are able to obtain insurance, most insurance programs do not include services related to their specific needs.  Almost every health insurance program excludes transgender related procedures in their plan, also known as the “transgender exclusion”.  Insured patients with well-paying jobs see the cost of these procedures overly expensive making the reality of these procedures slim to none.

There are many reasons why insurance companies should require to cover services related to being transsexual or transgender, I will be outlining the four reasons that are the most important.

Number One.  I want to clarity the most common misconception inflicted with this topic and one that many insurance companies use to justify their exclusion toward transgender individuals: “Transgender procedures are “Experimental” or “Cosmetic” and not a necessity”.   The only experimental procedure could be traced back to the original surgery in 1952.  According to the ‘Transgender Health Benefit’ article, for the transsexual procedure to be possible individuals must comply with the Harry Benjamin Standards of Care which, “strictly outline the diagnosis and procedure that must be followed for a true, medically necessary transition” (Transgender at Work, 2).  Transgender individuals must first be diagnosed with Gender Identity Disorder (GID); under these standards the most effective ways to treat GID is through counseling, medical, and surgical.  The World Professional Association for Transgender Health (WPATH) Standards have revised this issue and concluded that the treatment is a medical necessity.  It is time to begin to recognize that this treatment cannot be compared to a breast augmentation procedure, transgender individuals require this to live the life that they have always wanted, in the body that they should have been born in but were not.  Also, medical necessity is a term commonly used by health care coverage and insurance policies to allow Physicians to provide a patient with, “the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease or its symptoms” (WPATH Article, 2).  Insurance companies who deny these treatments are also prohibiting physicians to practice their job to full potential.  This also concludes that the only means behind health insurance provider’s exclusion is to discriminate against transgender individuals.  Procedures needed by transsexuals such as: Hormone Replacement Therapy (covered for post-menopausal women), Vaginoplasty or Phalloplasty, Mastectomies or Hysterectomies (for the treatment of cancer), and Gynocomastica for the treatment of a hormone imbalance are covered for non-transsexuals but NOT transsexuals individuals (Transgender at Work, 1).

Number two.  Now that we have concluded that transgender procedures are necessary and that insurance companies choose to exclude based on discrimination, we must look at the actual cost of this procedure.  Furthermost I must begin with stating the following, according to the DSM-IV, “Transexuality is very rare, it affects an estimated 1 in 30,000 people” (Transgender law center, 1).  We need to keep this number in mind because when it comes to how much these procedures are going to affect health insurance cost overall, the number of how many individuals may need it becomes crucial.  According to ‘The Cost of Transgender Health Benefits’ article, the average cost for a male-to female primary surgery can range from $4,500 to $26,000, this however does not include the extra costs for therapy ($1000), hormones ($15000), and doctor visits and lab tests ($500).  The average cost for female-to-male primary surgery can range from $4,000 to $60,000 which does not include the extra cost for the necessary therapy, hormones, or doctor visits (Horton, 2).  Without these procedures included in health care plans, patients need to pay this amount out of their own pocket; which becomes extremely difficult.

The opposition side worries that their health insurance cost will increase dramatically if there procedure were to be added to their plan, however this is a misconception.  Due to the fact that the number of individuals who will actually benefit  from this is very small, according to a surgical cost analysis, assuming that 1,166 procedures occur per year, the total cost per insured would result in an estimating 24¢ (2008) a year (Horton & Goza, 43).  This amount is a reasonable amount to contribute to help transgender individuals; it demonstrates that the total cost that would be expected to pay is very minimal, so why not contribute?  One may argue that by allowing this procedure to be available that the amount of individuals would increase therefore increasing the cost.  This may be true because many do not even begin the procedure due to lack of funds.  However, if there is a high demand for these procedures there would need to be more surgeons and specialists to be able to accommodate those needs.  This could increase the number of new specialists performing these procedures which would then increase competition and bring prices down.  (Horton, 10).  The fear of having insurance cost raise is a valid concern, but when thinking about how this could affect our economy, it can be predicted that competition will take care of that problem.

Number three.  We need to keep in mind that not all transgender individuals require or want the same treatment.  According to ‘Recommendations for Transgender Health Care’ article, “Many transgender people, to fully actualize their gender, want only hormones, or only surgery, or low doses of hormones, or no surgery and no hormones” (Transgender Law Center, 4).  Despite the fact that diversity in procedures exist for each unique individual, doctors often will require transgender people to have all the procedures or none.  By forcing individuals to require all procedures not only violates an indivuduals’ own needs and choices, but it also increases the cost of the patient which without insurance will be impossible to cover.  The assumption that all transgender individuals will want the same exact procedure is therefore

Number Four.  Finally, I believe that the consequences of not including transgender procedures in health insurance plans will in the long run cost more money.  By limiting their services health insurance companies in a way force transsexuals to obtain drugs illegally and cause more harm to their bodies.  Out of desperation transgender individuals risk their life by buying sex change hormones via online without medical supervision, this could result in fatal blood clots and liver damage (Batty, 1)

Also, according to Mary Ann Horton, “individuals suffering from untreated GID may exhibit symptoms of other conditions (such as stress, depression, substance abuse or suicide)” (Horton, 10).  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.  All of this could easily be prevented if insurance companies would include transgender services in the first place.  If the major concern is cost, untreated GID costs more.  The solution is to target the issue from the beginning by allowing these procedures to happen otherwise more transgender individuals are going to die.  By ignoring the problem and excluding them altogether causes more mental and physical problems for the transgender individuals.  To me it seems that insurance companies would rather want transgender people to die before giving them a helpful hand.

According to clinical experience and medical research, transgender medical procedures are vital to achieve the well-being of transsexual individuals, “A recent study found significantly improved quality of life following cross-gender hormonal therapy.  Moreover, those who had also undergone chest reconstruction had significantly higher scores for general health, social functioning, as well as mental health (Transgender at Work, 3).  In conclusion, health insurance companies need to stop discriminating against transgenders, they need to require cover services related to transsexual and transgender because as studies have shown these procedures are cost effective rather than cost prohibitive.  These individuals deserve the opportunity to be allowed coverage just like everyone else; lastly, this procedure is a necessity, insurance companies therefore have no reason to continue to deny them care!

Batty , David. “Warning Over Online Trade in Sex Hormones.” Wednesday 18 February, 2004 1-2. Web. 23 Nov 2009.

http://pol285.blog.gustavus.edu/files/2009/08/Batty-Warning-Over-Online-Trade-in-Sex-Hormones.pdf

“Clarification on Medical Necessity of Treatment”. World Professional Association for Transgender Health, Inc. (June 17 2008): 1-4. Web. 30 Nov 2009.

http://pol285.blog.gustavus.edu/files/2009/08/WPATH-Clarification-on-Medical-Necessity-of-Treatment.pdf

Horton, Mary A. “The Cost of Transgender Health Benefits.” Transgender at Work 6.5. (September 2008): 1-12. Web. 23 Nov 2009.

http://pol285.blog.gustavus.edu/files/2009/08/Horton-The-Cost-of-Transgender-Health-Benefits.pdf

Horton, Mary A. “The Incidence and Prevalence of SRS among US Residents.” Transgender at Work 6.5. (September 2008): 1-11. Web. 23 Nov 2009.

http://pol285.blog.gustavus.edu/files/2009/08/Horton-Incidence-and-Prevalence-of-SRS-Among-US-Residents.pdf

Horton, Mary A., and Elizabeth Goza. “The Cost of Transgender Health Benefit.” Transgenders at Work 1-44. Web. 23 Nov 2009.

http://pol285.blog.gustavus.edu/files/2009/08/Horton-and-Goza-Cost-of-Transgender-Health-Benefits.pdf

Marsamer, Jody, and Dylan Vade. “Recommendations for Transgender Health Care.” Transgender Law Center (2002): 1-5. Web. 23 Nov 2009.

http://pol285.blog.gustavus.edu/files/2009/08/TLC-Recommendations-for-Transgender-Health-Care.pdf

“Transgender Health Benefits.” Transgenders at Work n. pag. Web. 23 Nov 2009.

http://pol285.blog.gustavus.edu/files/2009/08/TaW-Transgender-Health-Benefits.pdf