Mercedes Allen

Why "Sex Change" Surgery is Medically Necessary

Filed By Mercedes Allen | August 05, 2009 1:30 PM | comments

Filed in: Fundie Watch, Living, Politics, Transgender & Intersex
Tags: America, Canada, health care reform, sex reassignment surgery, transgender, transsexual

The panic machine is in full swing, from far-right conservatives trying to terrorize Americans out of wanting universal health care. There are half-truths, such as the story of Ontarioan Shona Holmes who had to abandon Canada's public health system and go south for surgery because of wait times, but without mention of how the cyst was inactive, that she was born with it (which would have made it a pre-existing condition to American insurers) and how upon return she had the remainder of the issue dealt with in a timely manner at Canada's expense. And then there are outright lies, such as citing a line that is meant to help patients in end-stage situations put together an advance directive, and making it sound like the Obama administration is intending to encourage genocide of seniors.

The question isn't "How do you want to die?" The question is simply: "What kind of care do you want, and what measures do you want taken if - at the end of life - you are unable to speak for yourself?"

And in there, of course, we have the trans bogeyman resurrected, with WorldNetDaily, OneNewsNow and others raising the panic that if universal health care is implemented, Gender Reassignment Surgery might be covered.

Now, if you're a Fundamentalist, anti-gay, not-happy-about-the-black-guy-in-the-White-House, then chances are, nothing I say is going to matter. But if you're a typical live-and-let-live American who is maybe not too keen on the idea of the public coffer paying for "sex change" surgery but hasn't really delved into it, the following is for you. To my thinking, this is a reasonable time to bring out the facts to show how much of a straw argument this is. Could universal health care end up funding GRS? Actually, it could, and that would not be the travesty it's being made out to be. It's medically necessary, and here's why.

Popular opinion has it that Gender Reassignment Surgery (GRS, often popularly nicknamed "sex change surgery") is a cosmetic issue and motivated by a simple "want" to be female or male, by someone who was not born as such. However, extensive medical research into transsexuality dating as far back as the 1920s and continuing through modern studies have demonstrated otherwise, and consequently, medical standards of care have included GRS as a necessary procedure for decades. In order to understand this, people will honestly need to put aside preconceptions for a moment.

The experience of being transsexual involves one's entire identity. They attempt to hide who they are, living a lie that feels unnatural in order to live up to others' expectations, the hiding driven by a spiraling sense of shame and self-loathing, until it becomes an experience many liken to "suffocating," or vents itself in an explosion of frustration. Transsexuals are unable to explain why they feel that their gender should be something different than their birth sex, and sometimes spend years attempting to mask themselves, to "pass" as the gender that society expects them to be. This restricts their ability to function socially, emotionally, psychically, spiritually, economically (it's hard to be productive while constantly feeling out of one's element and/or "backwards"), maybe sexually, and leaves them often suicidal as a result. If this continues into later adulthood, often a crisis point is reached in which the person suffers a complete emotional collapse.

"Gender Dysphoria" is the name for this condition, and treatment follows the standards of care established by the World Professional Association of Transgender Health (WPATH, formerly HBIGDA), which includes GRS. No less than the American Medical Association has stepped forward advocating the necessity of surgery and its coverage. In fact, like the AMA, the American Psychiatric Association and their Canadian counterparts support GRS as a medically necessary part of treatment. It was partly for this reason that the Ontario Human Rights Commission ruled in 2008 that that Province should restore coverage of the procedure.

Treatment of Gender Dysphoria encorporates surgical and endocrine intervention, because analytical and aversion therapies have historically proven damaging. As much as mainstream society would like to believe that electroshock therapy, anti-psychotic drugs or conversion ("ex-gay") therapy would help transsexuals "just get over it," modern medicine has realized that this approach simply does not work, and usually results in suppression, suicide or extreme anti-social behaviour. Aligning body to mind, however, has enabled transsexuals to become valued and successful people in society. There are, in fact, a few transsexuals who feel that they can live without having GRS, but they are the exception and not the rule.

Gender Dysphoria (sometimes called "Gender Identity Disorder," or GID) is currently listed as a mental health issue, but ongoing study of both genetic "brain sex" and Endocrine Disrupting Chemicals (EDCs) show the possibility of some biological causal factor. In a study released in October 2003, UCLA researchers identified 54 genes in male and female mouse brains that led to measurable differences by gender, and went on to indicate the possibility of a brain being gendered differently to one's physical sex. Studies of EDCs show another, possibly concurrent potential that exposure to chemicals that simulate hormone characteristics -- particularly between the third and eighth week of pregnancy -- can affect the signals sent out to determine psychological gender and biological sex, which appear to develop at different times during gestation. In all fairness, nothing is conclusively proven at this point, and there is not a lot of research money being put into further study, as most pharmaceutical companies do not yet see a payoff from doing so. But the anecdotal and observational data from EDC and brain studies of human and animal populations would tend to support an innate origin or component of transsexuality, and coincides with transsexuals' convictions that they "just knew" that they were female (in the case of male-to-female transsexuals) or male (in the case of female-to-males).

There is more. Current legislation asserts that most forms of identification and legal documentation can only be changed to reflect one's new gender after surgery has been verified. Without GRS, many pre-operative transsexuals experience severe limitations on employment, travel and treatment in medical, legal and social settings in which verifying ID is necessary. Prior to GRS surgery, transsexuals also face limitations on where they can go (i.e. the spa or gym, or anywhere that involves changing clothes) and difficulties in establishing relationships -- as well as being in that "iffy" area where human rights are assumed to be protected, but have not yet been specifically established as such in policies and legislation. In hospitals, prisons and such, they are housed by physical sex rather than their gender identity, creating potentially risky situations, unless the authorities directly involved choose to keep them in isolation instead. And at the end of the day, without GRS surgery, one's gender is always subject to being challenged or stubbornly unacknowledged by those who don't realize that a transsexual's gender identity was not a matter of choice. There is also an extremely high risk of violence faced upon the accidental discovery that one's genitalia does not match their presentation. No other supposedly "cosmetic" issue so completely affects a persons rights, citizenship and safety.

It's a procedure that costs about $20,000 for male-to-female transsexuals, up to $80,000 for female-to-males, and most health insurance providers make specific exemptions to ensure that GRS specifically is not covered, so it's not like there are a lot of other options -- we're looking at a serious roadblock in a small group of peoples' lives. When the Alberta government delisted GRS, we calculated the total cost to Albertan taxpayers at 19 cents per year (not for one surgery, but for the maximum number performed each year) -- spread across a population size of America, it would be negligible.

Transsexuality is not widely known or understood in mainstream society, and should not be confused with other aspects of the larger transgender (umbrella term) culture. Although much sensationalism can be made of something like medical coverage of Gender Reassignment Surgery, the realities paint a very different story.

Mercedes Allen

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Thank you for stating our case so elequently, Mercedes. I totally agree and wish my insurance woudl have covered my surgery.
For what it's worth, I did a little research and found the average cost for maintaining a person with Type II diabetes for 1 year is as much or more than the average cost for Genital Correction Surgery. The surgery is a 1-time expense - and could save someone's life. Excluding GCS from health care wouldn't change the cost/person significantly, but their prejudiced mind is made up; don't confuse them with FACTS. They'd like to deport anyone who isn't a WASP anyway...

A person has to be careful about playing the comparison game. We've seen it before in Ontario and now in Alberta and Manitoba, people saying "why should we pay for GRS, while cancer patients are being cared for inadequately?" (and missing the point that the reason that cancer patients are being cared for inadequately is because governments are cutting services and creating deliberate shortfalls in order to push for 2-tier privatized health care like that of the U.S.)

Universal health care should be universal. Anything less only serves to pit downs' syndrome care against seniors' needs (i.e.) and create friction, dissatisfaction and inadequacy. Do not let your health care be sabotaged before it's acquired.

Keep in mind that it will be easier to fight for an inclusive health care program now than to fight for inclusion later.

I think the easiest argument to make in favor of GRS as a medical necessity is to look at what doctors and healthcare are really meant to do.

People see the words "medically necessary" and they presume only life-threatening conditions need apply. Putting aside that sometimes Gender Dysphoria can be life-threatening, that doesn't nearly come close to describing what healthcare professionals are really in the business of doing.

Healthcare is as much about quality of life as it is saving lives, if not moreso. There are plenty of non-critical conditions covered by insurance, ranging from a visit to the doctor to address the untreatable common cold to surgical procedures that do not address immediately mortal concerns (and for which there may be other alternatives for coping). These things are accepted without thought to the contrary because most people really believe that they're entitled not just to live, but to live pain-free (both physically and emotionally) and with a reasonable level of happiness.

The above article illustrates all of this well. Gender is the greatest single signifier of personhood, ever. In most cases it's assigned before we're born. It's the first thing people notice about us (in addition to ethnicity, perhaps). It shapes every moment of our lives, beginning to end. We only get one shot at this lifetime...if we have the means to make it happier or more productive for others, why wouldn't we do that?

Wonderfully explained, Mercedes. I hope at least some of that target audience sees what you've written here.

It's worth noting that some portion of these surgeries are performed on infants born with ambiguous genitalia in which case the procedure moves from necessary to essential and is presumably covered by insurance.

That aside, I just did some of the math on this using $20,000 as the average cost ( ).

It works out to about 3 cents per capita per year or about 0.0004% of our health care expenditures. That would be insignificant unless you happen to be a radical right wing fundamentalist.

I cannot think of any reason that this should not be covered by insurance.

It isn't just surgery that is being excluded for transgender individuals - routine care is also excluded. I have supposedly good insurance with my employer. I am unable to get even routine doctor visits covered by insurance; they are excluded based on my gender identity. This is happening in Washington state, where we have an antidiscrimination law that covers gender identity; unfortunately, this law does not protect me in practice. To top it off, my employer scores 100% on HRC's Corporate Equality Index. Yes I am feeling bitter.

eastsidekate | August 5, 2009 9:35 PM

Absolutely, Vivian. Don't get me wrong, I want to see universal coverage for all transition-related health care. However, transsexual people's struggles to obtain "routine" health care is often lost in the shuffle.

Me too, Vivian. I am excluded from specialty care for conditions unrelated to transition-- because of my gender identity and in violation of civil rights laws in California. And my employer (I'm retired) also uses a fraudulent 100% HRC CEI score to excuse these discriminatory practices. It's even more frustrating, as I was instrumental in adding gender identity and expression to their equal opportunity policies.

For more on the role of the Corporate Some-Are-More-Equal-Than-Others Index in enabling healthcare discrimination, see my March post.

Transsexuality is a condition that affects individuals in their entire being from the moment they are born--if not before--and by the time one is able to think it has already become the backdrop to one's entire life.

Although the term sexuality has long been used to describe who one desires to be intimate with, whether male or female (the terms for sex) and its relationship with one's own sex, it has always seemed to me at least as good a word to describe one's sense of whether one is male or female, whether the attributes of one's body are correct: the various sexual characteristics, the secondary ones, such as breasts or not, facial hair or not, larger or smaller hips, others less obvious to cissexual people, but quite obvious to those who undergo sex hormone replacement therapy.

Which is the replacement of testosterone with estrogen and progesterone or the reverse.

Sex Reassignment Surgery applies to the primary sexual characteristic between one's legs and, unlike putting on a dress, say, which is an indicator of gender, is the final alignment of one's body with one's sexuality.

This is not an exploration of one's feminine or masculine side, gender terms--nor is it something that one can return from should the exploration be found not to be a satisfactory way to spend, say, a weekend.

Transsexual people's need to end the dissonance between their body and their internal certainly of sexuality is no less important than, say, fixing a cleft palate--which is funded by single-payer health care.

Universal, as the system has been called in Canada, should no more discriminate against the well-being of transsexual people than against those with other birth defects. This should be the policy of all public health care systems.

In Canada, it has been the rather reactionary governments, of whatever political stripe, that have delisted, or removed, the service from public health care insurance, often, as the Manitoba government is now doing, by saying it is too expensive. Such a claim simply cannot be sustained and is only a smoke screen for prejudice.

It is simply the repudiation of, or refusal to accept, the reality of transsexual people and the incongruity of their sexuality with their physical sex and birth-assigned/imposed sex.

It has been fascinating to watch the bald-faced lies that have been used to attack current health care reform in the United States.

First, it has been to claim that the very things private insurance companies do are what will be done by the public option: prevent the free choice of doctors, that people will be dropped from coverage, and that pre-existing conditions will be used to prevent coverage.

Now, the claim is that seniors will be killed.

O yes, that in the reform Medicare shouldn't be touched--a prime example of a government service. Socialism, anyone? Just as VA health care is--or the health care that Congressional Representatives, Senators and all senior government employees receive.

Now just on the horizon is the claim abortions will be funded as well as sex-change surgery, both covered in the Canadian single-payer system.

I expect that in the month ahead the campaign of the big lie will accelerate--just this evening on the Keith Olbermann program I heard the health insurance companies are spending more money that George Bush and John Kerry spent in the 2004 presidential election campaign to fund this big lie.

I fully expect we will soon be seeing images of, not those who have sought physical correction of the birth defect in their physical sexuality but of:

Stu Rasmussen, Thomas Beattie and RuPaul.

It is my understanding none of these people have or will seek Sex Reassignment Surgery, being quite content with their transgender identities and gender play.

My argument is not that transgender people should not have human rights--my own advocacy in Canada has always included both gender identity and gender expression--but that the images those who support the struggle of transsexual people to be whole should be of transsexual people.

And their advocacy should be consistent.

My argument is that for those who support our struggle to end dissonance by aligning our physical anatomy with our sexuality they should not confuse the situation by conflating sex and gender; the inevitable result of this confusion is to see no difference between wearing a dress and the physical correction of the primary sexual characteristic.

The final stage in the treatment of transsexuality.

The simple first step to clarity is not to make the simplest of logical errors, the usually deliberate conflation of the categories of sex and gender, by refraining from calling the corrective surgery transsexual people need gender reassignment surgery.

battybattybats battybattybats | August 6, 2009 10:15 AM

Might it be that the reason enemies of basic human rights will use images of cissexual transgender people to oppose proper medical care of transsexuals is not because of anything done by transgender people but solely because transphobia is strongest centered around non-binary people.

Just as the homophobes often trot out the images of the most flamboyant gay people they can find.

And one of the troubles is when any group tries to 'fit in' as much as posible to gain acceptance it results in bas-treadmarks on someone's head.

In Australia we have currently a big push to get same-sex marriage (with polls showing almost 60% support) but very little mention of trying for federal anti-discrimination legislation even though the most recent poll showed 85% in favour of protection on sexuality AND gender-identity! 85%!!!

State by state we have a mess of 'incremental' results, GLB covered by antidiscrimination and antivilification legislation in some states but not others, Transsexuals covered under the term transgender against discrimination in some states and not others and not covered by antivilification legislation and a court battle currently arguing that a 24/7 crossdresser must prove that 'sexually they are a transsexual' in order to be classed as Transgender so as to suceed in suing a casino for throwing them out of a casino that has a bar called 'Priscilla's' where drag queens serve customers! Seriously!

And the Australian universal health care, think that TSs are covered? Nope! We have very little services, we have states where doctors can use their religion to turn patients away, we have some TSs having to voluntarilly go onto the sex-offenders registru just so their doctors can legally prescribe some of the hormones they need!

And when the AHRC (then HREOC) did their report on S&GD issues despite the huge numbers of people calling for medical TS and IS issues being the primary focus (myself very much included at that despite all the initial hate-filled comments of several factions objecting to the presence of other groups including folk like me being in the same report as somehow ensuring only non-binary issues would be dealt with and not TS and IS issues even though we'd already started raising those issues and argued for them to be the priority) they went and focussed solely on identity documentation anyway (allegedly because the were the main issues raised in the capitol-city meetings but many involved suspected that it was what was considered more politically 'feasable') with but some asides about the rest.

Then AHRC followed up on a promise to deal with the IS Infant surgeries issues we were clamouring about merely by a simple paper on the ethics involved that said little more than I already had in the forum posts i did on the ethics of the situation.

All the factional squabbling and incrementalism and tribalism does is waste opportunities and provide additional inertia to changing towards rational equatible and consistent principles.

And so the problems of people I know remain.. A suicidal TS still unable to get full SRS refused shelter at the local womens shelter and put into a hotel and left unsupervised where she (unsuccessfully thank goodness) overdosed on pills, doctors declining a TS proper ordinary basic treatment on a 'religious objection', coercively getting a drug-effected TS to consent to electro-convulsive therapy and labeling her with a personality disorder diagnosis to 'explain' the GID she'd always had her whole life long... oh and thats just the tip of the iceberg of the problems with health services of TSs I know personally offline from my own local community in the last 6 years!

And of course depression initiative Beyond Blue ignoring the GLB stats on their own site and concentrating all their work on other less-at-risk groups and ignoring the huge GLB numbers.. and no sign of the T suicide rate which studies have even higher than the worst of the GLB stuff in this country.

Even with Universal Healthcare fair and equal treatment is far from assured.

Colleen Fay | August 6, 2009 2:44 PM

Thank God for this discussion! As a 65-year old trans woman this debate could not be more timely. Not only do U.S. private insurers refuse to cover SRS (or GRS) and all other forms of health care that could possibly be related to one's transgenderism, but Medicare and Medicaid do as well. The "medically necessary" designation is recognized as encompassing more than life threatening conditions. Therefore this now has become a human rights issue regardless of what any of the folks on the far right have to say. Both Canada and the U. S. have the opportunity to lead the way on this issue.
[You may be interested to know that the actuaries tell us that post-operative trans people utilize the health care system much less than pre-operative folks. GRS besides being a humanitarian good is also cost effective.]

"The question isn't "How do you want to die?" The question is simply: "What kind of care do you want, and what measures do you want taken if - at the end of life - you are unable to speak for yourself?""

Here in Australia we call this a Living Will. It is there to as you say, give a voice when there might not be one. It gives the medical team the knowledge of how you as a person would like to be treated in your care. If you want to be DNR or not, important things to you as a person, and said when one is for medical and legal reasons 'of sound mind'.

On the point of the cost spread over a nation, it seems crazy that the Medicare systems will fund public operations for Breast reductions or Liposuction and Tummy Tucks, why not GRS?

I have one very dear friend who desperately needs/wants the operation but has been denied it for 'lots of reasons', this caused her to attempt suicide. This is not acceptable on a human rights level. We are supposed to all be able to receive the level of medical care we NEED... and we are supposed to be in a 'developed' country/society NOT 3rd world....

Off my soap box... this issue will NOT go away and until Govts accept this as 'genuine reason to fund' and society gets the puritan blinkers off then there are going to be many people die both physically and emotionally that need not have.

Great article.