The New Gender Paradigm

1 Year Later...

A year has passed since the introduction of the Affordable Care Act.  What's the current status?

It's no secret that the rollout was an utter disaster.  Technical problems with the website and sign-up process continue, although there's constant improvement.  More important, some of the key provisions have been wavered -- for example, because of a misguided campaign promise, people have been allowed to retain healthcare insurance that doesn't comply with the ACA (i.e. pre-existing illness and transsexual exclusions.)  Insurance mandates have also been delayed.  21 states have chosen not to implement the law. 

For more details, go HERE.

Healthcare Reform

Healthcare access is the Number One problem facing transsexuals around the world.  Transsexuals need healthcare for survival, but a 2011 Survey by the National Center for Transgender Equality (NCTE) found that 24% of transsexual women seeking medical care aren't even allowed through the door -- just because of who they are.  Another 28% are harassed by the medical staff once they're inside.  And 48% can't get necessary medical care because they can't afford it. 

The federal Patient Protection and Affordable Care Act of 2010 (PPACA) is supposed to improve access to healthcare for millions of Americans.  The Act eliminates exclusions for pre-existing and chronic illnesses.  Health maintenance visits are mandatory and free.  Coverage continues during changes of employment.  Having coverage is mandatory, but may be subsidized.


      ...But will the ACA grant transsexuals access to the healthcare they need? 

Specific Exclusions

In the past, most insurance policies have specifically excluded transsexual care.  How broadly that exclusion applies depends on the location:  
 That means: 

          -- It definitely excludes all forms of surgery on the chest and in the groin area, even prohibiting removal of the gonads which is the least expensive, most effective, and safest path to hormonal control.

          -- Often it's extended to include surgery-related complications, like post-op infection, bleeding or inadvertent injury to adjacent tissues.  

          -- It may also exclude hormones along with their complications & side-effects. 

        -- And sometimes insurance companies extend the exclusion to virtually any & every medical condition.  For example, a transsexual with a broken arm may be denied because hormones might have weakened the bone.

       -- These exclusions are justified because transsexuality supposedly is a choice, not a need.  Surgery & hormones are therefore "cosmetic" and "experimental".  

Does the ACA continue these specific transsexual exclusions?   The answer depends on the location.  

The ACA requires coverage of care that is "medically necessary".  Any procedure offered to one patient group must also be made available to other patient groups.  Each state makes it's own rules & policies regarding what these phrases actually mean.  For example, in Colorado the Division of Insurance  published Bulletin B-4.49 that mandates "medically necessary" care (as determined by the physician).  Specific groups can't be excluded from care.

Other states may continue the exclusion by claiming that transsexuality is a choice, so that medical care is voluntary, not necessary.  When exclusion occurs, the patient will have to go through the court system for redress.  ...A prospect outside the financial means of most transsexuals.

Court rulings on this subject in the past have been variable:  some courts have agreed that transsexual medical care is "necessary", while other courts hold that psychotherapy is sufficient (or any other form of treatment) -- as long as an established policy exists and it's applied equally to all people:

"We do not believe, by the wildest stretch of the imagination, that such surgery can reasonably and logically be characterized as cosmetic."                                         
               -- Judge J Abbe, California Court of Appeals, Jane Doe v Lackner (1978)

However, in Rush v Parham (1980) the court allowed the Georgia Medicaid agency to over-rule the diagnosis and treatment recommended by a transsexual patient's medical providers.  

And in Smith v Rasmussen (2001) an Iowa court ruled that blanket exclusion of transsexuals was permissible as long as standardized review criteria were followed.

The Federal Model

The ubiquitous transsexual exclusion actually originates from policies of the federal government itself.  Most insurance companies base their coverage on government statements of medical necessity, known as National Coverage Determinations (NCDs).  The NCD for Transsexual Surgery is number 140.3: 

"Transsexuals are persons with an overwhelming desire to change anatomic sex because of their fixed conviction that they are members of the opposite sex.  Transsexual surgery for sex reassignment of transsexuals is controversial.  Because of the lack of well controlled, long term studies of the safety and effectiveness of the surgical procedures and attendant therapies for transsexualism, the treatment is considered experimental.  Moreover, there is a high rate of serious complications for these surgical procedures.

"For these reasons, transsexual surgery is not covered."

          -- NCD 140.3, Centers for Medicare & Medicaid Services (CMS)

Much of the text comes directly from the DSM / Mental Health Model.  Strictly speaking, the NCD applies only to Medicare reimbursement, but most states extend the NCD's to include Medicaid.  It's also the perfect excuse for transsexual exclusion from private insurance plans.

Mental Illness

Another major obstacle to healthcare access is the widespread myth that transsexuality is a mental illness -- after all, the DSM says so.  According to WPATH and other treatment guidelines, medical treatment is allowed only after a psychiatric evaluation (sometimes even two independent evaluations.)  These evaluations offer no actual benefit to the patient, but add $500 - $1000 to the healthcare cost.

Insurance coverage for mental health care has always been limited.  The ACA mandates that all plans must provide some coverage for mental health care, but it's up to the state to decide how much coverage is enough.  Often there's a limit of, say, six visits a year with large co-pays.

But then, coverage may not really be an issue:  ​A recent study showed that only 53% of psychiatrists accept insurance even when it's available (compared to 89% of medical doctors).  Acceptance isn't a requirement under the ACA.  The demand for mental health services far exceeds the number of visits available.   

Surgery & hormones for a mental health disorder has always been a major disconnect, leading to almost automatic reimbursement denial.

Social Exclusion

Remember that transsexuals face three levels of healthcare denial:  specific exclusion, harassment and financial.  Mainstream society has yet to be convinced of the need for transsexual healthcare, particularly when paid with public funds.  In fact, it became an issue during the legislative debate prior to the passage of the ACA.  For example, Peter LaBarbera from Americans for Truth about Homosexuality (5 August 2009)  [] reported:

"When asked by Senator Orin Hatch (R-UT) whether President Obama's proposed socialized healthcare plan will mandate taxpayer funded abortion, Senator Barbara Mikulski (D-MD) admitted that it will require 'any service deemed medically necessary or medically appropriate.'

"In addition to abortion on demand, the weight of the evidence indicates that cosmetic "gender reassignment" surgeries for both U.S. citizens and illegal immigrants who suffer from APA recognized "Gender Identity Disorder" (GID) may also be provided - free of charge - courtesy of the U.S. taxpayer.  The current price tag for such a procedure can exceed $50,000.

"I contacted the offices of Sen. Harry Reid, Rep. Charlie Rangel, Rep. Barney Frank and the House Subcommittee on Health.  I asked, very simply, for 'an assurance that the proposed healthcare plan will not allow taxpayer funded gender reassignment surgeries or hormone therapies.'  When faced with the bill's relevant language, every staffer I spoke with either declined to answer or would neither confirm nor deny that such procedures would be covered."


A Bad Example

Consider what happened in Washington State, a progressive region noted for gender acceptance.  During the past 15 years, the Washington State Medicaid Review Board has received a total of 6 requests for medical transitioning.  (The issue is hardly a budget-breaker!)  Most of the requests were immediately denied, but in a couple of cases, surgery was actually paid for under Medicaid. 


The state legislature freaked out when they heard the news:    

"When news surfaced earlier this year that Medicaid, the federal-state insurer for the poor and disabled, had paid for such procedures, some state lawmakers tried to impose a ban.  A U.S. senator even weighed in, writing letters to top state officials and calling for a federal investigation. 

"Even before the political uproar, however, Medicaid officials were working on new rules that essentially classify sex-reassignment surgery as experimental and not eligible for coverage.  The state would pay only for less costly treatments, such as hormone therapy and counseling."

                        -- Ralph Thomas, Tax dollars and a sex change: a story of one patient (Seattle Times, 11 April 2006)

The controversy went to the court system, where the judge ruled that transsexual healthcare was indeed a medical necessity.  Not to worry, the Washington State Medicaid Review Board held an emergency joint hearing that overruled the judge's decision.  

There's no reason to expect the Affordability Act will be handled any differently.  There's bitter irony that transsexuals will be forced to purchase insurance policies that specifically exclude them from receiving care.

Data Collection   
Don't underestimate the importance of the ACA's provisions on improving data collection.  The goal is to identify, track and reduce health disparities in minority groups.  Hmmm.  That sounds just like transsexuals.

Transphobia thrives in ignorance.  For instance, NCD 140.3 exists only because no researcher has ever bothered to compare outcomes from transsexual surgery vs psychotherapy alone or the health impact of exclusion.  In a data vacuum, the most outrageous claims can be made and no one can refute them.   

However, statistics can easily be manipulated, especially through a vague & distorted definition of the study population.   For example, crossdressers & androgynous people don't benefit from transitioning, surgery or hormones.  Including them in a study group under the guise of "transgender" will lead to the conclusion that transitioning, surgery & hormones are useless.  Likewise, a study group defined by having a psychiatric diagnosis of  "gender dysphoria" will automatically support the contention that transsexuality is a mental disorder.


      ...Both approaches would allow continuing the current denial of healthcare to transsexuals.                                                                                                                                                       

                  © Cassandra Branch, MD