Trans Health Coverage – Looking Ahead

Yesterday at the Huffington Post, Joanne Herman offered an interesting article: More Employers To Cover Transgender Surgery, But New Hurdles Expected

(Let’s not  derail over the use of the words “transgender surgery” here. Note that this is the language called for by the AP Stylebook, which is widely adhered to by U.S. journalists. They don’t use the word “transsexual.” It’s not technically accurate, but that’s a topic for another time.)

The article speculates about the impact of the upcoming change to Human Rights Campaign’s Corporate Equality Index, which has been updated for 2012 to require employers to offer extensive trans related medical care as a condition of achieving a perfect score.

The required changes are summarized by the HRC as…

• transgender exclusions must be removed or substantially modified to ensure coverage for transgender-specific treatment
• either directly in the contract or in clinical guidelines referenced by the contract, the insurance plan must acknowledge the WPATH Standards of Care to determine what treatment will be considered medically necessary and not cosmetic.

It’s not certain at this point what impact the updated CEI requirements will have. After all, most companies don’t ask for a CEI rating in the first place.

But quite a few companies not only care about getting a perfect CEI rating, they have gotten into the habit of boasting about it annually. One would assume these companies have some motivation to take action to keep their rating. And if they do so, that’s good news for trans health.

Another interesting item from Herman’s article comes near the end.

Regardless of the hurdles, the new coverage is timely. The recently-released U.S. Department of Health and Human Services’ Healthy People objectives for the next 10 years include, for the first time, a specific objective of recognizing transgender health needs as medically necessary. The change in attitude brought by the new surgery coverage will go a long way toward achieving this objective.

A departmental objective isn’t exactly a law, but it’s a heck of a lot more than I would have expected at this point. If all it does is raises awareness and gets people to better examine the evidence, I’d see that as making solid progress.

I may be reading too much into this, but it seems to me like transsexualism is coming to be recognized by a much broader audience as a medical condition responsive to medical intervention, just like the evidence has long shown.

I personally hope that this recognition spreads bottom-up throughout the minds of the general public who then respond accordingly (and I see the voluntary nature of the CEI to be a good step in this direction), rather than being mandated top down at some point. I don’t want trans health to become a political football. I’d prefer lasting recognition of trans health needs based on good science and sound medical evidence, making it about as political as treating a cleft palate.

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Aussie Court Slams Trans Men

I’m not sure why I haven’t seen more commentary about this news item tonight. I’ve been a little preoccupied, but it jumped out at me in my quick search for what’s happening.

A Western Australia court, in a landmark decision, has ruled that transsexual “men” are, in fact, women. …

The appeal prohibits two female-to-male transsexuals from being recognized as men, the West Australian reported Thursday.

The case hinged on the lack of male “genital and reproductive physical characteristics,” the court ruled. In addition the court noted that the two women, who have not been named in court documents, have female reproductive organs.

I’m not as familiar with the impact of court decisions on Australian law, but in U.S. terms this would be a bombshell dropped on the trans community.

I’d like to know more about what was really decided here. Are they saying “top surgery” is irrelevant for FTM’s or that any surgery isn’t enough? If it’s just about the nature of surgical status it’s something I strongly disagree with, but not that unusual compared to the laws elsewhere. But if it’s tossing out the possibility of changing legal gender designation even after surgery, this is a BIG step backward.

Can anyone help clarify this for me. I truly won’t have the time to do my own research here for a while.

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Your Papers Please

Navigating the Red-Tape Jungle During Gender Transition

One of the less appreciated aspects of trans life surrounds the paperwork required to legally establish ones gender. If you’re born with a body unambiguously male or female and you never have any doubts about it (I’m looking at you, 95% of the population) this is little more than an afterthought which you’d only ever encounter if someone has made a clerical error. For trans people establishing their gender identity in legal paperwork its a daunting challenge. It’s frequently expensive and generally frustrating due to constantly changing and often contradictory rules.

And suddenly it’s becoming newsworthy.

Yesterday, in regard to the Nikki Araguz case, I quipped that… “…if Nikki wanted to get re-married to a woman does anyone seriously believe the State of Texas would be groovy with that? I’m pretty sure they’d see that as a same-sex marriage as well even through it would require a total contradiction of the reasoning in the current case.“

Right on cue comes an article today talking about the same thing in the Austin American Statesman:

“Something for Texas legislators’ 2011 to-do list: Take another stab at defining which government-issued documents can be presented by marriage license applicants.

Seems simple enough, doesn’t it? It’s not. Buckle up for a bumpy ride through the current confusing situation.

Under current law, revised in 2009, marriage license applicants can have officially recognized forms of identification that offer diametrically opposed declarations of gender. That can be a problem because to get married in Texas, couples have to include one of each.”

The article goes on to mention how lesbian couples including a trans partner have applied for marriage in Texas based on a “male” birth certificate. Some have succeeded. Some have not. It’s a bit of a crap-shoot at the moment, because those who work in the state bureaucracy are widely confused. Need an illustration?

“That leaves El Paso County officials confused as to what to do in situations such as the one encountered in February when Sabrina J. Hill and Therese Bur sought a marriage license. Hill’s New York birth certificate certifies birth as a male. Texas law says a birth certificate is an acceptable form of identification for marriage license applicants. Sign the forms, throw the rice and wish the couple well, right?

It’s not that simple.

Hill also presented an Arizona driver’s license (also an acceptable form of ID in Texas for a marriage license, as are all out-of-state driver’s licenses) that lists her as female. Hill, born a hermaphrodite [in modern terms we'd say "intersexed" rather than the h-word -D] (with male and female sex organs), also submitted a Washington state court order from the name-change petition granted after gender reassignment surgery that made her a female.”

I would like to note that there is nothing unusual about Ms. Hill’s situation in regard to the paperwork surrounding her legal gender identity. If she followed the Standards of Care, as defined by The World Professional Association for Transgender Health (WPATH), this is a more or less “normal” state of paperwork for a trans woman based on the competing requirements of various state and federal agencies.

Currently in the U.S. the laws covering gender marker changes on most documents are covered by state law, but sometimes the state laws require federal documents (e.g. Social Security) before they will modify a gender marker. Furthermore, different federal and state agencies (e.g. the DMV) often have their own policies further defining the requirements necessary to implement gender marker changes. These are remarkably inconsistent and frequently contradict one another. And that’s even before you get to the standard way in which gender transition is governed in the medical and mental health world.

The current WPATH Standards of Care require the following key steps to complete gender transition after a rather rigorous set of eligibility criteria have been satisfied:

1. Hormone therapy – This alters the appearence (sometimes radically), giving the transitioner the secondary sexual characteristics of their target sex. In so doing it makes it increasingly difficult for the transitioner to function in society as ones birth sex.
2. Real Life Experience (RLE) – This is a period lasting a minimum of one year in which the transitioner must “prove” that they can successfully manage their life in their new gender role, in terms of relationships, employment, social role, etc.
3. Gender Reassignment Surgery (GRS) (a.k.a. Gender Affirmation Surgery, Sexual Reassignment Surgery) – This is “the surgery” which non-trans people seem so fascinated by and place so much emphasis on as THE act which changes ones sex, (trans people generally don’t agree on its singular importance in this regard, but it’s still pretty important).

It’s generally during the Real Life Experience (Step 2 above) that gender marker changes are important on legal documents for all sorts of practical reasons (e.g. you no longer physically appear to be your former gender which leads to identification problems; there are employment and legal contract implications; etc.). This is the point at which – as far as the rest of society is concerned – you are now the sex opposite of your birth. The Standards of Care, in fact, require this to be a full time thing in all phases of your life or else you may not qualify for gender reassignment surgery.

However some of the most important paperwork required for changing gender markers on legal documents relevant to the Real Life Experience (birth certificate, social security number) require proof that GRS has been completed in order to change the gender marker. Remember, the Standards of Care says GRS should take place no sooner than one year after the Real Life Experience begins so there as at very least a significant time lapse between these two events – and the sequencing is the opposite of the legal requirements for making the change.

Timelines aside, there’s another tremendous problem here, as gender reassignment surgery is generally not covered by medical insurance. That means a great number of transitioners may linger for years – or even permanently – living completely as the sex opposite of their birth but lacking the financial means to attain GRS. Requiring someone to spend tens of thousands of dollars on a surgical procedure regardless of income level in order to update basic government paperwork is at the very least problematic.

Think about the situation here. The mental and medical health professionals insist you must be on hormones and living full time as your target sex for a long while before you qualify for surgery. Government officials insist you must show proof of surgery before they’ll change your legal gender marker to recognize you as your target sex. And the insurance companies insist this surgery is all just a cosmetic procedure anyway – like a nose job, or liposuction – and they won’t pay for it. And that’s a best case scenario. Usually this gets further complicated as things vary from agency to agency, state to state, so an individual transitioner has to figure out which hoops they personally need to jump through and in which order. Meanwhile the paperwork inconsistency results in continual problems with employers, medical providers, interactions with government agencies, and much more.

I hope that the visibility these issues are starting to receive will lead to some common sense reforms in the near future. In the meantime, I hope those who aren’t personally affected by this red-tape tangle can begin to appreciate how it affects real people and help us make some noise to get things put right.

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Sexuality, Science, and Public Policy

One of the big national stories in the trans sphere at the moment is about Nikki Araguz, the widow of a firefighter killed in the line of duty. The ex-wife and mother of the firefighter filed a great big media-seeking lawsuit to invalidate Nikki’s marriage, thus denying her legal benefits as a widow, on the grounds that she was born male and the state of Texas doesn’t recognize same-sex marriages.

The case is being covered extensively by people other than me, so I’m not going to dive into the details here (Although, on a side note, if Nikki wanted to get re-married to a woman does anyone seriously believe the State of Texas would be groovy with that? I’m pretty sure they’d see that as a same-sex marriage as well even through it would require a total contradiction of the reasoning in the current case.).

I bring up the case because it’s drawing the attention of a lot of otherwise disinterested people into the nature of transsexuality. And some of the resulting comments are interesting.

Here’s one that leaped out at me today, from Bryan Fischer, director of issue analysis at the American Family Association:

“We think that our public policy ought to be guided by science and biology, and not by political correctness,” he said, noting that gender is a biological reality and not a choice or a role one plays, as contemporary gender theorists maintain.

So far, so good.

I mean you may or may not agree with the “political correctness” quip, as that particular straw man can conceal quite a lot upon which people legitimately disagree. And that’s an incomplete description at best of the various concepts surrounding  gender. But anyway, I certainly agree science ought to play an important role in informing public policy, and that our policies ought not attempt to treat as true things which are known to be false. But I’m not sure Mr. Fischer is quite as committed to that proposition as he seems, as illustrated by the next part of his quotation.

“This case just certainly indicates how complicated and bizarre things get when you simply ignore the biological reality that this individual is a man,” he said. “He’s a male in every cell of his body. His DNA has been male from the moment he was conceived and will be until the day he dies.”

Here’s where we get into interesting territory. Fischer apparently believes that “science” and “biology” tells us that people conform to a rigid gender binary. Nikki has “male DNA,” so that’s what she is. That’s what he’s calling the “biological reality” anyway.

But, if you’re actually following modern science regarding the matter, it says no such thing. Certainly our culture attempts to restrict us to such a gender binary, but the science is illustrating a far more complex biology surrounding human sexuality and gender identity.

Here’s a sampling of things science knows to be true, which contradict the notion of a rigid gender binary:

• It is possible for a person with 46XY (i.e. male pattern) chromosomes (i.e. the DNA “in every cell of our bodies”) to naturally develop as a normal woman, with the ability to conceive and give birth to children.
• It is possible for a person with an external anatomy of one sex to have a brain which structurally appears to be that of the opposite sex.
• It is possible for a person with the external anatomy of one sex to spontaneously develop the secondary sexual traits of the opposite sex.
• It is possible for a person to be born with genitals which are not identifiably male or female, and to identify – in conformance with their own “biological reality” – as neither male nor female.

That’s a smattering of the “biological reality” underlying human gender. Unfortunately for people like Mr. Fischer none of this stuff supports the notion of a rigid gender binary because, in scientific terms, a biological gender binary simply isn’t true.

Simplistic notions like “if you have XY chromosomes, you’re a man, and if you have XX you’re a woman” cannot account for the range of human sexuality currently known to science. Simplistic gender binaries are to the science of sexuality what creationism is to the science of evolution.

Those who respect actual science let scientific evidence inform their decisions. Those who invoke science in order to legitimize legal discrimination of gender variant people don’t tend to be among these people.

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What’s Wrong With This Picture?

Last Friday there was a big trans-related story in the Washington Post. Apparently the conservative governor of Virginia has a former in-law, Robyn Deane, who has come out as transsexual. What’s more Deane is speaking out against the governor publicly in an election year over his positions on GLBT issues.

It’s a decent enough story. If I was writing for the Post, I’d run with it. Nothing wrong there. But then we come to the picture they decided to attach to the story.

Robyn Deane applies eyeliner

Let me ask the obvious here. What does a picture showing Deane putting on eyeliner have to do with this story? In politics scandalous little family dramas like this pop up all the time. Yet only in this one does anyone deem it relevant to focus their camera on one of the principle characters in the story applying makeup, blow-drying hair, and pulling up stockings (all of those pictures are prominently featured on the web page of the story, but I’m not showing them all here).

It’s not exactly a mystery what’s going on here. Introduce a word like “transgender” into a news story, and suddenly there’s an expectation that it needs to be covered like a drag show. Look at the man putting on makeup and womens clothes! (insert nervous giggling) It’s just like Nathan Lane in the Birdcage! (more giggling)

Every time I try to think we’re making some progress in getting people past a junior-high level of dialogue about trans related issues, I see something like this. Yeah, we’ve come a long way but there is still a LOT more room to grow.

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Thunder Bay, Here I Come

Good news today from an unlikely source… The U. S. State Department.

(June 10, Washington, DC) Last night the US Department of State announced new guidelines for issuing passports to transgender people. Beginning today, applicants for a gender marker change on their passports will need to submit certification from a physician that they have received “appropriate clinical treatment” for gender transition. Most importantly, gender reassignment surgery is not required under the new policy.

This is good news for the transgendered population and their families. It’s a small but important (and hopefully precedent setting) change in the way the government treats those who are transitioning.

The previous policy put transsexuals in a no-win position. Under the WPATH standards of care, we’re supposed to live as our intended sex full time for at least a year before being eligible for gender reassignment surgery. However our passports would continue to designate us as our previous sex until after surgery was completed (which, due to the cost and near universal lack of insurance coverage for he procedure, is typically even more than a year after living full time).

What’s more some transsexuals (particularly female to male) choose not to have surgery at all for a host of reasons (e.g. cost, health risks, dissatisfaction with current surgical options). I’ve met transsexuals who have been living as their non-birth sex for more than twenty years without surgery. You would never guess that such a person was anything other than the sex they appeared to be, and yet “officially” they were still supposed to be a member of the sex they no longer have the ability to portray. And you think your experience with airport security is annoying?

So anyway, now when I get my name, drivers’ license, and all that other crazy paperwork changed this fall, I can also get my passport updated. Then, next time we visit the North Shore of Lake Superior, we can finally take a trip to Thunder Bay, Ontario, rather than stopping at Grand Marais, MN.

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