The Future Of Transgender Healthcare

Massachusetts recently began covering transgender care, including hormone replacement therapy and gender reassignment surgery, in their Medicaid program. Governor Patrick’s administration also moved to, “Prohibit private insurers from denying coverage for gender reassignment surgery or other treatments medically necessary for patients who are transgender, saying that would constitute sex discrimination.

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Could New York be next? Last week news broke of a lawsuit filed by the Sylvia Rivera Law Project, an organization that provides free legal aid to transgender people, against Medicaid in New York City on behalf of transgender residents seeking hormone therapy and sex reassignment surgery (SRS). Such suits have appeared before only to be disregarded. In 2008 a similar lawsuit was filed but the judge dismissed it, referencing a ruling from a 1998 case that cited “serious complications from the surgeries and danger from life-long administration of estrogen and testosterone,” as the cause for denial of care.

APICHA Community Health Center is home to one of New York City's leading transgender health clinics. I spoke with the organization's Transgender Health Coordinator, Cecilia Gentili. "After years working for my community's health, I've seen that frustration precedes accomplishment in medical care." Gentili's frustration is with a system that is fundamentally flawed. "Some years ago my reality was not only trans but undocumented immigrant working in the sex trade. Finding a provider that had experience with the trans community and who was willing to work with me in a non judgmental way was nearly impossible. "

The lawsuit currently filed against Medicaid cites the Department of Health and Human Services recent ruling that Medicare must cover transition services, and also claims modern findings affirm these treatments are safe stating, “there is evidence that the medical community has since reached a consensus that gender reassignment surgery is an effective treatment.” 

Which ought not be surprising, given the ample testimony and evidence throughout the past 50 years supporting transition related treatment for transgender people.

Dr. Harry Benjamin was a radical physician who in 1966 wrote a groundbreaking text, The Transsexual Phenomenon, on trans people and the treatment of gender dysphoria. In the book’s preface, Benjamin writes that the topic of transsexualism and its treatment have long been shadowed by a cultural taboo. On societal reception of transsexualism, Benjamin writes that, “Its therapeutic implications, were largely neglected, at least in the United States…any attempts to treat these patients…is often met with raised medical eyebrows, and sometimes even with arrogant rejection and/or condemnation…the forces of nature, however, know nothing of this taboo… I have seen too many transsexual patients to let their suffering be obscured by uninformed opposition.”

Last month the American Medical Association released a statement in support of trans care, advising that trans people should be able to change the sex on their legal documentation without undergoing surgery. The AMA also supported the medical necessity of trans care by stating, “the only effective treatment of [gender dysphoria] is medical care to support the person’s ability to live fully consistent with one’s gender identity.”

I’ve lived in NY for the better part of a decade. There are excellent resources here, such as the clinics at APICHA and the Callen-Lorde Community Health Center, which both provide affordable transition services to people with and without insurance. Like most trans people, I’ve had to be strategic and creative in piecing together my transition. Fortunately the resources that are available help connect the dots the system fails to bridge. Many trans people seek assistance from these agencies, and though they are useful, they are an inadequate alternative to affordable health care with trans-inclusive coverage. Others, like 24 year old trans woman Aamori Olujimi, ask their community for support through crowd-sourced fundraisers. While these commendable ventures can be inspirational, accepting them as an alternative to institutional care is unacceptable.

For transgender people who are medically insured, seeking treatment can pose more obstacles. They're often tasked to speak with insurance providers who stutter in discomfort at the mention of transgender, having a taste of what Harry Benjamin described 50 years ago as the "raised medical eyebrows" of "uninformed opposition".

On June 25th, State Insurance Commissioner Mike Kriedler sent a letter addressed to the insurance providers of Washington, directing them to cover transgender health care stating, “Whether specific services are considered medically necessary should be up to the provider to decide on behalf of their patient.”

It is clear a cultural shift is occurring. The future of transgender health care is one of inclusive, comprehensive coverage. In a country that is working to fix its broken health care system, the change in trans health accompanies changes like those in the Affordable Care Act (ACA). 5.4 million Americans enrolled in the federal health insurance marketplace this spring. The ACA has been criticized, but regardless of speculation, many people are concerned they won't find affordable, adequate coverage. Those who are insured wonder if their premiums will rise, or if other complications might make maintaining a plan more difficult.

I enrolled before the March 31st deadline, and have been insured by MetroPlus for two months. My premium is $374 dollars, but I only pay $80 a month for my plan because of the tax credit available to lower income individuals. Last week I received a letter stating the company’s petition to the New York State Department of Financial Services to raise my premium rate in 2015 to $439 a month. I'm not sure what my cost will be after the tax credit is applied. Though I'm pleased to have coverage, I didn't expect an increase so soon, and my plan doesn't even cover the cost of estrogen, an integral part of MTF hormone replacement therapy.

"This is unfortunately normal practice," Gentili explained, "The majority of policies don't cover hormone replacement therapy unless you've had a legal gender change. Even when they do, a patient's coverage only pertains to certain parts of their trans body. Insurance companies often dictate the course of a patient's treatment, selectively denying one kind over another. Some will only pay for a certain dosage of hormones, and if you need to increase they'll deny you without argument."

I called MetroPlus, to inquire about my Obamacare policy’s coverage of transgender services. The polite woman on the other end of the line must not have been asked that question before because she didn’t seem to know that transgender care exists. “Your policy wouldn’t cover cosmetic procedures,” the representative explained.

Why do we encounter ignorance to the existence of Gender Dysphoria, a medical reality endorsed by the AMA and APA, from the arbiters of our medical care? Sex reassignment surgery has been performed on transgender individuals since the early twentieth century. Christine Jorgensen was the first transsexual woman to make international headlines in 1952 when she had her vaginoplasty performed in Copenhagen. This news illuminated the American public to the existence of transgender people. It was in the 1960’s when transgender truly became a cultural hot topic. The research being done in the 50’s by psychiatrists and sexologists who specialized in the trans phenomenon was finally published, and the first gender identity clinic opened at Johns Hopkins Hospital in Baltimore, MD. Hopkins was the first in a series of academic institutions that would house these clinics. They provided comprehensive treatment including sex reassignment surgery and HRT, but their work was experimental, not political, by nature.

The Harry Benjamin scale of gender identity, a spectrum that functioned, much like Kinsey’s scale for sexuality, to categorize individuals with more nuance than a strict binary system, informed how trans people were cared for. Though these developments had an inherent radicalism, in the sense that medical professionals were providing treatment for transgender people, the banal societal norms that governed transition protocol were conservative. Heterosexual, young, passable, and feminine transsexual women rated well on Benjamin’s scale, and qualified for transition services while older, lesbian, masculine women were refused.

If New York comes to adopt a policy similar to MA, the state’s trans resident’s insured by Medicaid would have greater access to services once prohibitively expensive. Gentili explained that access to care shapes the lives of transgender people. "Many folks relocate to states that have better transgender health policies. Some of my patients work in NYC and live in Connecticut in order to get the care they need" The gender clinics of Johns Hopkins closed in 1979, which caused sex reassignment to become privatized. For those who could afford the inflated cost, privatization enabled access to a surgery that had once been controlled by the strictures of academia and the sterility of an experimental clinic. But for the economically disadvantaged, SRS is still inaccessible.

Sex Reassignment Surgery costs approximately $20,000 in the United States, and it is only one in a number of surgical procedures that may be part of a trans patient’s course of treatment. Breast Augmentation, and facial feminization surgeries (FFS) are far more common than SRS, but comparable in cost. A patient seeking a full range of FFS with Dr. Jeffrey Spiegel, a teaching physician at Boston University Medical Center, and a global leader in the art of facial feminization, costs between 30 and 40 thousand dollars. The surgeons who are capable of adequately meeting the needs of trans patients number a handful in this hemisphere. For many trans people who will never be able to afford them, they are more than a world away.

The Obama administration has done more for transgender rights than any other. In an ABC News article from earlier this week, the president’s progress was lauded for it’s far reaching and strategically discrete application. ABC writes that,“The administration has quietly applied the power of the executive branch to make it easier for transgender people to update their passports, [and] obtain health insurance under the Affordable Care Act.”

Perhaps one day that insurance will cover transgender health. Gentili described the limits of care, "I was happy to find a job that enabled me to assist other folks in my community in dealing with these issues, and soon realized that health care does not end with having a provider. I'm trans myself, and I've had to educate many providers around the needs of my gender non-conforming body. Its exhausting, politicians remember to talk about us during pride and at election time, but the change doesn't happen."

Critics of transsexualism may consider these procedures cosmetic, but who cares? The AMA and APA, two organizations in place to govern and administrate the standards of the medical health care of American citizens, have clearly affirmed their medical necessity and value in the treatment of gender dysphoria for transgender patients. Health care in the USA is an industry, and insurance providers are corporations. Cutting costs by denying coverage, to the detriment of the mal-insured, is an American insurance agent pastime. These agencies are more motivated to exclude trans coverage to meet their bottom line than to institutionalize cultural bias against trans people, but it is that bias they capitalize upon.

When I spoke with my MetroPlus insurance representative, I asked her why there wasn’t a policy on gender dysphoria, given its presence in the APA’s Diagnostic and Statistical Manual of Mental Disorders (the DSM V) and the AMA’s recommendation that transgender people need to be medically supported in their transitions. She simply repeated that my plan does not cover cosmetic costs, and I thanked her for her time.

Perhaps Harry Benjamin said it best in 1966, in his book The Transsexual Phenomenon, “Conservatism and caution are most commendable traits in governing the progress of science in general, and of medicine in particular. Only when conservatism becomes unchanging and rigid and when caution deteriorates into mere self-interest do they become negative forces, retarding, blocking, and preventing progress, neither to the benefit of science nor to that of the patient.”