Trans Healthcare Exclusions — The History

trans healthcare oregonHow would you react if it turned out that your insurance company refused to pay for surgery your doctor said you needed based on an analysis of the surgery’s effectiveness published before the dawn of the internet?

Would you be concerned if you found out that federal equal opportunity educational policies were based on a position paper written by someone who believes African-Americans are an inferior race?

Would you want someone who had gone through a bitter divorce determining whether their ex-spouse should be provided life-sustaining medical treatment?

Would you agree that public policy ought to focus on the elimination of unwed pregnancies by refusing to pay for the health care of pregnant women who are unmarried?

If any or all of those scenarios appall you, you should be advocating for transgender health care justice, because all of these questions reflect the history behind trans people’s restricted access to health care services.

Currently five states and the District of Columbia have forbidden insurance companies from refusing to pay for care of transgender people; everywhere else such exclusions are not only legal, but ubiquitous.  Such “transgender exclusions” are typically said to exist because transgender related health care is “experimental,” “cosmetic,” “elective,” and/or “too expensive.”  In truth, all such treatments are routinely covered by insurance companies when they are provided to patients who are not transgender.  Furthermore, such exclusions were never based on medical evidence, but instead can be traced to one policy paper written by a person who had had unhappy experiences dating transsexual people and who had subsequently developed a rabid anti-transgender philosophy.

You cannot find an online, original copy of “Technology on the Social and Ethical Aspects of Transsexual Surgery,” by Janice G. Raymond because it was written in 1980, before the World Wide Web existed.  Transcribed copies can be found in a variety of places, including http://auntyorthodox.tumblr.com/post/82585002623/technology-on-the-social-and-ethical-aspects

The paper was written at the request of the National Center for Health Care Technology (NCHCT), which was a government-funded body that was charged with making evidence-based judgments about the efficacy of medical technologies.  Rather than consulting medical experts, NCHCT asked Janice Raymond, an assistant professor of medical ethics and women’s studies at the University of Massachusetts, to address the issue of the medical care of transgender people.  The year before, Raymond had published The Transsexual Empire: The Making of the She-Male, arguing that not only was it impossible to change one’s sex, but that those who did so were anti-feminist.

The NCHCT paper was filled with political and even inflammatory statements.  Raymond said medical care of transgender people brought up “questions of bodily mutilation and integrity,” argued that “transsexualism is an ethical” issue, and called for “the elimination of transsexualism.”  She worried that clinics that specialized in working with transgender people “could become potential centers of sex-role control for non-transsexuals – e.g., children whose parents have strong ideas about the kind of masculine or feminine children they want their offspring to be.”  She made an analogy between medical care of transgender people and “oppressed people us[ing] heroin to make life tolerable in intolerable conditions.”  Just as the “contentment and euphoria produced by the drug [heroin] diffuses the critical consciousness of the user,” she said, “Transsexual surgery produces satisfaction and relief for the transsexual at the expense of muting his or her critical consciousness of the ways in which such surgery reinforces sex role behavior.”

When she did address legitimate medical issues, Raymond did so in a skewed and misleading way.  For example, she stated that “[t]ranssexual treatment…has been known to cause cancer,” citing two cases of breast cancer in trans women.  She suggested “that the malignance was entirely due to the hormonal imbalance created by castration plus the massive doses of estrogen received.”  Apparently she felt the fact that breast cancer is extremely common in women across the board, whether or not they have ever taken estrogen pills, had no relevance.

Despite the obvious political bias of its author, “Technology on the Social and Ethical Aspects of Transsexual Surgery” became the basis of Medicare’s exclusion of coverage for transgender related care.  Medicare’s decision, in turn, led to the exclusion of such care not only in other public programs such as Medicaid, but also by most health care insurance companies.

And that is how one woman’s personal 1980 prejudices and worldview came to shape medical care for thousands and thousands of transgender people ever since.

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