Tag Archives: Transgender

The Costs and Benefits of Eliminating Trans Health Care Exclusions

Transitioning to better health careMany public and private health care insurance programs have “transgender exclusions” that refuse to pay for transition-related care for transgender people.  One common argument against ending such exclusions is that covering the cost of transgender people’s surgeries and/or hormones would raise the cost of health care insurance premiums for everyone.

The State of California’s Department of Insurance found that not only was that a false assumption, but covering such care could even “lower costs.”

How is it possible that an expansion of health care availability could actually lower health care costs?  The answer lies in accounting for the costs of discrimination:  “The Department [of Insurance] has determined that the benefits of eliminating discrimination far exceed the insignificant costs associated with implementation of the proposed regulation [requiring insurance companies to cover transgender-related care]. …Further, the Department’s evidence suggests that benefits will accrue to insurance carriers and employers as costs decline for the treatment of complications arising from denial of coverage for treatments.” (p. 9)

First, let’s talk about the costs.  The Department looked at the costs incurred and projected to be incurred by several employers who decided to cover such care, including the University of California, the City of Berkeley, the City of Portland, the City of Seattle, and the City of San Francisco.  Projected cost estimates were much higher than actual costs turned out to be, in one case 15 times higher.  Once there was actual utilization data available, the various plans’ premiums increased, at most, by 0.19%.  In several cases, insurers determined no premium increase at all was needed to cover the transgender-specific healthcare. (pp. 6-7)

So how are actual savings possible?  The report addresses four specific ways in which overall health care costs for transgender “insureds” might decline:

1. A decrease in suicide attempts and completions.  Transgender people have an extremely high rate of suicide attempts, with one large national study showing that 41% of trans respondents had attempted suicide at least once.  The Centers for Disease Control and Prevention estimate the average acute medical costs of a single suicide attempt in the U.S. is $7,234.  This figure does not include post-attempt mental health care or ongoing medical costs.  The California Department of Insurance found multiple studies showing that the rate of suicide attempts by trans people drops dramatically among those who are able to access transition-related medical care.  The Department concluded, “These studies provide overwhelming evidence that removing discriminatory barriers to treatment results in significantly lower suicide rates.  These lower rates, taken together with the estimated costs of a suicide attempt and completion, demonstrate that the proposed regulation [banning trans-related health care discrimination] will not only save insurers from the costs associated with suicide, but prevent significant numbers of transgender insureds from losing their lives.”  (pp. 10-11)

2. The Department referenced multiple studies that found mental health improvements among transgender people who were able to access transition-related medical care, including decreases in the rates of depression and anxiety.  “This overall improvement in mental health and reduction in utilization of mental health services could be a source of cost savings for employers, insurers, and insureds,” the Department of Insurance concluded. (p. 11)

3.  Substance use and abuse is one of the ways in which transgender people try to cope when they cannot access transition-related medical care.  “There are numerous studies that provide evidence that substance abuse rates decline” when transgender people can access the care they need, the Department reported.  (p. 11)

4.  Transgender people – particularly transgender women – have much higher HIV rates than the general population (28% in a meta-analysis compared to a general population rate of 0.6%).  Studies have shown “high rates of adherence to HIV care for trans people when combined with hormonal treatment,” the Department said, which is “particularly relevant to insurers because it provides evidence that offering treatment may reduce the long-term costs of treatment for HIV/AIDS.”  Furthermore, this benefit extends to the general public:  “[w]hen compliant with care, HIV-positive people stay healthier longer and are far less likely to transmit the virus to others.”  (p. 11)

In addition to these ways in which health care costs might decline as a direct result of trans people being able to access transition-related care, the Department pointed out two additional types of benefits:

5.  One of the ways some transgender individuals cope with being denied surgical assistance in modifying their body so they feel safer or more comfortable is by using silicone injections.  These are often administered by laypeople without medical training, often using construction-grade rather than medical-grade silicone.  This practice is extremely dangerous and can result in many adverse health consequences and even death. (p. 12)

6.  Finally, the California Department of Insurance noted that multiple studies have found that transgender people have higher employment rates and improvements in socioeconomic status after they have had access to transition-related care. (p. 12)

You can access the whole California Department of Insurance report at http://transgenderlawcenter.org/wp-content/uploads/2013/04/Economic-Impact-Assessment-Gender-Nondiscrimination-In-Health-Insurance.pdf

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.

Trans People, Marriage, and Social Security

social security cardAfter sustained lobbying by the National Center for Transgender Equality and others and after Robina Asti’s public statement (see http://www.grayprideparade.com/2014/01/29/i-was-shocked-i-was-shamed/), the Social Security Administration has finally issued guidance telling staff to automatically assume that most marriages involving transgender people are valid.

Of course, given the mish-mash we currently have with some states refusing to recognize other states’ “same-sex” marriages and some states’ bad decisions concerning the legal gender of transgender people, the guidance is complicated.  The guidance now requires Social Security staff to determine where the marriage was performed and if the sex change took place before or after the marriage.  If the sex change took place before the marriage and the transgender person currently lives in (or died in) American Samoa, Florida, Idaho, Kansas, Ohio, Oklahoma, Puerto Rico, Tennessee, Texas, or the Virgin Islands, a legal opinion about the validity of the marriage is still required.  Otherwise, marriages involving transgender people are to be treated under existing rules for opposite-sex and same-sex marriages, bypassing the current procedure of referring all marriages involving transgender people to legal counsel.

The actual bureaucratic memo is available at https://secure.ssa.gov/apps10/public/reference.nsf/links/03252014040307PM  (Trigger warning: in discussing sample cases, the memo uses typical bureaucratizee about applicants “alleging” personal facts.)

“I Was Shocked, I Was Shamed”

Robina Asti 92 yo transwomanThat’s how Robina Asti, 92, described her response when the Social Security Administration denied her benefits as the widow of Norwood Patton.

Although Robina transitioned genders decades before her marriage to Patton in 2004, the Social Security Administration ruled her marriage wasn’t valid when it was entered into because “she was not legally a woman,” and so denied her request.

While the case itself is important enough to write about, what is really remarkable is the 7-1/2 minute video Lambda Legal made of Robina.  This lovely portrait beautifully highlights her love of flying as well as her occupational and romantic history.  She says, “I have lived a very private life, but the SSA is forcing me to speak out.  I don’t want other people to have to experience this.”

Lambda Legal is representing her in her struggle with the Social Security Administration, an effort that will benefit many, many marriages involving trans people and their partners when it is — as it inevitably must be — won.  In the meantime, however, Robina and Lambda Legal deserve many thanks for a really remarkable oral history.  Make sure you check it out:  http://www.lambdalegal.org/blog/20140129_robina-asti-92-year-old-transgender-widow

“I Never Knew a Transgender Person Could Be…Somewhat Valuable Within a Church”

Rosie Del MarYet another aging-related piece in this week’s Advocate is “Op-ed: 72, Transgender, and Finally Myself,” a profile of Rosie Del Mar.

Del Mar’s story is similar to some others of her age in that she describes multiple life phases in which she tried to live in different genders and sexual orientations, with corresponding changes in the ways she could make a living.  What makes her story different from some other trans elders’ is the kinds and amounts of support she experienced, which included multiple church homes and, now, an affordable living complex for LGBT elders.  Still, even with the support she’s found, she was surprised five years ago when she was asked to become a deacon at her latest church.  “I never knew a transgender person could be looked upon as somewhat valuable within a church,” she said.

The article is available at http://www.advocate.com/commentary/2013/08/28/op-ed-72-transgender-and-finally-myself

New Report on Trans Veterans

TAVA logoDid you know that transgender people are twice as likely to be veterans as non-trans people?

A new report, based on the 2011 National Transgender Discrimination Survey, discusses the findings of 1,261 people who reported being both transgender or gender non-conforming and having served in the military at some point.  This was 20% of the overall survey respondents, a figure that is twice the 10% military service rate of the overall U.S. population.

The findings include:

  • Trans veterans were more likely than non-veterans to have lost a job (36%), not been hired (53%), and have experienced on-the-job harassment (54%), physical violence (9%) and sexual assault (8%) because of their gender identity or history.
  • Trans veterans were more likely than non-veteran trans people to have been evicted from their home or apartment due to bias (14%) and to have experienced homelessness (18%).
  • Nine percent of those who had served had been discharged because of being transgender or gender nonconforming.

The report, “Still Serving in Silence: Transgender Service Members in the National Transgender Discrimination Survey,” is available free at http://www.thetaskforce.org/downloads/reports/reports/still_serving_in_silence.pdf

Bathroom Politics

public-restroomsEveryone needs them, which may be why they have been the site of so many pitched political battles:  bathrooms.

Interestingly, the battles usually revolve around “safety.”  When some people wanted human races kept separate, they argued that blacks and whites had different germs and/or hygiene practices, and that having them use the same facilities would lead to the spread of disease.  Now the argument for segregation seems to revolve around women’s “safety,” which apparently is assured by never, ever allowing an adult male to use the same facilities.

Any segregation, of course, involves formal and/or informal policing, and the forced assignment of people into distinctly separate categories.  That’s why the simple right of transgender people to pee in facilities built specifically for that purpose has so often been challenged or denied: if men have to be kept out of women’s bathrooms, then we have to determine who a man is.  Apparently, that cannot be decided by the person him- or herself; instead, something else — a body part, a government identity document, manner of dress or appearance — is the determinant.  Or so the lawsuits, arrests, and civilian bathroom-rules-enforcers insist.

As society battles out these issues over who is safe and who isn’t and who is allowed to “go” where, though, real casualties mount.  Actual people get hurt.  A new study recently released by The Williams Institute begins to quantify the damage: it reports that in a survey of transgender and gender non-conforming people in Washington, D.C., 70% reported having been denied access, verbally harassed, or physically assaulted in public restrooms.  The damage didn’t stop there: many of these victims reported negative ramifications of bathroom denial or abuse on their education, their employment, their health, and their participation in public life.  You can read more about it at http://williamsinstitute.law.ucla.edu/wp-content/uploads/Herman-Gendered-Restrooms-and-Minority-Stress-June-2013.pdf

 

Australia Gets Transgender Aged Care Specialist

LGBT-flag-map-of-AustraliaAs part of the Australian government’s effort to ensure its Living Longer Living Better aged care reform plan reaches everyone, funding has been provided to the Gender Centre Incorporated to hire a Transgender Aged Care Specialist Support Officer.

The new position will focus on “front line crisis management, psycho-social and community support,” training, and providing referrals.  It is part of the government’s National LGBTI Ageing and Aged Care Strategy.  You can read more at http://anthonyalbanese.com.au/better-care-for-older-lgbti-australians-in-inner-west

ElderTG Members in Long Feature Article

Robyn and Emery1As you may or may not know, www.GrayPrideParade.com is sponsored by FORGE, which also sponsors the Transgender Aging Network and our now 15-year-old peer support listserve for trans people age 50+, ElderTG.

Two of our most illustrious ElderTG members, Robyn and Emery Walters, are the stars of a long feature article in the most recent edition of The Gay & Lesbian Review.  Check out their pre- and post-transition pictures and life stories in, “Portrait of a Transgender Marriage,” at http://www.glreview.org/article/portrait-of-a-transgender-marriage-2/

If you are interested in subscribing to ElderTG or to our sister listserve for professionals and others who are interested in transgender aging issues, email LoreeCD [at] aol [dot] com

Social Security Gender Change Changes

social security cardThe Social Security Administration (SSA) recently issued new guidelines that make it far easier for transpeople to change their gender marker.

Previously, changing the gender marker on your Social Security account generally required proof of having undergone sex reassignment surgery; no more!  Now people can update their gender marker using any of four documents:

  • A U.S. passport showing the correct gender;
  • A birth certificate showing the correct gender;
  • A court order recognizing the correct gender; or
  • A signed letter from a physician stating the person “has had appropriate clinical treatment for gender transition to (the new male or female) gender.”

The physician letter does not have to specify what clinical treatment has been done, and what is “appropriate” can remain private between the patient and their doctor.  The physician letter needs to be on the physician’s letterhead, include their medical license or certificate number and the jurisdiction that issued it, and the statement, “I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct.”

The National Center for Transgender Equality has written a plain-English fact sheet that includes additional details and links for those who are interested.  It’s available at http://www.transequality.org/Resources/SSAResource_June2013.pdf