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Recommendations

for Transgender Health Care

 

Transgender Law Center

www.transgenderlawcenter.org
info@transgenderlawcenter.org
(415) 865-5619 or 865-0176

 

Problem 1:  Private health insurance companies deny coverage to transgender people

One of the most pressing needs of the transgender communities is access to healthcare. Many transgender people are denied health insurance coverage altogether solely because they are transgender.  Most transgender people who apply for private health insurance on their own (not through a group plan with their work or school) have been denied coverage if the insurance company is aware of their transgender status. 

In San Francisco, a relatively transgender-friendly city, 51% of transgender people do not have any form of health insurance.[1]  At the Transgender Law Center (TLC), we frequently see clients who are denied health insurance, and so have no health coverage whatsoever. Together with the Employment Law Center, TLC is potentially filing a suit in one of these cases under California’s Unruh Act (public accommodation protections).

Results:  Without health insurance, many transgender people have no access to health care.  Transgender people who develop health problems, break a leg, get an infection, etc., have nowhere to turn unless they pay for the services themselves.  Health care in the United States is extremely expensive. For instance, the average doctor visit costs around $400. Repairing a knee ligament costs around $25,000.

Recommendation 1: Require that health insurance companies stop discriminating against transgender people.

Denying health insurance coverage to transgender people, solely because they are transgender, should be illegal.

An even better solution for this problem would be universal health insurance coverage.


Problem 2:  Public and private health insurance companies exclude transgender related services from coverage

Problem 2 A: Transgender people who have managed to acquire health insurance cannot get coverage for any services that are related to being transsexual or transgender.  Almost every public and private health insurance program has exclusionary language in their contractual terms such as:

All procedures related to being transgender are not covered.

This coverage exception has been labeled the “transgender exclusion.”  This means that very few transgender people can get any transition-related procedures, hormones, or therapy paid for through their health insurance and must instead pay for any treatments out-of-pocket. 

 Results:  Even those transgender people who do have health insurance will most likely have to pay for their hormones, therapy, and surgery (ies) themselves. Hormones cost approximately $100 per month. Therapy is about $100 per session. Surgeries typically cost between $7000 and $50,000; some phalloplasties can cost upward of $100,000. Even with a well-paying job, these costs are often prohibitive. As a result, many transgender people cannot obtain medically necessary treatments because they cannot afford to pay for them.  This can result in severe emotional turmoil, depression, and even suicide.  To avoid this, some transgender people will resort to the black market to get their hormones or even attempt doing surgery themselves (such as cutting off their genitalia) – resulting in serious harm and sometimes death. 


Problem 2B: Further, insurance companies often interpret the exclusionary language broadly to exclude coverage for treatment that is not directly or in some cases even remotely related to a person’s transgender status. For instance, a female to male transperson broke his arm. His insurance company refused to pay for the costs of treating him because they erroneously assumed that any health problems he developed must be due to his transgender status.[2]  Transgender people have also been denied insurance coverage for treatment related to the flu and other commonplace ailments and injuries for the same reason.[3]

Recommendation 2: Removal of all transgender exclusions in health plans

Related Caselaw:

Jane Doe v. Diana M. Bonta (Writ of Mandate in Superior Court of the State of California – 2001) held that Medi-Cal (state insurance for low income people) cannot categorically deny treatment to transgender people, must treat each individual case on a case by case basis, and cannot deny medically necessary procedures, which include sex reassignment surgery (SRS) and hormone treatment. Thus Medi-Cal is now covering SRS. Further, J.D. v. Lackner (80 Cal. App. 3d 90, 1978) and J.D v. Lackner (80 Cal. App. 3d 64, 1978) hold that SRS is medically necessary.

 

Related Successes and Models:

The City of San Francisco recently removed the transgender exclusions from its City health plan, and is now covering SRS, hormones, and therapy for transgender people. Kaiser Permanente in California removed its transgender exclusions with respect to hormone coverage, therapy, and any other procedures other than SRS.

 

Problem # 3: Health insurance companies and medical providers rely on the gender binary

 Problem 3A: The medical system only recognizes the existence of males and females.  This creates problems for many transgender people whose bodies do not fit the standard male/female model. For instance, health insurance companies require that everyone identify themselves as either male or female.  There are many female to male transgender people (FTMs) who take testosterone but have not had a hysterectomy, and therefore have secondary male characteristics as well as uteruses. If a transgender man checks the ‘male’ box on his insurance form, he may be able to get his testosterone treatment covered, as hypo-gonadism is a recognized disorder for men who are not transgender. But, if he checks the ‘male’ box, he cannot get coverage for any gynecological care. This creates many problems.  Private health insurance companies will not pay for services that they understand stand only to be necessary for “females” if they are already paying for services that they understand are only necessary for “males”, or vice versa One FTM checked the ‘male’ box and later developed uterine cancer. His insurance policy would not pay for any cancer treatment because they did not “treat uteruses in men.”[4]

 Result: Many transgender people who have insurance cannot get all their health care needs met and have to chose whether or not they want to have coverage for the female aspects of their bodies or the male aspects of their bodies.

 Recommendation 3A: That insurance companies recognize that there exists great diversity in bodies; that insurance companies cover every person holistically and completely; that insurance companies not require people to check ‘male’ or ‘female’ boxes.

Problem 3B: Even when a transgender person can pay for hormones or surgery out of pocket, they often run into healthcare providers that require that they meet very particular and specific criteria before they are willing to prescribe any transgender related services.  While some providers have come to an understanding in the last several years that not all transgender people are alike and that trans identity can be more fluid, there is still a long way to go before self-determination is respected in the medical system. For instance, many doctors, before prescribing hormones, will require that the transgender person identify as 100% male or female, that the transgender person present as stereotypically male or female (for instance, some doctors require that male to female transgender people wear dresses or that female to male transgender people say that they played with cars when they were young), and that their sexual partners be of the opposite sex. In reality, many transgender people (just as non-transgender people) do not fit narrow stereotypes of femininity and masculinity. For instance, some female to male transgender people are effeminate gay men. Also, many transgender people, particularly young transgender people, do not identify as female or male, or as a combination of female and male.

Results: It is very hard for transgender people to get appropriate transition related care. Some transgender people have to go to therapy for six months in order to prove they are a ‘true transsexual.’ The therapist then tells the person they are not really a transsexual because they are gay, because they are a strong woman, because they don’t wear the right clothing, etc. Sometimes, transgender people, out of frustration at not being able to access medical treatment, will commit suicide. To avoid being denied medical treatment, some transgender people tell the therapist what the therapist wants to hear or tailor their appearance and self-presentation for their therapy appointments – thus making it impossible to gather any accurate information on the true diversity of transgender people.

Recommendation 3B: That the medical establishment recognize that there is a great diversity among transgender people, that not all transgender people identify as male or female, that not all transgender people are stereotypically feminine or masculine, and that not all transgender people are heterosexual.  That the medical establishment does not use criteria for who is a ‘true transsexual’, but instead listens to and believes the transgender person themselves, who ultimately is the best and only judge of their gender.

Problem 3C: Many health care providers are invested in ensuring that transgender people fully transition and complete every aspect of sex reassignment as quickly as possible.   Not all transgender people desire to follow this path.   Many transgender people, to fully actualize their gender, want only hormones, or only surgery, or low doses of hormones, or no surgery and no hormones. Some transgender people want genital surgery while others do not.  Yet, often doctors require that in order for a person to have access to any of the above procedures, they have to have all of them.

 Recommendation 3C:  That medical providers recognize that there is great diversity among transgender people and provide the care that is best suited for each transgender individual, based on the individual’s own needs and choices.

 Positive Examples:

The Dimensions Youth Clinic and the Tom Waddell Clinic in San Francisco serve transgender clients. Both provide individualized care in accordance with the current medical knowledge and practice.

  

Problem #4: Many medical providers are transphobic

Even if a transgender person has the ability to pay for their health care, either through insurance or out of pocket, too often they experience discrimination from their health care providers.  This discrimination takes many forms.

 Health care providers often have refused to treat transgender people, solely because they are transgender.  For instance, Robert Eads, a female to male transperson who developed ovarian cancer, was denied treatment by over twenty doctors who did not approve of him and his trans body.  He eventually died, untreated.[5]  Transgender people have also died because emergency response teams have stopped treatment when they realized that the person they were treating did not have the genitals that they expected or have entirely refused treatment because of the gender androgyny of their patient.  

 Health care providers also often do not treat transgender people respectfully or appropriately. The Transgender Law Center has taken many complaints from transgender people who have been harassed and mistreated by medical providers.   Transphobic providers will tell their patients that they find them disgusting or inappropriately insist on seeing their patients’ genitals.  Providers will not ask medically necessary questions or will tell their patients that they deserve the illness that they are experiencing. 

 In order to avoid this type of discrimination, many transgender people stop going to the doctor altogether.   Others decide not to inform their health care provider of their transgender status.  When providers are not fully informed of their patient’s medical situations, accurate diagnosis and treatment can be compromised. This is especially true for male to female transgender people (MTFs) who do not receive prostate cancer screenings and FTMs who do not receive gynecological care.   In addition, if a transgender person has complications due to their hormone treatment, providers may not recognize these systems or misdiagnosis them.

 Finally, many health care providers have no understanding of the medical effects or risks or transgender related treatments.  Therefore many transgender people are not fully informed about the medical decisions they are making for themselves. 

 Recommendation #4: Mandatory transgender education for all medical students and for all health care providers.

That the medical establishment educate medical students and health care providers about transgender sensitivity, that the medical establishment support training providers on medically appropriate treatment for transgender people; that the medical establishment support criminal liability and medical malpractice liability for providers whose refusal of treatment results in injury.

 

Prepared by Jody Marksamer and Dylan Vade

 The Transgender Law Center is sponsored by the National Center for Lesbian Rights, Female-to-Male International, the Echoing Green Foundation, the Yale University Initiative for Public Interest Law, the Horizons Foundation, the Sisters of Perpetual Indulgence, and the Common Counsel Foundation.

 



[1] Transgender Community Health Project Descriptive Results, San Francisco Department of Public Health, 1999.

[2] Interview with anonymous FTM in San Francisco (2002).

[3] Interview with anonymous FTM at FTM International Meeting (2001).

[4] Interview with anonymous FTM in Oakland (2001).

[5] Robert Eads, whose fight with ovarian cancer is documented in “Southern Comfort”.

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