Diagnosis vs. Treatment: Barriers to Medical Care
August 8, 2008 1 Comment
Kelley Winters, Ph.D.
GID Reform Advocates
The psychiatric classification of gender variance as Gender Identity Disorder (GID) in the Diagnostic and Statistical Manual of Mental Disorders (DSM)  has long been cited as necessary to provide access to medical transition procedures for transsexual individuals who need them. According to Dr. Ira Pauly of the DSM-IV Subcommittee on Gender Identity Disorders,
“Research in the field has been facilitated by having standardized criteria available for correctly diagnosing individuals with GID…. This has greatly increased our knowledge and understanding of GID, and has resulted in improved and more standardized treatment protocols.” 
Standards of Care of the World Professional Association for Transgender Health continue to require a GID diagnosis for access to hormonal or surgical transition procedures . Many fear that hormonal and surgical procedures might be withheld without some kind of diagnosis to validate their medical necessity and justify their risks. While the existence of a diagnostic coding has helped affirming, supportive care providers to make transition procedures available to some transitioning individuals, the specific diagnostic criteria and supporting text of the current Gender Identity Disorder category support the opposite approach – punitive gender-conversion or gender-reparative therapies intended to change or suppress gender identity or expression which differ from assigned birth sex roles .
However unintended, the consequences of the doctrine of “disordered” gender identity in the latest DSM-IV-TR include barriers to medical care for transitioning individuals far beyond the scope of transition itself. The following examples of disparate health benefit coverage are common among large corporate employers  and would apply to transitioning intersex as well as transsexual employees. Similar barriers exist within government health benefits, small business health plans and private insurance policies.
Denied Coverage for Corrective Surgical Procedures
Transsexual individuals who suffer distress with their physical sex characteristics or ascribed social gender role (defined here as gender dysphoria ) are singled out by many employers for exclusion from coverage for corrective procedures that are commonly covered for cis-gender or non-trans employees.
Medically necessary surgical treatment for gender dysphoria does not necessarily require expanded or special coverage, but often employs the same or similar procedures already commonly covered for non-transsexual employees for a wide variety of congenital and endocrine conditions. 
Surgical Procedures Performed on Transsexual and Non-TS Individuals
In Non-Transsexual Individuals
Congenital androgen insensitivity syndrome,
Congenital adrenal hyperplasia,
Vaginal agenesis, Vaginal atresia,
Congenital Buried Penis Syndrome,
These surgical procedures correct the same physiology and function for non-transsexual people and transitioning people alike and are not broadly excluded in health benefits for employees who are not transsexual. However, transitioning employees at many corporations are singled out for denial of coverage with a broad exclusion such as,
“All expenses related to gender reassignment, including those related to complications arising from such services.” 
This discrimination is based solely on gender identity, often in violation of corporate and state equal opportunity policies.
Denied Coverage for Endocrine Specialty Care
There is much confusion around coverage for hormone replacement therapy (HRT) for gender dysphoric employees or those who have completed physical transition. At my employer, one woman was covered for HRT while employed, but then she was denied coverage under post-employment, or Cobra, benefit after she was terminated in the course of her transition. Non-trans men and women who require HRT for treatment of androgen or estrogen deficiencies are covered under most benefit plans; while the same or similar treatment for transitioning employees is explicitly excluded by many plans under the phrase, “All expenses related to gender reassignment.”  Such policy can be used to prevent any transitioning or transitioned employee from equitable access to hormone replacement therapy.
Denied Coverage for Conditions Prevalent among Females
Natal cis-gender (non-trans) women are typically covered for a variety of conditions prevalent among women. However, transitioned women (male-to-female, or MTF) fear denial of coverage for conditions like breast cancer or osteoporosis at many employers, which exclude any conditions that might be construed as a “complication” of the transition process or hormone therapy. At these employers there is no assurance of equal coverage for these potentially fatal conditions.
Moreover, transitioning or transitioned men (FTM) may possess atypical physiology with the possibility of conditions prevalent among natal women, such as cervical or ovarian cancer. Transmen may be singled out for denial of coverage for these fatal conditions at many employers for treatments “not appropriate based on the gender of the patient.”  The award-winning documentary, Southern Comfort chronicles the tragic death of Mr. Robert Eads, a trans-man who was similarly refused treatment for ovarian cancer. 
Denied Coverage for Conditions Prevalent among Males
Conversely, natal men are typically covered for conditions unique or prevalent among men. However, transitioned men (FTM) may be denied treatment for conditions covered for other men by many employers if they are construed as “complications” of the transition process or hormone therapy.
Transitioning or transitioned women (MTF) may possess atypical physiology susceptible to conditions unique or common to natal men, such as prostate cancer. While prostate cancer risk is much lower for transitioned women than natal men, cases have been reported , and regular examination and PSA screening are recommended. Such care is currently denied under many benefit policies, which deems it “not appropriate based on the gender of the patient.” 
Denied Mental Health Benefit Coverage
There is also a great deal of confusion about mental health care benefits for transitioning employees. Recognized medical standards of care for treatment of gender dysphoria and correction of physical sex characteristics are defined by the World Professional Association for Transgender Health (WPATH). While there is no scientific basis for casting gender diversity in itself as mental illness, gender dysphoria (persistent distress with one’s physical sex characteristics or ascribed social role ) is effectively treated with medical transition procedures.
However, the current standards require evaluation by a mental health professional with specialized knowledge of gender dysphoria and gender diversity issues prior to prescription of hormone replacement therapies. For those who require surgical correction of sex characteristics, a period of 12 months of full-time “real-life experience” in their affirmed gender role is necessary for eligibility. An evaluation by a mental health professional is required for reduction mammoplasty and chest reconstruction for transmen, and evaluation by two mental health professionals is required for genital surgery eligibility for transmen and transwomen. 
However, benefit coverage for mental health evaluation and any psychotherapy specific to hormonal or surgical treatments may be denied under broad exclusions common to many employers, “All expenses related to gender reassignment.” 
This exclusion could be used to deny any transitioning employee access to mental health assessments that are required by standards of care in the course of physical transition.
Maligning Stereotypes of Mental Illness
At many employers, the only mental health benefits explicitly covered for gender dysphoric employees are those not “related to gender reassignment.” Psychological treatments known as gender-conversion or gender-reparative therapies, which attempt to reverse innate gender identity or sexual orientation, fail to relieve distress of gender dysphoria and are considered extremely offensive to the transgender community. Unfortunately, benefit coverage at many employers for these damaging psychotherapies, and simultaneous denial of hormonal and surgical medical care, combine to reinforce these defamatory stereotypes. The message implied by these benefits policies has contributed to a hostile work environment for transgender employees. In recent years, a transsexual woman at my employer was mocked and ridiculed as mentally disordered by her supervisor, who told her,
“I don’t know why a ‘man’ would want to cross-dress. You know, the company will pay to fix this condition.” 
She was terminated in the course of her transition.
The 2008 Corporate Equality Index  from the Human Rights Campaign surveyed 11,369 major U.S. businesses for policies and practices pertinent to GLBT employees, consumers and investors. Of these, less than one percent, 109, offer health benefit coverage for medically necessary surgical procedures to transitioning employees and their families.
The attitudes behind this epidemic transsexual health care discrimination are perhaps revealed by looking at those employers most publicized for their “equal opportunity” policies. The HRC awarded 195 employers with perfect 100% scores, denoting the very “best” workplaces for GLBT people. A disgraceful sixty percent of these, 117, specifically exclude transition surgical procedures. An important clue is found in nearly 80% of this group, 93, which cover “mental health counseling” for transitioning individuals while denying surgical benefits. Their intention to promote gender-conversion or gender-reparative psychotherapies in lieu of transition for those who suffer gender dysphoria seems clear. In my view, this is evidence that prevalent transsexual health benefit discrimination is based on a false stereotype of “disordered” gender identity that equates gender difference with mental illness – a stereotype grounded in the DSM.
The current diagnosis of Gender Identity Disorder has contributed to derogatory stereotypes of mental illness and sexual deviance, creating barriers to medical care for transsexual and other gender variant people before and after transition. The DSM-V Sexual and Gender Identity Disorders work group has an opportunity to refute these stereotypes with diagnostic criteria and supporting text that are affirming of transition rather than promoting punitive gender-conversion therapies. It is time for mental health policies that do not harm those they are intended to help. 
 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., 2000.
 I. Pauly, “Terminology and Classification of Gender Identity Disorders,” Interdisciplinary Approaches in Clinical Management, New York: Haworth Press, 1992.
 World Professional Association for Transgender Health (formerly HBIGDA), “Standards of Care for The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons,” http://wpath.org/Documents2/socv6.pdf , 2001
 K. Winters, “Gender Dissonance: Diagnostic Reform of Gender Identity Disorder for Adults,” Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM), Ed. Dan Karasic, MD. and Jack Drescher, MD., Haworth Press, 2005; co-published in Journal of Psychology & Human Sexuality, vol. 17 issue 3, pp. 71-89, 2005.
 Examples of health benefit inequity updated from K. Winters, “Issues of Transgender Health Benefit Inequity in the Corporate Equality Index,” Seminar presented to the Human Rights Campaign, Washington, D.C., June 2008.
 Working definition of Gender dysphoria by Dr. Randall Ehrbar and I, following our panel presentations at the 2007 convention of the American Psychological Association. It is defined in glossary of the DSM-IV-TR as “A persistent aversion toward some of all of those physical characteristics or social roles that connote one’s own biological sex.” (p. 823)
 Thanks to Becky Allison, M.D., Gary Alter, M.D., and Marci Bowers, M.D., for input and information on these procedures and common health coverage practice. This table is far from exhaustive but illustrates examples of corrective surgical procedures, often denied to transsexual individuals, that are analogous to those covered for patients who are not transsexual. While not all health plans cover all of these procedures for cis-gender (non-transitioning) individuals, broad exclusions to their coverage are not common.
 This language is used by my own employer, a Fortune 20 corporation, to deny coverage for all transition-related medical expenses in health plans administered by Aetna, UnitedHealthcare, and BlueCross BlueShield. It is representative of common language I have heard in employee and private health plans.
 Southern Comfort, New Video Group, 2001. It may be viewed online at http://www.logoonline.com/shows/dyn/southern_comfort/videos.jhtml.
 R. Miksad, G. Bubley, et. al, “Prostate Cancer in a Transgender Woman 41 Years After Initiation of Feminization,” Letter to the Journal of the American Medical Assoc., v. 296 no. 19, Nov. 2006. http://jama.ama-assn.org/cgi/content/full/296/19/2316
 This language is currently used by UnitedHealthcare to exclude coverage of care for post-transition individuals at my employer that is unrelated to transition itself. It is representative of language I have heard in other employee and private health plans.
 World Professional Association for Transgender Health (formerly Harry Benjamin International Gender Dysphoria Association) “Standards of Care for Gender Identity Disorders,” Sixth Version, http://wpath.org/Documents2/socv6.pdf , 2001.
 GID Reform Advocates, Advocates’ Statements, http://www.gidreform.org/advocate.html.
 Human Rights Campaign, Corporate Equality Index, 2008. http://www.hrc.org/issues/workplace/cei.htm.
 K. Wilson (former pen-name for Kelley Winters), “Gender as Illness: Issues of Psychiatric Classification,” 6th Annual ICTLEP Transgender Law and Employment Policy Conference, Houston, Texas, July 1997. Reprinted in Taking Sides – Clashing Views on Controversial Issues in Sex and Gender, E. Paul, Ed., Dushkin McGraw-Hill, Guilford CN, 2000, pp. 31-38. http://www.gidreform.org/kwictl97.html
Copyright © 2008 Kelley Winters, GID Reform Advocates