Recently I attended training on lobbying for transgender issues. One of the big "no-no's" was talking about medical care for transgender people. The reason is pretty simple: people have a visceral negative reaction to the idea of genital surgery. In many ways, the reaction the idea of Gender Confirmation Surgeries (GCS) resembles the reaction people have to the thought of two men having sex.
The problem is that the lack of understanding about GCS for transgender people is the biggest impediment to actually receiving care. When I read the comments section of a recent article on an individual who is resorting to crowd funding her GCS, I saw the same misconceptions popping up over and over again. As a result, I wanted to address the most common comments on the subject.
1. "It's not life or death"
Without GCS sexual functioning, self-esteem, body image, socioeconomic adjustment, family life, relationships, psychological status and general life satisfaction are all negatively affected. This is supported by the numerous studies (Murad M., 2010, DeCuypere, 2006, Kuiper M. 1988, Gorton 2011, Clements-Nolle K., 2006), which also consistently show that access to GCS reduces suicidality by a factor of three to six (between 67 percent and 84 percent). Eighty percent of transgender people contemplate suicide, and 41 percent of transgender people attempt it. Lack of access to care is in fact likely to kill many transgender people. If this was a type of cancer that was killing 41 percent of the people who developed it, and it was possible to reduce the mortality rate by similar percentages, there wouldn't be any argument happening.
It doesn't even have to be life or death to be medically necessary, though. A herniated disk won't kill you, but it will wreck your quality of life. Similarly, this is why every major medical, psychological, psychiatric, and therapist organization in the U.S. has issued statements supporting the medical necessity of GCS. The court system is increasingly acknowledging this, with five Circuit Courts having ruled that withholding transgender specific health care from prisoners is a violation of the 8th Amendment, because it is medically necessary.
2. "These people need therapy, not surgery."
I have been over this before. They tried for decades to change people's gender identities, the same way they tried to change sexual orientation. Drugs. Therapy. Electroshock therapy. Lobotomies. Institutionalization. It doesn't work. It's why California and New Jersey have banned reparative therapy that tries to change sexual orientation OR gender identity. Those bans are holding up in court, because the overwhelming scientific consensus is that you can't change a person's gender identity, and you can't just make their dysphoria go away with drugs or talk therapy. If you could, then that would be the preferred treatment, not expensive surgery.
Support for the necessity of GCS is based on scientifically-based national medical research, professional medical specialty organizations, and widely and generally accepted medical and surgical practices and standards, and is supported by prevailing peer reviewed medical literature.
The opposition to the notion of necessity this comes from religious zealots and people who aren't qualified to be making medical decisions anyway.
3. "It's cosmetic."
Again, every major medical, psychological, psychiatric, and therapist organization agrees GCS isn't cosmetic. AMA Resolution 122, states:
An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment for many people diagnosed with GID .... Health experts in GID, including WPATH, have rejected the myth that such treatments are 'cosmetic' or 'experimental' and have recognized that these treatments can provide safe and effective treatment for a serious health condition.
Indeed, GCS improves functionality in socioeconomic status, family life, sexuality, and mental health.
The irony surrounding the first three myths on this list is they are generally perpetuated by people who would be outraged if bureaucrats were making medical decisions for them instead of their doctors. These same people, however, are perfectly fine with the public making health care decisions for transgender people instead of actual doctors, psychiatrists, and psychologists.
This should be a giant red flag. Consider that the last few times we crowd sourced medical ethics on the treatment of unpopular minorities. We ended up with the Tuskegee Experiment and the AIDS epidemic.
4. "Transgender people are just wimps because they can't handle the mental strain"
Existing halfway between genders is stressful. Imagine for a moment if you woke up one morning with the wrong factory equipment. Most people can't, but Chloë Sevigny, who played a transgender assassin on "Hit & Miss," found wearing a prosthetic penis unbearable. "I cried every day when they put it on," she said in an interview. This, for a prosthetic that she knows isn't real, and comes off when the the day is over.
When lesbian journalist Norah Vincent tried to live as a man as a social experiment, it took less than a year before the strain caused her to have herself voluntarily committed.
When straight, healthy people try and pull off what transgender people do on a daily basis (live in the wrong gender), the strain is enough to make them suicidal too.
5. "It's not like being born with one arm."
Actually, it's similar neurologically. There's significant evidence that transgender people are hard wired with their brains expecting one set of physical characteristics, but physically having another. (Ramachandran & McGeoh, 2008). Similarly, Ramachandran found similar phenomena in people with phantom limb sensations.
This is potentially the reason why GCS has been successful where other treatments have failed. It is far easier to align the body with the mind than the other way round when body image is so deeply hard wired.
6. "Suicidality has nothing to do with your physical body"
If something was physically wrong with your genitals, how desperate would you be to have it fixed? How would you feel if they couldn't? Think you'd be depressed because you potentially face a lifetime of solitude and celibacy? Of feeling like a freak every time you looked in a mirror, went in a bathroom, took a shower, etc..?
It is very difficult for transgender people to have romantic relationships, because most cis (non-transgender) people's sexuality isn't made to handle mismatched primary and secondary sexual characteristics. The incongruence between the brain's internal body map and the physical body is also very distressing (as noted above).
7. "Treat the depression, not the gender dysphoria."
This is similar to the idea that the best way to treat chronic back pain is with vicodin, rather than a surgery that would address the underlying problem.
8. "The Affordable Care Act (Obamacare) pays for this."
No, it does not. Most of the state exchanges have exclusions of transgender coverage.
9. "I don't want to pay for that."
Study after study shows including medical benefits for transgender people costs close to nothing, if not actually nothing. The Transgender Law Center put it in perspective when they noted that if a health care plan costs you $4,000 in a year, then adding transgender coverage would add 17 cents per year to the cost of the policy. The low dollar amount is because this is a one-time cost, and it is rare. For comparison's sake, a company including same sex partner benefits would add $40.00 per year to that $4,000 total. That's a 231 fold difference in magnitude between the cost of adding partner benefits and adding transgender health care.
If it neither breaks your leg nor picks your pocket...
10. "It's mutilation of healthy tissue."
Given Ramachandran's findings, GCS is much more accurately described as reconstructive surgery. The overwhelming body of evidence showing an improved quality of life (including sexual function) for people who have had GCS also supports reconstructive surgery as accurate.
11. "I'm actually a feline trapped in a human's body. Can I get can surgery to make me a cat?"
Also known as the "I think I'm funny, but I'm not," answer. Generally used by guys who watch South Park.
When people use this argument, they assume that transgender people are mentally ill (they're not), assume it's a delusion that can be cured (wrong), and ignores one key fact. People can naturally be mentally hard wired to identify as male or female. Sometimes the wiring and the equipment don't synch up during development. We have 40-plus years of neuroscience research basically telling us gender identity and body image are written early on in development, and sometimes they don't match.
People, however, do not naturally identify as a cat, or other non-human animal.
12. "I don't like the term Gender Confirmation Surgery (GCS)."
The other two most common medical terms used are Sex Reassignment Surgery (SRS), and Gender Reassignment Surgery (GRS). However, given the growing evidence that gender dysphoria stems from an incongruence between the brain's internal body map and the physical body, Gender Confirmation Surgery is probably the most technically accurate of the three.
Also known as the honest answer. It's been said before, but it bears repeating. If you don't like gay sex, then don't have gay sex. If you don't like gay marriage, then don't get married to someone who's the same sex. If you feel abortion is wrong, then don't have one. If you don't like the idea of GCS, then don't have GCS.
14. "They should pay for it themselves."
Perhaps nothing encapsulates privilege quite like this one. Who has $25,000 lying around, a corporate short term disability policy, a supportive supervisor, and/or the means to fight an 18 month long legal battle against an insurance company? If you're not one of the lucky few transgender people who work at a big company with very pro-LGBT policies, these are the hurdles you have to face. Simultaneously, transgender people face massive discrimination in the workplace, suffer twice the national average unemployment rate, and live in extreme poverty four times more often than the general public (despite being twice as likely to hold advanced degrees).
For most transgender people, this isn't even an option.
15. "It doesn't change your DNA"
This is irrelevant. There are lots of intersex people whose identities vary from their chromosomes. The relevant part of the discussion is whether GCS is medically necessary (it is in the opinion of everyone who matters), and if it significantly improves quality of life (it does).
16. "Gay people should distance themselves from people like this before they lose some of the progress and acceptance they have received over the last 20 years."
Just like lesbians distancing themselves from gay men in the 1980's because of the stigma of HIV/AIDS would have been expedient.
And every bit as unconscionable.