Seattle
— For more than two decades, Andy had collected
monthly disability checks and food stamps. Taxpayers
picked up his medical bills, too, including the cost of
more than half a dozen stays in mental hospitals.
But Andy has a job now
and says his life is finally under control. He says he
received his last disability check this month.
What's
changed?
Andy used to be Ava. A
woman. Tormented since childhood with what doctors later
diagnosed as gender-identity disorder, Andy six years ago
won a legal settlement that required the state to pay for
him to undergo a sex change.
In all, Medicaid paid
about $84,000 over three years for nearly 20 surgeries to
complete Ava's conversion to Andy.
"I'm finally being
allowed to live my life and contribute to society," said
Andy, who is approaching 50, "instead of having to hole
up in a corner someplace and eat drugs and be taken care
of all my life."
Gender-identity
disorder
People with
gender-identity disorder <http://en.wikipedia.org/wiki/Gender_dysphoria>
have strong and persistent feelings that they were meant
to be the opposite gender.
The cause is unknown, but
researchers theorize hormonal influences in the womb,
genetics and environmental factors, such as parenting,
are involved.
The condition is rare.
According to some estimates, fewer than one in 12,000 men
and one in 30,000 women have the disorder.
The cost of surgery
varies. Male-to-female surgery averages between $10,000
and $30,000. Female-to-male surgery can cost $80,000 or
more.
For more information,
contact the Harry Benjamin International Gender
Dysphoria Association at <http://www.hbigda.org/>.
Andy did not want his
full name published, fearing it might embarrass his
bosses and fellow employees at the building-supply store
where he works.
His story provides a
real-life look into what has become a highly charged
debate over whether taxpayers should pay for sex-change
operations, also known as sex-reassignment
surgery.
When news surfaced
earlier this year that Medicaid <http://www.cms.hhs.gov/home/medicaid.asp>,
the federal-state insurer for the poor and disabled, had
paid for such procedures, some state lawmakers tried to
impose a ban. A U.S. senator even weighed in, writing
letters to top state officials and calling for a federal
investigation.
Even before the political
uproar, however, Medicaid officials were working on new
rules that essentially classify sex-reassignment surgery
as experimental and not eligible for coverage. The state
would pay only for less costly treatments, such as
hormone therapy and counseling.
But those rules might
not stand.
The state has six pending
requests from people seeking Medicaid coverage for
sex-change operations. In the past few weeks, state
hearing officers have reversed Medicaid decisions denying
coverage for two of those people.
The state is appealing
the rulings, and both cases could wind up in court. Other
states, including some that have moved to bar using
Medicaid money for sex changes, will be watching
closely.
While a few companies,
including Microsoft, offer coverage for sex-change
surgeries, the vast majority of public and private
employee health-insurance plans do not.
State Medicaid officials
acknowledge gender-identity disorder is a real and
serious medical condition. But they argue that sex-change
surgery is risky and unproven.
"In gender surgery, you
cannot predict who will benefit and who will not benefit
— or perhaps even be harmed," said Dr. Jeff
Thompson, medical director of the state Medical
Assistance Administration.
Many experts in the field
disagree. For some transgender patients, they say,
surgery is the only way to relieve the mental anguish
that prevents the patients from leading productive
lives.
"Isn't this empirical
proof?" said Andy, who figures he collected more than
$100,000 in disability checks alone over the years. He's
certain his mental-health care was far more
costly.
"I'm off services, I'm
off funding, I'm paying taxes," he said. "Isn't this what
the goal was?"
Forced to wear a
dress
Gender-identity disorder,
also known as gender dysphoria, has been
recognized in some form for more than two decades by the
American Psychiatric Association's diagnostic manual. In
general, people suffering this condition feel trapped
inside a body of the opposite sex.
Andy recalls having such
feelings since he was a little girl. To make matters
worse, he says, he had an abusive father who seemed bent
on beating him into being a regular girl.
Forced to wear dresses to
school, Andy recalls ducking into an alley to change into
his younger brother's clothes.
"I'd get clobbered at
school, sent home and then clobbered again for not being
dressed appropriately," he said.
He doesn't think the
abuse contributed to his gender disorder. Instead, he is
convinced it was a birth defect, something that happened
to his brain while he was in the womb.
Wanting so much to be the
woman his parents and others expected him to be, he got
married and had a daughter. The marriage lasted only a
few years, and he soon wound up in another relationship
with a man who had three kids.
But his life never
felt right.
Andy went on disability
in the early 1980s. He says he was originally diagnosed
with bipolar disorder and other ailments because Social
Security did not recognize gender dysphoria. He suffered
debilitating migraines and couldn't hold a job for more
than a few months.
He says he came "damn
close" to committing suicide on a few
occasions.
"The more depressed you
get, the more physical aches and pains you get, the more
pain pills you take," he said. "It goes downhill from
there. Sometimes I'd go into migraine phases because I
couldn't handle being an 'it' anymore and end up in
hospitals for 50, 60 days on Demerol and
morphine."
Andy went to great
lengths to look like a man. For 10 years, he lashed a
back brace to his chest to flatten his breasts and wore
two shirts to conceal the brace.
In the early 1990s,
doctors confirmed he suffered from gender
dysphoria, and he began testosterone treatments, paid
for by Medicaid. Within a year, his beard came in and his
hairline receded.
But the hormones weren't
enough. Andy wanted a full sex change.
Though at the time the
state said it covered "medically necessary" sex-change
operations, Medicaid officials denied Andy's request.
They said he had not proved surgery was necessary or that
he was a suitable candidate.
Andy sought help from
Lisa Brodoff, an attorney at the Seattle University Law
Clinic <http://www.law.seattleu.edu/>
who represents indigent people over Medicaid
coverage.
In 2000, after a state
attorney cautioned Medicaid officials that they would
likely lose if the case went to trial, the state
negotiated a settlement acknowledging that surgery was
necessary. The state agreed to cover a long list of
procedures, including a double mastectomy, removal of
ovaries, and a surgically constructed penis.
The state also agreed to
pay Andy's travel costs to Florida, where most of the
surgeries were performed.
He is legally a man now
— it even says so on his revised birth certificate.
He owns his own home and is in his second straight year
of holding a job. He says he's off the mental-health
drugs and out of counseling.
"I had to be a man," Andy
said.
Backlash
erupts
Few things make better
political hay than a taxpayer-funded sex-change
operation.
A 2004 report by the
state Auditor's Office faulted Medicaid for spending more
than $180,000 of federal and state money on what it
called questionable sex-related or cosmetic surgeries in
2003.
Among the items auditors
singled out were about $9,500 worth of Andy's sex-change
operations. (The report didn't mention the other $75,000
the state spent on his sex change.)
When the audit findings
made headlines earlier this year, state House Republicans
tried to bar Medicaid from putting any money toward
"gender reassignment surgery or treatment." But majority
Democrats, who thought the total treatment ban went too
far, blocked it.
The auditor's report also
caught the attention of Republican Charles Grassley of
Iowa, chairman of the U.S. Senate Finance Committee. In a
letter last month, he told Democratic Gov. Christine
Gregoire that he was requesting that the federal Office
of Inspector General look into the matter.
In a response letter,
Gregoire suggested the auditor's report was
misleading.
For one, she pointed out,
the report didn't mention that the sex-change procedures
were the result of a legal settlement. And she noted that
the state no longer authorizes surgery for gender
dysphoria.
The state's Medicaid
agency pays for more than 500,000 surgical procedures of
all types a year. But Medicaid officials say the state
has covered sex-change operations for just five people in
the past 15 years.
The last two cases, both
approved in 2000, were Andy's and a male-to-female
sex-change operation that cost the state nearly
$29,000.
Report questions
surgery
The state used to follow
guidelines established by the Harry Benjamin
International Gender Dysphoria Association, an
organization of experts who specialize in gender
disorders.
The Harry Benjamin care
standards require people with gender dysphoria to undergo
hormone treatment and live as the opposite sex for a year
or more before having surgery.
But in 2004, Medicaid
shifted to an "evidence-based medicine" process for
determining whether a certain procedure should be
covered. As part of that effort, the state commissioned a
report evaluating studies on sex-change
outcomes.
That review — done
by Hayes Inc., a firm that assesses health-care
technologies — concluded that sex-change surgery
remains experimental. It said that while some people
benefit from surgery, there is not enough solid data to
prove it is safe or more effective than hormone therapy
and counseling alone.
Many medical experts
disagree.
In a letter last spring,
the Harry Benjamin association said the Hayes report is
flawed because it relies too heavily on outdated studies
done when sex-change surgery was still new and
complications were frequent.
Walter Meyer, a professor
of psychiatry at the University of Texas' medical school
and past president of the Harry Benjamin association,
said more recent studies show significant improvement in
people's mental health after surgery.
Dr. Marci Bowers, who
performs more than 120 sex-change surgeries per year
through her clinic in Colorado, said surgery is not
always the right solution. But for some, she said, it
works wonders.
"What people describe
over and over again is a sense of relief," said Bowers, a
former Seattle doctor who underwent surgery in 1998 to
become a woman. "Finally, their bodies align with what
their souls have told them from a very early
age."
But Thompson, the state
medical director, stands by the Hayes report and
questions the objectivity of its critics. "I guess the
question is, are they practicing evidence-based medicine
or are they being advocates?" he said. "I think in this
case they're being advocates."
Armed with the Hayes
report, Medicaid since last year has denied three
requests to cover sex-change surgeries. All were appealed
to the state's Office of Administrative
Hearings.
Rulings were issued last
month in two of those cases. An administrative-law judge
concluded surgery was medically necessary and should be
covered.
The Medicaid agency is
taking both rulings to the Department of Social and
Health Services board of appeals. If Medicaid loses
there, it cannot appeal. If the board sides with
Medicaid, the cases likely will wind up in
court.
In the meantime, the
state has received three more requests for sex-change
surgeries.
