by Jenji C. Learn, BA
How much are your genitals worth to you? Your beard? Your breasts?
What’s a reasonable price for them? It’s not like you really need them, right? They aren’t essential organs. They’re purely cosmetic- superficial!
If an accident or a malicious act cost you one of those things, you certainly wouldn’t expect your health insurance to cover it, or expect anyone to feel any sympathy for you. Why should they? That’s your responsibility, and you should pay out of pocket, because after all, you can live just as well without any of that stuff, surely.
If you found what I just said to be shocking, grotesque, callous, offensive, or positively inhuman… then so too must you apply those same words to describe the status of healthcare for trans and intersex people in America.
To this day, not only do most insurance providers and plans not offer coverage for the medications, procedures, and treatments necessary for people trying to transition their primary and secondary anatomical sexual characteristics to those that correspond with the neurophysiology of their brains (or in many cases, even their genomes), but in fact many insurers explicitly hold blanket exclusions or bans on such coverage, in some cases even mandated by law. It was only this year that any steps were taken to begin to end these flagrantly discriminatory exclusions. Instead, a Federal District Court Judge appointed by George Bush Jr, issued a ‘preliminary injunction’ to halt those anti-discrimination protections from being enforced nation-wide, just hours before they were supposed to go into effect on January 1. While many private plans and providers, as well as Medicare (after legal precedings) had ended their blanket exclusions for things like hormone replacement therapy or gender confirming surgeries, most plans, including many private or ‘managed care’ Medicaid plans, still continue to deny coverage for these treatments on the grounds that they are ‘cosmetic’ and non-essential to overall health.
But before one can truly grasp the intellectual inconsistency and moral depravity of such claims, one must juxtapose and contrast them with the treatment and care received by cisgender and intrasex (the other 98% of the population) who face similar challenges as the result of injury, illness, or genetic or congenital anomalies.
When a cis-woman discovers that she may be unable to bear children due to any number of developmental abnormalities with their reproductive system, it is regarded as a great tragedy and a loss, and moreover no expense is spared to try to treat these conditions or provide individual remedies. Consider the many thousands of people with Mayer-Rokitansky-Küster-Hauser Syndrome who are born with underdeveloped vaginal canals and cannot even have sex or menstruate let alone become pregnant- until recently. They are women born without vaginas who are regarded with nothing but understanding and compassion by medical providers, whom no insurance provider would dare refuse treatment. \
Or consider the thousands of cis-men in our armed forces who have sustained catastrophic genital injuries serving in Iraq or Afghanistan, primarily due to IEDs (improvised explosive devices) which detonate directly beneath them in their patrol vehicles and convoys, with results that everyone acknowledges as horrific and tragic. Yet trans-men who struggle with the same disability, only as the result of birth rather than injury, are regarded with contempt and shunned by insurers and providers for their simple and most imminently human desire to also have a working penis- the irony being that many of these veterans are now being treated (rightly, at no cost to them) with surgical techniques that were originally researched and invented to benefit trans-men (who have always been required to pay out of pocket to fund all of it).
Likewise, trans-men are told, they must borrow or raise money out of pocket for the essential matter of their mastectomies because it is “cosmetic” and not essential for mental health and wellbeing, while cis-men who develop breasts are treated very differently. When the psychiatric drug Risperdal was proven to cause male breast development, many of the men and boys affected were awarded not only the cost of their mastectomies, but millions of dollars for their psychological pain and suffering. Courts and their paid medical experts decided that for a man or boy to have to live with one of the secondary sexual characteristics of a woman was so emotionally damaging and psychologically traumatic and physically taxing that it warranted making them millionaires overnight. Meanwhile at any given time I have countless friends on social media conducting crowdfunding campaigns or taking on debt trying desperately just to raise enough money to cover their medical expenses alone.
What possible moral justification can there be for this disparity? One could attribute this prejudicial disparity to a simple ignorance of biology, genetics, and neuroscience. However, when the population we are discussing are medical and insurance provider, such an ignorance of the science which belies our existence and our medical needs is inexcusable. The only other possible motivation for these blatantly discriminatory exclusions is prejudice toward patients who were born with anatomy that does not match their neurology. An unwillingness to treat transgender patients is an explicitly unscientific and irrational refusal. You do not get to avoid me simply because my existence makes you uncomfortable.
You don’t even need to be a professional to intuitively understand the medical necessity of these procedures- which is nothing less than the need to be physically and emotionally whole and not psychologically and physiologically alienated from your own sexuality and neurologically defined sense of self. Anyone who insists that these most basic of biological impulses and human needs are “cosmetic” for us must hold the same true for themselves in order to be intellectually and morally consistent. If our genitalia and other sexual characteristics are trivial, cosmetic, and unimportant, then so too are yours.
It is the affirmative moral responsibility of every medical practitioner and bioethicist to stand up and insist that these prejudicial policies which were conceived in ignorance and sustained in fear are swiftly brought to an end. Every day that they are not is causing millions of people needless pain and hardship and costing them their dignity, economic security, or even their lives.