Sunday, May 6, 2012

Insurance and Mammograms

This week a New Jersey transgender woman, finally convinced Aetna to cover her mammogram after two years of rejections. I saw someone post that this sense of gender identity being separate from sex has only been with us for 40 years.

Here I must disagree with them. Magnus Hirschfeld encountered transgender people who knew their gender identity was separate from their physical sex and could not change how they felt. The Nazi's destroyed his offices, burning them to the ground, and added his patients to their list of undesirables. It was not just jews who were sent to concentration camps.

Before Hirschfield, at the turn of the last century, some the world's first sociologists visited the Zuni tribe to discover that 1 in 300 people lived in the gender role not consistent with their anatomy, a rate that is fairly universally consistent even today. Our budding nation pretty much wiped the Zuni out.

The Zuni were not the only Native Americans who had trans people living in their midst. The early explorers from Europe found them honored in the tribes under such appellations as the Berdache. The Spanish found their existence against their religion and proceeded to wipe them out, mutilating them before exterminating them. The whole Native American culture was almost completely exterminated and the remainder forced to live under other people's religions. Those who have returned to the old ways, recognize the two-spirit among them and honor them today.

There were Indo-European priestesses who drank the urine of pregnant mares in order to feel more at home in their own bodies.

It's only in the last 40 years that the rate of massacre has dropped off to allow some trans people to live.

Science is showing, and has shown that trans-identified people have a different brain structure than cis-identified people; in fact, their brain aligns more with the gender they claim to be than otherwise. The impact on the brain is that the neural circuity at birth is pre-wired to develop as the gender that does not reflect the genitals they carry. In addition, until hormone treatment is started, the presence of testosterone on a female mind and the presence of estrogen on a male mind cause severe emotional crises, from chronic anxiety to chronic depression. Hormone treatment actually make the person more productive in society. And because estrogen develops breast tissue, those who are on it will grow breasts, which will need care.

We are complex organisms. Even the the birth process is complex. A strange phenotype or external hormones added; a genetic failure or mutation; there are literally hundreds, if not thousands of ways that a child can be born intersex; and if the hormone levels are not right or a testicle doesn't work, or a gland doesn't work, or the hormone receptors don't work; you wind up with someone who's brain structure doesn't match the body they're born in.

I ought to know. I am an undiagnosed intersex woman. In 1974, the military doctors sent me to a specialist to correct a dilated urinary bladder and perform a minor hypospadias repair. I also had an undescended testicle that would cause me severe abdominal pain on an almost monthly basis before making its appearance each and every month. I also had signs that I had some form of endometrial tissue at that age, and through the rest of my life, even though I didn't understand the implications.

I felt wrong in my body, and I knew from a tender age that I expected female genitalia. I also had difficulty hanging with boys and felt absolutely comfortable with the girls. Because I had no idea on how to get help, I lived under the testosterone-induced chronic anxiety until I was in my early 40s and had a wife and two children, both girls. What I saw as the problem would not go away.

I started counseling and, seeing no other way to inner peace, began a trial with hormone therapy. While I lost my family as a result, it quite literally saved my life. The anxiety had gone on for so long that I was quite suicidal.

Everything gradually improved in my life as I embraced who I was instead of fighting it. Eventually I had surgery, and thinking that it might be covered, I filed a claim. At that point, practically all my care was denied, even the exploration into my intersex condition to verify it was not cancerous. Eventually, during the appeal process, everything but the surgery itself was covered.

Until yesterday, when I received an explanation of benefits that my mammogram, the mammogram that the insurance company themselves called me to take, was denied. So it is very obvious that if I had kept quiet about my surgery, my mammogram would have been covered. Instead, they seek to punish me, and like Ms. Scott, I am going to fight them every step of the way for such prejudicial treatment.

Another person writes that doctors can't create women, that transwomen are brainwashed into surgery and that they regret being mutilated by them, because this person listened to a group of women supposedly put together on the Howard Stern Show.

If you believe that, I recommend that you look up the WPATH Standards of Care. Also section 802 of DSM IV. While you're at it, check out True Selves by Midred Brown, et al. You don't want to base your knowledge on an interview on the Howard Stern show. Surely you know that he self-identifies as a shock-jock.

I had to get several letters of approval before I had surgery, and it took me four years. The first letter was for hormone treatment. Even though I was diagnosed in 6 weeks with gender identity disorder, it took me a year before I started HRT. Why? Because, we wanted to exhaust other alternatives, like living as a cross-dresser, because I was married. The second and third letters came from my next therapist, and endocrinologist, who concurred that I had been on hormone treatment for two years and indeed, would benefit from the surgery. I had had to change therapists, because I moved to another state, thanks to losing my job in a round of layoffs. I had been living full-time outside of work for 6 months and full-time female for 4 months before I had that letter. It was three years since I walked into the counselor, with me driving my own transition. My early counselor had only provided the resources and the pros and cons of the choices I could make. No one tried to convince me to get surgery. Once I was comfortable with who I was, I didn't need them to.

It cost me 16,000 dollars to have surgery in Thailand with a world-renowned surgeon and there was a 10 month waiting list. This doctor requires 2 years of hormone treatment and 1 year of living as full-time female before he would operate. I had to get another letter from my endocrinologist for the gender marker on my passport, and when I got to Thailand, I was given another psychological evaluation before the would operate. That was almost exactly a year ago. I don't consider myself mutilated, nor do the people I met in Thailand that I keep in touch with or any of the post-op women that I have met in Fort Worth, Dallas, Louisville, Lexington or Salt Lake City.

For a sample like Howard Stern put together, it was obviously not drawn at random, and can therefore not be used to infer a statistical rule. There are a lot of substandard doctors out there, and many transwomen cannot afford one that's worth his salt, thanks to insurance not covering and people not employing. Those women I do know that have some complaint don't regret having the surgery, they regret having the wrong surgeon do it. They are still happier as women than they have ever been as men.

Hugs and Blessings,

Hope to see you at the Utah Rennaissance Faire and Festival on the 19th. I'm unveiling a new solo with veils and zils.


  1. Hi, Sophie --

    I've been navigating the insurance maze for over a year now, and it's been interesting. So far, surprisingly, almost everything has been covered. That includes therapy, HRT, and quarterly blood work. My mammogram a few months back was covered without question.

    There is a BUT, however, in that I think "they" are catching on. The legal name and gender change last year finally seems to have registered in someone's mind, as our MED unit at Embassy Bucharest is now in a letter-writing battle over the diagnosis behind my blood tests. The head of our MED unit is a fighter and has so far fended off any denials with a loose diagnosis of "hormonal imbalance."

    What I am wondering is what will happen when I make my own trip to Thailand next year. Perhaps your experience is a guide. My hope is that OPM will succeed in getting the "transgender exclusion" removed from FEHB policies sooner rather than later. . . .

    Best from Bucharest,

  2. Hi Robyn,

    I am sorry to hear that you are already having a battle. You definitely want to do everything you can to get that exclusion removed; because if you don't and you file for a claim for surgery, expect a more prolonged fight.

    I must have made an impression during my last round of appeals, because the appeals department called me and said that they were not going to process the appeal and were going to reprocess the mammogram claim instead. I don't know if it has worked yet, because it takes up to 30 days to process.

    Meanwhile, I have a lawyer from TLDEF (Transgender Legal Defense and Education Fund) on standby pending the outcome of the appeal and I have been working with my employer, trying to get them to provide an alternative.

    Good luck on your battle.

    Hugs and Blessings,

  3. Hi Sophia,

    Thank you for those thoughts that I should be keeping in mind!

    My contacts in the Office of Personnel Management are optimistic the transgender exclusion that is in the FEHB policies that we federal workers get to choose from will be removed. My own organization, Gays and Lesbians in Foreign Affairs Agencies (GLIFAA), has weighed in with OPM as have LGBT organizations in a number of other federal agencies and departments. The big question is whether it will be removed in policies for the 2013 calendar year. Some say that this being an election year, a removal in 2014 is more likely.

    As to my own SRS plans, it's 2013 for certain due to the assignments cycle in the Foreign Service. I'm working on the assumption that I will be out-of-pocket, but if OPM is able to get the exclusion removed in 2013, I will be the most ecstatically happy American woman east of the Danube :).

    Hugs back to you,

  4. Sophie,
    How ironic that i see an advertisement for Humana on your page; as a retiree, this was what I used for all my medical care. They paid for all of my hormone treatment, breast cancer treatment and care. They paid for all of my mammograms, psa testing and blood workups, surgeries which included mastectomy, breast augmentation and great implants. Now that I am on Medicare, they also pay for mammograms, what they had a problem paying was that as a female they balked at covering my psa testing because of the gender designation conflict, because I haven't had the full grs. I learned that President Obama had directed the Office of Health and Human Services to write an exception and implement it throughout the national Medical Healthcare program and Medicare. It took an informed and dedicated person working in the doctor's office to finally get my testing paid for by Medicare.

    This is the same medical program that all Government employees should have, or supported under. If someone is taking HRT and is that age, mammograms should be covered; no questions asked. But there have been Men diagnosed with breast cancer and their medical plan did not cover them, just because they were not 'female'. That's sooo wrong.