23 September, 2014

On (not) providing transgender people with healthcare

When I transitioned, I also transitioned careers.

I recently transitioned from working for private industry to the public sector. I am really happy with this transition, actually (and may write more on it at a later date).

What has really been shocking for me, however, is the difference in healthcare.

Before coming to work for government, I had heard just about everywhere that "the government has great health benefits." I had heard about the miseries of tricare, but I had largely assumed this was a sort of defense-specific thing. When I worked for Microsoft, I spent a lot of time talking to government workers, specifically at Postal, who would talk at length about the "great benefits" the government had. I suppose I did not consider at the time that most of these people were career civil employees (many having tenure exceeding fifteen years).

On the first day of my second week in the office (I’d spent the first week mostly figuring out what I needed to hack and then got down to actual hacking), I spent a very long time on the phone with our health plan providers. I threw out my notes from that day in disgust, but I spoke with Aetna, Blue Cross, Kaiser, and something called Blue Choice, which I thought was Blue-Cross-related but is evidently not really.

Every single health plan provider I called gave me the same answer: "transition- and gender-related care are explicitly not covered by [their] plan." I was prepared for this. I explained that Washington DC has just passed legislation ordering district employers to provide transgender-specific healthcare, including all the vagaries therein.

I was positively crushed to hear, specifically the person from Aetna, tell me quite assertively, "well, the federal government is not obligated [emphasis hers] to follow that law." Crushed, kind of shocked, and disappointed.

You see, Booz Allen, for all the pros and cons of working there (basically, I liked working there, but it had its moments of frustration and disappointment; on balance, I think less than at other employers) was actually an ardent supporter of their transgender employees (unicorns that we were). In fact, Booz is pretty quick to tout their HRC Gold rating.

Booz, if you are wondering, covers everything. Hormones and therapy, surgery, and even a support structure internal to Booz (this is to say, not relying on a "healthcare provider") to help employees transition. In fact, when I came out, people were positively effusive in their support. I never once encountered the sort of proactive hey-fuck-you-for-wanting-trans-related-things that I got from Aetna (…who is acting on behalf of…yeah, my employer). I don’t think it is fair to name names, but I am incredibly thankful for the support I got from people, especially in Booz’s "Diversity & Inclusion Team" and the mentor they assigned to me as part of my coming out at Booz. (I mean, imagine this; I thought I was going to be fired when I came out. Instead, I gained new friends and people to support me at work)
What does this actually mean?
I understand that for someone who doesn’t actually require this treatment, this may seem vague, or may seem to refer to surgeries people will titter about in break rooms and on television; the reality is actually much more mundane.

Recent SCOTUS decisions aside, a huge number of American women take hormonal birth control. It comes in various forms, oral, injectable, patches, IUDs. As it happens, transgender women (aside — I know transgender men, I understand they take hormone replacement therapy as well, but I cannot speak for them and do not know the specifics. My understanding is it is harder to obtain testosterone because it is a Schedule-III substance whereas estrogen and progesterone are not.) take these very same drugs. No transgender person is asking for mystical medications concocted in a lab somewhere; in fact, some such drugs are literally isolated from mare’s urine (no, I couldn’t believe it either).

Additionally, a curious and unfortunate side-effect of coming out transgender in America is you are essentially required to have a therapist. In order for me to change my gender marker on my driver’s license, I needed a doctor’s note (my psychologist). In order for me to change my gender marker on my passport, I needed a different note (my endocrinologist). In order to have gender confirming surgery (GCS), a person needs two notes (a physician and a psychiatrist), as well as to sit and be evaluated by a third person (usually a social worker but sometimes a psychologist or psychiatrist). This is to say that, even though the state will not actually cover my transgender-specific healthcare, they will insist that I have it, whether it’s cash out of pocket or insurance from some employer-looking vehicle.

I have had a couple of surreal sessions with my psychologist about this; she will look at me and say, "So why are we here today, Jane?" And I will just reply that I don’t really know, that I am required to be there by law, and that we can just sort of chat and catch up and be some sort of awkward friends.
Hormones, surgeries, and this is expensive, right?
So I take estrogen, birth control, and progesterone, which is also used for birth control, fertility treatments among other things. The cash cost for these two drugs is about $100 a month, which I paid until I could find a doctor to prescribe it to me (which is still another problem). This hardly seems expensive compared to a standard course of antibiotics. I use the very same branded drugs in the very same preparations as any other woman.

There are other issues that are specific to transgender people in the healthcare field, but the one everyone always wants to talk about is surgery.

I would like to go on record as saying it is unconscionable that this care, gender confirming surgery (GCS, sometimes called SRS or "sex change surgery" [although please do not use this latter term, it’s kind of offensive]), not be provided to people that need it.

Uncharacteristically for me, I refuse to talk about this part of my transition. But generally-speaking, we can talk about what this costs, and what it costs to not do.

For people who want GCS (and understand that not every trans person does want it), usually the cheaper way to do it is to have it done outside the US. This is because healthcare is quite exceptionally expensive in the US for people paying cash. Two of the most common and prominent doctors of this surgery are doctors Suporn and Chettawut, who also happen to perform the most advanced procedure available. Their cost is between $8500 and $18000 (hotel and hospital inclusive, exclusive of air fare, which is a couple thousand at most).

Does this sound expensive? I know a person who was hospitalised recently in the DC area for a little less than ten days for acute, intractable depression. This person’s hospital bill (submitted to insurance) was $19,000 and change. I know another person who was hospitalised for depression in 2010, and her bill was $27,000 for just a week.

It is not uncommon at all for transgender people to be hospitalised for suicidal depression (which is not, actually, due to their ‘being transgender,’ but rather to how people treat them for being transgender). If these people are hospitalised for a suicide attempt, the acute care plus the psychiatric hospitalisation can run into the many tens of thousands of dollars. Some are hospitalised more than once. Some for much longer than a week or ten days.

Really, surgery starts to look cheap if you decide to "only" provide psychiatric care (and many employers do not even provide this).

What’s happening here is that transgender people are asking for medical care that is offered to anyone else in the public with insurance and they are being denied it because it is "gross." Or something. The arguments about surgery being "cosmetic" or "un-needed" are entirely irrelevant given it is the cheaper, and more permanent, and more effective therapy for acute gender dysphoria (which I think most of us struggle with at some point during transition or later in life).

Nobody has any cogent, consistent reason to deny trans people healthcare coverage. It’s ignorant, bigoted, and it’s fucking horrible.
Elective surgeries, genetics & choices
Much of the modern "transgender narrative" discusses this idea that people are "born transgender." That trans women have sort of physically distinct brains, and that they are therefore genetically predisposed to this "legitimate medical condition," and that accordingly they should be treated for it.

This is not my narrative. I did not know until my thirties, and only had vague inklings before then (many people, incidentally, said they knew long before I did when I came out). I do not believe I have an "intrinsically female" brain any more than I believe I have an intrinsically male brain, any more than a man with half a brain is not a person or people who have a split corpus callosum are two separate people, any more than any other neuroatypical is any less or more a person. Generally, I am pretty happy with my body.

Our brains, bodies, and genes play a part in who we are. But they are not, in and of themselves, who we are.

Accordingly, because we afford healthcare to all cisgender people without some magical cisgender brain formula or "cisgender gene," we must provide that same care to transgender people. It is the right thing to do, regardless of biology. We do not provide healthcare because a person has a suitably acceptable or approved body or neurotype; we provide health care because we care about people and it is the right thing to do.

If we do talk about genes, bodies, or a biological basis for "being trans," however, let us first talk about a particular genetic peculiarities I have that is treated without question.

I have a deviated septum. My ENT has actually called it "pretty significantly" and "creatively" deviated (which I suppose is appropriate). This is a genetic quirk of mine; I have never broken my nose, and outwardly it appears fine. But this means I get sinus infections really easily. In fact, I average 5-6 in a given year (I spend about 13% of the year sick with a sinus infection!). We can add up the incredible number of doctor visits this entails, or the amount of antibiotics prescribed, or the really incredible saga of Jane-is-allergic-to-augmentin-and-her-liver-failed-and-she’s-out-of-work-for-four-months, but the bottom line is this tiny little "deviance" of mine has cost my health providers, and accordingly my employers, many tens of thousands of dollars over the twenty years I’ve been working.

My ENT has finally decided I need surgery to fix this. And, you know, my health insurance will cover it, and nobody stops me to say "We don’t have to cover that. It’s a choice to live in an area with pollen." or "Maybe we aren’t obligated to pay for your genetic anomaly. Try being normal."

So while my employer’s health insurance plans will all cover things like a seriously unreasonable number of sinus infections leading to hospital visits, they will not cover far cheaper therapies because they are related to this icky, "life-choice", "transgender stuff." We call this bigotry.
Where this leaves us
As an employer, it’s actually cheaper to provide trans-inclusive healthcare to employees.

Even if it weren’t cheaper, it is the humane and sane thing to do, to support a class of people actively and violently oppressed by society.

There simply aren’t logically consistent arguments against providing this coverage. You have an argument of bigotry in the case of "they're different and…", a zealot argument in "well, it's not in my belief system…", and an irreedemably flawed argument in "but I shouldn't have to pay for…" presented as frugality-not-bigotry (of course!).

We are living in an era where it is becoming more and more common for companies as big as Booz Allen, Amazon, and Apple, to provide transition-related healthcare, up to and including surgery. To not provide this coverage is to show your lack of willingness to take care of your employees, and leaves you at a competitive disadvantage when it comes to salary/compensation packages. Good luck hiring the best people in a field when they won’t even come to an interview (this happens). An astonishing number of very highly-placed engineers are trans.

I love what I do, and where I work, and who I work with, and even who I work for. But I am disgusted by the way I have been treated by the healthcare apparatus offered to me. I am incredibly disheartened by the utter lack of resources to even begin to discuss this sort of thing with my employer. And I am frankly shocked to see the federal government, which is actively trying to recruit the best and brightest, provide such miserably shitty benefits. Had I known before I interviewed what health benefits would be available to me, I would not have ever taken an interview, let alone accepted an offer. Effectively, this lack of coverage translates to a reduction in compensation (read: salary).

It leaves me, day-to-day, wondering whether it is "worth it," whether really loving what you do is being worth made to feel unworthy, literally worth less then my coworkers.

What does this really say?