Heart over at The Margins posted this article from The Seattle Times, “Tax dollars and a sex change: a story of one patient.” It’s…weird. Stupid, but also weird.
(NB: The Margins is cisgendered-women-only space. I will bring the ban hammer down on anyone here who behaves trollishly. Restrict the discussion to the article.)
I get the sense that the author realizes–not to say cares–that he doesn’t know what he’s talking about, per the vague estimates below.
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.
Wow? That much? That’s a lot! Pray tell, Ralph!
Okay, so remember how I posted yesterday about how difficult it is to draw these distinctions when your audience hasn’t quite figured out how to understand or acknowledge you as a broad group yet?
That goes for surgery, too.
This is the thing you have to understand when you discuss the procedures transpeople sometimes undergo in transition:
There is no such thing as “sexual-reassignment surgery.” That goes for male-to-female transsexuals and female-to-male transsexuals. That term does not–cannot–refer to any single procedure. There is no standard legal definition of when you’ve gone and changed sex. There is no clinical definition of when you’re post-sex-change. “Sexual-reassignment surgery” has been used to refer to any one of a collection of procedures involving genital reconstruction and to all surgeries undergone by any given transperson and to transition as a whole.
The truth is that there are many different surgeries, practiced by different surgeons in different places under different programs on different patients. Costs vary. Procedures vary. Results vary. Demands vary.
Here and here is a two-part article by the aforementioned Jamison Green that’s pretty responsible in establishing a standard taxonomy of ftm surgery. He talks about the major procedures; bear in mind that his cost estimates are a few years old. I don’t think anyone plans on paying fifteen-hundred dollars for a masculinized chest anymore. But the lowest estimate for my out-of-pocket costs for a single procedure is approximately one-fifth the highest estimate; his broad spectrum of fees is right on.
So it’s difficult if not impossible to figure out exactly how much each transperson pays for SRS. How much will it cost to get a referral? What does that transperson want done? (Do they even want genital surgery? Do they want it right now? If so, which one?) What are his or her choices? (How large is the ftm in question’s pre-op chest?) What special health issues might he or she have? (In need of a prophylactic mastectomy? Suffering from PCOS?) What coverage or partial-coverage options are available? (Do they have a health-savings account? Will their insurance pay for it? Is it deductible? (Usually no, no, and no)) What surgeons do they have access to? Will they have to travel out of state? Can they travel? Will they need to stay in a recovery center, or can they stay at Best Western? How much time can they take off work? Will that time be compensated? Will they need revisions or touch-up procedures? Will those revisions be major or minor? What if they end up with an excellent surgeon? What if they end up with a butcher?
That’s not an exhaustive list of potential concerns. Every single one of those questions has to be taken into account when tabulating expenses. There’s also the biggest question of all: What can the transperson in question afford? If you’ve got eight thousand dollars, your preferences are less important; if you’ve got four, they’re immaterial. As with so many other things, the poor spend more: if you bargain-hunt, you could very well end up with results so bad that you’ll need a whole new procedure(s) to fix the damage. If you’ve got good health coverage, you may be able to get a hysterectomy covered by insurance. And so on.
Virtually all transpeople in this country pay completely out of pocket. (Thanks, Ralph! And thanks, taxpaying citizens!) I know transguys who have remained pre-op for years and years on hormones because they simply didn’t have the money. That’s a difficult situation to be in, particularly if you can’t pass without surgery.
Although I just said that it’s difficult to put any dollar amount on “SRS” in general, the cost listed in the Times seems way out off. Most transpeople can’t come up with eighty thousand dollars; most transpeople therefore do not pay eighty thousand dollars. The article doesn’t detail the procedures in question, probably because the writer’s ignorant and writing to an ignorant audience. I can’t figure out from that amount what exactly Andy opted for. (I do know that “20 surgeries” is as unusual as “eighty thousand dollars.”)
It occurs to me–and this could account for the bizarrely high cost and number of procedures–that Andy underwent one procedure in particular whose cost is either the bulk of the listed total expense or being confused with the total expense. That procedure is phalloplasty, which Jamison Green describes thusly:
The skin to make the penis was (and still is, in the classical phalloplasty technique) usually taken from the abdomen or hip and grafted into the groin area, sometimes above the mons pubis, sometimes directly on it. The ability to urinate through the penis has been technically problematic until relatively recently, and urethral extension is still not always successful. Erections are achieved with either a stent or rod implanted permanently or inserted temporarily in the penis, or with an implanted hydraulic pump like those used to assist some men who have lost erectile capability.
The type of phalloplasty that can be erotically sensate usually employs the skin and muscle from the forearm, though sometimes thigh or deltoid muscle is used. The muscle makes a denser phallus, and nerves in the tissue can be connected with existing nerves in the genital area, most importantly the pudendal nerve that enervates the penis (and clitoris). The scrotum can be constructed from the labia majora (better for sensation, but possibly not forward enough on the body) or from tissue from the lower abdomen, depending on the surgeon’s technique. These procedures can range in cost from around $15,000 to well over $100,000, depending on technique, complications, etc. Usually more than one trip to the operating room is required, as the procedure is rarely successful when done in one stage, though exceptions do occur.
(NB: I have never, ever heard of anyone paying $15,000 for a phalloplasty; usually the estimates are far towards the higher limit, particularly the “well over” bit.)
Most transguys do not have “well over;” most transguys therefore do not undergo phalloplasty. It’s insanely expensive, and indefinitely out of reach for the overwhelming majority of us. Other concerns cited include the results and the bodily investment in one of the most elaborate procedures available; the expense is far from the only issue. The bottom surgery most of those of us who get bottom surgery get is metoidioplasty. Jamison Green’s description:
Metaoidioplasty (commonly spelled metoidioplasty), meaning “a surgical change toward the male,” is a term coined by one of the surgeons who developed the technique in the 1970s. It results in a small penis, but one that is erotically sensate and capable of unassisted erection. Derided by some as not masculine enough, for many transmen it is an acceptable alternative because it does not leave scars on other parts of the body, and because of the promise of erotic sensation. Not all transmen are good candidates for this procedure because acceptable results require a significant amount of testosterone-induced growth in the clitoris (usually discernable after about one year of testosterone treatment). And not all transmen are capable of accepting themselves with a small penis.
Metoidioplasty techniques can be compatible with urethral extension, and with the proper placement of the penis and scrotum forward on the body (which sometimes doesn’t happen, due to the transman’s original physical construction or the surgeon’s technique), a very natural-looking, natural-feeling package is achievable. This procedure may be done as an outpatient in a clinic, though, as with phalloplasty, a general anesthetic is required. It can be done in one stage, though some surgeons prefer to construct the penis and scrotum first, then place testicular implants in the scrotum in a second procedure using local anesthetic and a sedative rather than a second general anesthesia. Costs for this procedure range from roughly $10,000 to $20,000.
(NB: transguys who undergo meta are generally required to undergo hysterectomies first; cost estimates frequently don’t specify whether hysto expenses are included, and that may account for the range cited here.)
I’m planning to pay somewhere in between four thousand and twenty thousand dollars for surgery. That will all be out of pocket; however, I have a supportive health plan and a health-savings account, so my burden is lighter than it could be. I might also have coverage for a hysterectomy. Were I interested in meta, I would pay perhaps forty or fifty thousand altogether–assuming I could come up with that kind of money at all. If I were to join the ultraselect brotherhood of transguys who have undergone phalloplasty, that total expense could easily go up to as much as one hundred and fifty thousand dollars. That’s “well over” one hundred thousand completely hypothetical dollars that no one will ever be charged.
Anyhoo, virtually all of the “That’s Outrageous!” stories I’ve heard about transguys who actually manage to use taxpayer money to pay for their surgeries have involved phalloplasty, the procedure that virtually none of us undergo. (If this one doesn’t, there’s some other very special circumstance at work.) Exception upon exception, and a picture that doesn’t much jibe with reality. The fact that we all pay out of pocket makes it difficult to figure out how many transguys would opt into phalloplasty if they could afford it; nevertheless, this guy’s story isn’t standard in a bunch of ways.
When I clicked through to the story, I expected to see hallmarks that “Andy” was a “composite,” by which I mean a materially false and misleading concoction by an unethical reporter. (What, like it doesn’t happen?) I was surprised to see that the reporter actually had some facts that would kill him if he made this up: one specific surgery for “Andy” was singled out in a congressional inquiry. The medicaid payments were the result of a settlement after litigation. Those things are verifiable, even if many of the details are sealed.
Piny, I definitely share your sense that the reported didn’t understand the details, knew his audience would not either, and simply wanted to write a John Stossel- style taxpose. (Did you hear the one about the woman in Brooklyn with seventeen children by fourteen men, with two Cadillacs and a Rolls Royce, receiving thirty-seven different AFDC checks every month …) I’m pretty sure that if someone managed to dig up some facts, there’s a much different story here. My bullshit detector is registering in the overexposure zone.
Same here; this article is a fairly cliched one, particularly the “fair and balanced” juxtaposition of the Hayes report and the representative from Harry Benjamin. (And, oy. There are transguys who are happy with no surgery, but everything I’ve seen suggests that they are a minority whose numbers are artificially inflated by the enormous expense of surgery. I know transguys who are forced to spend years on hormones-only, and they aren’t terribly comfortable.)
I have to say I disagree with Thompson’s drawing the line between evidence-based medicine and advocacy. History has shown us many times that sometimes the two need go hand-in-hand.
Where would we be, medically, if our doctors still had to abide by the old proscription that dissection of cadavers is immoral? Where would we be if young women were still dying from illegal abortion procedures? I hate how men like Thompson (and, it pains me to say, they are almost always men) brush off medical procedures they find in conflict with conventional faith, labeling dissent as “advocacy.”
I think the only thing being advocated here is that new medical treatments should be freely available for the individuals that want or need them. In a supposedly enlightened, democratic society, I don’t think that’s so unreasonable.