Who deserves health care?

Michelle Kosilek

… and specifically, what kind of health care?

With Michael Moore’s Sicko out in theatres, everyone’s talking about the blindingly obvious need for universal health care in this country, and the “I got mine” mindset that seems to trip up many of us in the United States who are used to fighting tooth and nail for coverage. As Jill pointed out last week,

I also found myself having the occasional knee-jerk individualist reaction to the idea of universal health care. That individualism is also so deeply ingrained in Americans — the idea that I can do it on my own, that personal freedom and independence trumps all — that a system wherein we all contribute in order to help each other is a hard sell.

Pam Spaulding over at Pandagon had some similar thoughts, noting that “We are very much a “me” culture, with an acceptance (as well as envy and disdain) of the ability of those with money to be able to buy services they want and need.”

So… these were some of the thoughts in my head as I started looking back at discussions from the last five years about whether the woman above, Michelle Kosilek, is eligible for health care that’s been prescribed by her doctor. There are a number of complications, in Kosilek’s case. First, she’s incarcerated; that means she’s certainly not paying for her own medical care, but that the government is responsible for keeping her healthy–at least to some degree, most everyone would agree. Second, she’s trans, and the health care in question is genital surgery. If it were practically anything else, you’d hardly have any fodder for controversial news stories. Third, the crime she’s been put in prison for is particularly heinous and repulsive: she was convicted for strangling her wife.

Seems to me that Kosilek’s case has been the nexus for a whole bunch of different knee-jerk reactions about health care, prisoners, and trans people.

One thing most non-lunatics seem to agree upon is that yes, people do need SOME way of getting health care, even the poor, even the incarcerated, sometimes even (*gasp*) immigrants. It would be inhumane to suggest, at least openly, that some people can do without health care, right? (I’m sure one of you will kindly link me to some wingnut who’s declaring otherwise.)

Unsurprisingly, there are some big blind spots in this least-common-denominator agreement; one of them has to do with trans people, and the kinds of “controversial” health care we often need. The conventional wisdom, I’m sure a lot of you can guess, is that the kind of health care Michelle Kosilek’s been prescribed isn’t “really necessary.” That’s why mainstream and conservative media outlets, from coast to coast, can have a field day trumpeting about how the sky is falling because “tax dollars are being used for sex changes” whenever any government health care funds are used for trans health care. That story about San Francsico employee benefits, from six years ago, is the first time I remember seeing the reactionary backlash–from sources other than the New York Times, although I wouldn’t call “another minority flexes its muscle” an objective headline by any means–and it hasn’t stopped since.

So… here’s something that’s very difficult for most people to grasp: for a whole lot of trans people (although not all), some kind of trans-related health care is a medical necessity. Sometimes this means hormones; sometimes it means surgeries, or other procedures. The exact details are not that important — and indeed, are often used to distract and sensationalize. They’re not as important as they’re made out to be in part because good trans health care, just like good health care in general, is individualized. There aren’t any one-size-fits-all solutions.

A quick and dirty history of trans health care, before I go back to the media and Kosilek:

Trans health care was first pioneered more than a century ago, and has been recognized by the medical establishment for decades. Despite this, a lot of courts, government agencies, and insurance companies persist in calling it experimental or untested, and generally treating trans health providers and servics like sketchy red-headed stepchildren of the medical industry.

Trans health care used to be concentrated in a few large institutions here in the US, with Johns Hopkins being the most famous… or I should say, infamous, for forcing trans people to jump through all sorts of ridiculous, misogynist, stereotypical hoops. (Check out How Sex Changed: A History of Transsexuality in the United States by Joanne Meyerowitz, for more.) Interestingly, the two experts paid by the government in Kosilek’s case are both from the Johns Hopkins unit that used to treat trans people before shutting its doors in 1979 and more or less declaring trans people untreatable.

In the last few decades, trans health care in the United States has become much less centrally controlled, and probably significantly more accessible than it was… to those with enough money. Not too dissimilar to a lot of “quality health care” in this country, I’m afraid–and as usual, insurance companies bend over backwards to avoid having to pay. There has never been a shortage of cultural prejudice and exploitative shock to help insurance administrators out with denying trans health care; it’s often mentioned explicitly in insurance policies, in terms like “any treatment related to change of sex is excluded.” Go check your own policy, and see what kind of creeped-out language some bureaucrat wrote in. to foil us devious trans people from getting any monetary assistance whatsoever!

The parallels with Sicko come up again when you look at other countries. In many nations where the government funds universal health care, trans health care is part of the funding. It hasn’t been easy to achieve–in Canada, coverage went on a province-by-province basis, and access is still tightly controlled in some places by large clinics, similar to Johns Hopkisn, that I’ve heard horrific stories from. And the right wing still protests that trans health care is covered in the UK all the time. But increasingly, in nations with universal health care, that also means health care specific to trans people.

So it’s been interesting to see how Americans react to situations here where federal, state, or local government money pays for trans health care — just as it does in Canada, the UK, and many other nations. Part of the tragic absurdity of ambivalent-about-welfare-states health care in this country is that since the system has to recognize that we’d be flat-out killing our citizens if there was no government-funded health care, the government DOES foot the bill for some people’s health care: people who wouldn’t be able to get it otherwise. People who are in the care of the state, like foster kids and orphans and incarcerated prisoners. Poor people who are eligible for Medicaid, and the elderly and disabled folks who get Medicare benefits. Of course, it would outrage conservatives if any of these people actually got equivalent or better services than what more privileged people have to pay for, so it seems sometimes like some effort is made to ensure that they only get crappy, crappy health care.

Michelle Kosilek’s story isn’t new, but it’s been showing up again in the news recently because of the lengths that the state is trying to go to in order to avoid responsibility for trans people’s health care: $52,000 is the tab so far, and this is just one of the battles against trans health care that federal, state, and local governments have been trying to wage over the last few years (at least). Kosilek herself has been a subject of a lot of disagreement and name-calling in trans communities. Although Kosilek claims she killed her wife in self-defense, the facts of her case are ugly, and the jury didn’t buy her claims. Although I hate to take the word of the criminal justice system about someone’s merits, it’s altogether too likely that Kosilek is at the very best a person with some very serious mental health problems, who shouldn’t have ever been married to her own psychotherapist. At worst, she’s a psychopathic wife-killer, one who’s now “paying her debt to society.”

Even I have to admit that the fact that Kosilek is trans weighs heavily on my evaluation of her case, and not in a positive way. I can’t help but realize that I would be looking at this story very differently if I wasn’t aware that Kosilek was trans. The nature of her crime has understandably made a lot of people recoil, including other trans people–some of whom refuse to believe that she’s really trans at all, who prefer to just label her as a man–it’s safer in some ways. But you know, trans people come in all shapes and sizes. There are republican trans people, and trans hip-hop artists, and trans CEOs of large corporations, and there are trans murderers, thieves, liars, and crooks. At a stretch, Michelle Kosilek might confirm some of the worst “Silence of the Lambs” stereotypes that make trans people cringe or rage or ache. Does that mean she doesn’t deserve health care?

I’ve read a lot of arguments about Kosilek’s health care over the last five years. (Here’s a recent discussion on livejournal and half of a debate from 2002, between two trans women.) A lot of the discussion strikes me as having a unique flavor: the tang of a country without universal health care. I’ve seen it argued that someone who would kill a woman can’t possibly be a woman herself and therefore can’t be trans and shouldn’t have access to trans health care. I’ve also read arguments that her crime is so heinous that she doesn’t deserve the usual goal of trans health care: a body more consonant with one’s gender identity, that can be lived in without dissonance and pain. It’s trans people arguing this, people who know what it’s like to be denied a gender, who’ve experienced that same pain. But the most recurring theme I’ve seen is, “why should she get to have what I can’t have / what I can’t afford?” But can any of us really afford to stay in this mindset, with the state of health care in this country, with Michael Moore shaking it with his mixture of sarcasm and weary hope, right in our faces?

Even this specter has been raised: “what if trans people start committing heinous crimes just to get into prison, where their surgeries will be paid for?” It breaks my heart to hear this for so many reasons: the unbearable ache of dysphoria that so many trans people are all too aware of; the naivete of anyone who doesn’t know how many trans women are raped and prostituted in the American prison system; the blunt awareness that no, there isn’t much assistance in this country for a trans person who needs hormones, surgery, any trans-specific care. You have to pull yourself up by your bootstraps, in that good old-fashioned independent American way, grit your teeth, and go get your own health care. The story isn’t that much different from the SNAFU’d story of the rest of American health care–just with the addition of conservative media pundits spitting contemptuously on the very idea that any help would be offered, and everyone else sitting on their hands, not sure what to think.

As for Michelle Kosilek, it seems pretty simple to me, at least at the level of what principles we should bring to bear:

If you listen to innumerable trans people and almost all of the health professionals who have treated and provided care for trans people, you’ll hear overwhelmingly that trans-specific health care is not only well-established but necessary. That it improves the well-being of individual bodies and lives. That in many cases, it saves lives.

Everyone wants to get in on the act, but ultimately it has to be a patient and their doctor who decide what care is appropriate, in each individual case. Bureaucrats shouldn’t be the ones deciding. Politicians shouldn’t be the ones deciding. Media pundits shouldn’t be the ones deciding. Livejournal users certainly shouldn’t be deciding, regardless of whether they’re trans or not.

If you accept that trans health care is neither experimental nor unnecessary, and a doctor has prescribed it to a patient, then you have to provide it to those patients who the state has an obligation to provide health care for.
Whether that’s a murderer or a city employee or a young woman in foster care.

Mariah Lopez’s case, previously mentioned here on Feministe when Jack at AngryBrownButch started her campaign to respond to the New York Post’s intensely transphobic reporting, is noteworthy because Lopez too has been described by the media as a “sociopath.” The Post called her that based on her criminal record, without bothering to check up on the fact that Amnesty International has been chronicling her harassment and arrests by the NYPD for years, as a striking example of police brutality against trans people.

But no–when “tax dollars for sex changes” are at stake, one of the easiest ways out is to label trans people as insane, sociopaths, deviants, etc. It almost makes me question how the media has treated Michelle Kosilek. Almost. I can’t find it in my heart to have sympathy for someone who strangled a woman from behind, apparently in a premeditated way, then stuffed her body in the back of a car before leaving it in a mall parking lot.

But there are more important principles at stake here than a single murderer, a single victim who should have lived, a single heinous crime. Who deserves health care? Does a murderer deserve health care? Even if the rest of us have to keep struggling uphill, in this land of pay-for-it-yourself medicine? What do you think?


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60 comments for “Who deserves health care?

  1. eastsidekate
    July 9, 2007 at 10:23 am

    Thank you, thank you, thank you for writing this! I’m inclined to agree that Michelle Kosilek is entitled to any health care her doctors deem necessary. Of course, that simply highlights the unfairness of the medical system– there are plenty of people who didn’t commit a crime who don’t have access to things like dental exams. Of course, society insists on viewing trans-medicine as something more than a root canal.

    The jealousy factor is huge. I’m a transsexual women who doesn’t make much money, has massive debts, and whose health insurance policy won’t cover anything trans-related. Forget about surgery, I have trouble paying for hormones. And that bitch got free electrolysis! Nobody has insurance coverage for that.

    I’ve done the math– if I committed a crime and got locked away for 18 months, I’d actually come out ahead financially (aside from the obvious scars on my record and psyche). What kind of fucked up society are we that I’d even consider that math (and for the record, I wouldn’t commit a crime, even for all the health care in the world)? What’s even more bizarre is that I’m a civil servant– the same tax dollars that aren’t funding my health care, are paying for this woman’s care. Yeah, it galls me– more than a little.

    The thing to remember is that health care is a human right. The prisoners at Gitmo deserve quality health care. Prisoners in the US deserve health care. It’s not absurd that they’re getting it. It’s absurd that the rest of us aren’t.

    Now if you’ll excuse me, I have to go not assault an insurance company executive, so I can continue to not get the care my doctor recommends. WTF?

  2. BabyGirl
    July 9, 2007 at 10:55 am

    This is a tough one. I think that prisoners do deserve health care, but I think allowing this woman to get free electrolysis and a sex change is a bit much. I’d say she deserves whatever medical treatment will keep her physically healthy, but that’s it. I am sure there are plenty of people in prison right now who would benefit from talk therapy who don’t get it. I am sure there are a lot of folks who have mild mental health issues that are exacerbated by being in prison who don’t get the help they need either, when it’s probably a lot cheaper and simpler than hormones and a sex change. I am not a trans woman, but I can’t even imagine how angry I would be to know that a murderer got access to this expensive and life altering surgery that basically no insurance will cover. My current insurance policy does not cover elective abortions which I think is disgusting and wrong, but what can you do? My best friend’s insurance doesn’t cover her birth control pills which she needs to control her dysmenorrhea, but does cover Viagra. It’s a fucked up world.

  3. July 9, 2007 at 11:12 am

    Is trans care generally in the category of physical or psychological care? I ask because that may explain some of the reactions to this case.

    With most medical care, the “deny care” scenario can be pretty dire: death, disability, etc, right? That may not be universally true, but it seems pretty true, especially for that care which people would think of an an ‘entitlement.’

    With psychological care, the “deny care” scenario can be fear, depression, etc. But less often a physical manifestation, right? That’s part of why the U.S. has such an odd relationship with psychological illness.

    Anyway, what’s Kosilek’s complaint? If it’s depression, unhappiness, “living in dissonance and (I assume emotional) pain” etc. then it’s not all that surprising people don’t feel sympathetic. Not because Kosilek is trans, necessarily, but because most folks don’t feel sympathetic for convicted, imprisoned, murderers who are depressed and unhappy. Living in dissonance (you want to be out, but you’re in) is, unfortunately, part of the prison package.*

    Living in physical pain, however, is not considered part and parcel of being imprisoned. That’s probably why many people don’t want to deny prisoners basic medical care for physical injuries.

    *Not that I think this is a good thing. But I think it’s factually accurate.

  4. kathygnome
    July 9, 2007 at 11:33 am

    I don’t believe she’s entitled to care that she wouldn’t be entitled to otherwise. I’m a public employee in Massachusetts and our insurance doesn’t cover transgendered care. Is it reasonable to say a prisoner should receive care that her guards wouldn’t? I don’t think so.

  5. Tom
    July 9, 2007 at 11:34 am

    You know, sometimes it seems as though the system goes out of it’s way to cater to the most exceptional, unlikely, outrageous and non-representative cases for the express purpose of souring people on the notion of healthcare as such.

    Seriously, a trans-woman, who murdered her wife gets electrolysis in prison as part of becoming a woman? Is this a common enough event that you should base policy on it? And since when are women hairless in the first fucking place?

    What situations like this seem to indicate, is that healthcare isn’t as hard to facillitate as the right-wing freemarketeers would have you believe; it’s just a matter of doing it.

    And it’s not a zero-sum game. Whether I have health insurance shouldn’t be contingent on whether some murdering lunatic also has healthcare.

    I hate these distracting discussions.

  6. Sally
    July 9, 2007 at 11:49 am

    I don’t believe she’s entitled to care that she wouldn’t be entitled to otherwise. I’m a public employee in Massachusetts and our insurance doesn’t cover transgendered care. Is it reasonable to say a prisoner should receive care that her guards wouldn’t? I don’t think so.

    I’m not sure that I want to start from the premise that what’s available to other people is acceptable and therefore some sort of standard. But even if you do start from this premise, I think you could argue that prisoners do deserve better care, because they have fewer options. People who aren’t in prison do all sorts of things to get better healthcare. They change jobs. They move. They find clinics with sliding scales. They take out loans or borrow from relatives or throw fundraisers to raise the money to pay for their own care. They get the care and then spend the rest of their lives in debt because they can’t pay for it. These aren’t necessarily great options, and they certainly don’t work for everyone. But they’re options that aren’t open to people who are currently in prison. And since people in prison are denied all of those options, I think you could argue that society has a higher burden of care for them than for other people.

    I don’t know. I start from the premise that healthcare, including mental healthcare, is a human right. You don’t forfeit it when you go to prison, even if you’re a terrible person who deserves to be there. It’s appalling that we fail to provide this human right to everyone, including good, upstanding people, but the fact that we don’t provide it to everyone doesn’t somehow offset the appallingness of not providing it to the most vulnerable members of our society.

  7. July 9, 2007 at 11:53 am

    Tom is exactly right here:

    And it’s not a zero-sum game. Whether I have health insurance shouldn’t be contingent on whether some murdering lunatic also has healthcare.

    What I think sometimes gets missed in the especially distracting, troublesome case of Michelle Kosilek (which I wrote about precisely for those reasons, despite it possibly being a bad idea) is that this works the other way too. Whether some murdering lunatic gets health care shouldn’t be contingent on whether we have health care either. The system we have sucks all around: Michael Moore has been pointing that out. There are injustices wherever you turn to look. But two wrongs don’t make a right.

    And here is the other thing that some of you might be missing: a lot of times, someone has to bring a challenge to the system, before anything is changed. Especially in the case of something like trans health care, which affects a very small and misunderstood minority, where the procedures themselves will always be a subject of incredulous looks and sensationalist media; things aren’t going to change at more than a glacial pace otherwise.

    No, I wouldn’t have ever picked Michelle Kosilek as the poster girl for “everyone should have access to trans health care, and the state should pay for trans health care for the same groups of people that it pays for other health care for, from civil servants to Medicaid recipients to prisoners.” Any time someone tries to bring a challenge to this lack of coverage, of course the state defense, the media too, will try to find some reason why this particular person shouldn’t be getting health care before anyone else. That’s why I included Mariah Lopez’s story too — she was tarred and feathered. Should we just be waiting until some model candidate comes along? Until then, should we just say “no way, I can’t get health care and you deserve it less than me, so get behind me in line!”

    This is what the lack of universalized health care has done to discussions about coverage in this country. If we truly regard adequate health care coverage as a universal human right, as a basic service that everyone deserves, why are we still establishing hierarchies — even between prisoners and guards? Is there no alternative except for scrambling over each other to try and get some of the health care pie first?

    I’ll have to write more about mental vs. physical pain later, and why it’s a classical mind/body distinction that might be confounded by the experiences and dysphoria that trans people deal with, which almost by definition crosses that boundary. Also about electrolysis.

  8. eastsidekate
    July 9, 2007 at 12:02 pm

    Tom: And it’s not a zero-sum game. Whether I have health insurance shouldn’t be contingent on whether some murdering lunatic also has healthcare.
    Agreed.

    I think that’s one of the reasons why this case is so unpleasant. It’s one of a handful of cases (although there are plenty of transsexual people in prison mind you– that’s another discussion) involving public financing of trans-medicine. When legislators start talking about paying for “sex changes” they never talk about the city of San Francisco, they always talk about the worst case they can find– namely this one. They use it to reinforce the idea that transsexual people are crazy, well, murdering lunatics. I really wish it would just go away, but I suppose it’s better to fight the stereotypes head on.

    Some of the previous comments suggest that psychiatry might help Kosilek. Perhaps. Certainly it’s worth a try in the lunatic and murder departments. But again, if she is transsexual, all the psychological care in the world isn’t going to help her resolve the issue. Presumably, this is what her doctors have decided.

    The real question here is why we’re having this debate in the context of Michelle Kosilek. It’s as if we’ve already decided, as a society, that trans-medicine for non-imprisoned inmates is forbidden. I mean, it’s not to the point where I can bring it up to my state legislators with a straight face– it won’t happen for a long, long time, and no lawyer in the world can help me. No way, no discussion needed. So why is it up for debate in the context of someone who’s committed a heinous crime?

    Just exactly who is framing this debate in MA (and in WI, where there’s a similar suit involving hormones for transsexual inmates)? It seems like it’s a handful a prisoners arguing that for themselves, health insurance is a right (but not for the rest of us), and a boat load of bigoted legislators shouting them down. It’s a stupid, selfish place to start the debate. Let’s start with universal health care for all– that includes trans-health care.

    If we, as a society are going to insure a warm bed, food, and health care for our prisoners, but not for the rest of our citizens, we’re going to look fucked up. And, I can’t for the live of me figure out how health care addressing transsexualism doesn’t count the same as any other health care.

  9. eastsidekate
    July 9, 2007 at 12:06 pm

    And as an addendum, if we’re not going to ensure a warm bed, food and health care for our prisoners, we’re also going to look like jerks.

  10. July 9, 2007 at 12:07 pm

    How is this a distracting discussion?

    The only reason Michelle Kosilek should have surgery or access to any other trans health care is because it is medically necessary. That’s the only reason, and it’s enough of a reason. This is a bad situation, but it would be bad precedent to claim that trans people don’t have the medical necessities that we do.

  11. Betsy
    July 9, 2007 at 12:08 pm

    With most medical care, the “deny care” scenario can be pretty dire: death, disability, etc, right? That may not be universally true, but it seems pretty true, especially for that care which people would think of an an ‘entitlement.’

    With psychological care, the “deny care” scenario can be fear, depression, etc. But less often a physical manifestation, right? That’s part of why the U.S. has such an odd relationship with psychological illness.

    I would just like to point out, as someone who’s lived with a partner with severe depression for a few years (thank god he’s finally started to get treatment and his condition is improving) that besides the obvious point that depression can lead to death (suicide), it also is physically and occupationally debilitating. This is not directly related to the discussion about Kosilek, but this is a common misconception that I would like to try to clear up. I never understood fully how life-wrecking something like depression can be until I saw my partner descend into it. It is NOT just feeling sad. It can be an inability to get out of bed, to perform the most basic tasks of daily life.

    I know that Sailorman’s point is that the effects of psychological ailments aren’t as obvious or popularly understood as physical ones, and I totally agree. I just wanted to point out that the “deny care” scenario of psychological care can also be disability and death. Not necessarily in Kosilek’s case, but in many cases.

    My apologies for going off topic.

  12. July 9, 2007 at 12:12 pm

    Yes, prisoners are entitled to a good amount of health care coverage. I would caution people against concluding from that fact that the prison system actually provides that coverage effectively. Prisoners suffering from mental health issues (about 20% of the incarcerated population) often go undiagnosed and untreated for years, though they are frequently punished for exhibiting symptoms of their disorder. I agree with the thrust of most of these comments, but when people say things like –

    “If we, as a society are going to insure a warm bed, food, and health care for our prisoners, but not for the rest of our citizens, we’re going to look fucked up.”

    – it obscures the important fact that we don’t provide those things for our prisoners, at least not consistently. And that, too, is fucked up.

  13. Laurel
    July 9, 2007 at 12:18 pm

    I’m going to admit to something here: my knee-jerk reaction against free trans care for this prisoner has nothing to do with her crime and everything to do with the fact that, since I can’t comprehend what it’s like to be trans/have gender dysmorphic disorder (?), I’m not completely convinced it’s a medical condition. Therefore, I can’t decide whether I believe it’s “necessary” in the same way an appendectomy is, or even in the way I feel my antidepressent is.

    I’m really wrestling with this one; I feel a little bit like the jerks who insist gays can “change” if they “really want to.” It’s making me look at the ugly places in my mind–always a good exercise, but never a pleasant one.

  14. Betsy
    July 9, 2007 at 12:22 pm

    All that said, I think that the moral repugnance of the crime/prisoner should not be relevant if you consider health care to be a human right, any more than the horror of the crime should be a factor if you oppose the death penalty on principle. I don’t know much about the medical/social consensus about trans health care, but I do know that I think that physical and psychological care should be a human right, denied to no one.

    I do think that in a system with limited resources, it is legitimate to debate where we’re going to put them. Which is not to say I think that trans people should be denied needed care – I just am not informed enough to know where the line should be drawn between what’s needed and what’s wanted. I had a breast reduction at 18 that was covered by insurance due to my back pain, and I’m extremely glad I did. It was certainly medically indicated and not primarily cosmetic, though it also had beneficial psychological results. However, in a single-payer system, I could understand if that was not deemed as necessary as hospice care for the elderly or exercise programs for children etc. etc.

    So, while I don’t know how we as a society should decide how to best use our medical resources, I do believe that whatever we decide is necessary and important should be available to everyone, regardless or age, ability to pay, or moral status.

    Bah, I feel like I’m making very little sense. Sorry my comments are so disjointed.

  15. July 9, 2007 at 12:25 pm

    Thank you for giving this such a thorough analysis. It’s a complicated issue, and you’ve given me a lot to think about in terms of this – this does seem to all go back to those problems of rethinking our goals of medical coverage and what constitutes necessary care.

    I’m not sure that I can contribute usefully to the discussion here, but I wanted to thank you for bringing this to our attention.

  16. Tom
    July 9, 2007 at 12:36 pm

    How is this a distracting discussion?

    It’s an exceedingly abberant case that hits every hot-button issue from univeral healthcare, to prison reform, to gender/sexual politics and cosmetic surgery. The only way it could be more inflammatory is if she were a black muslim and had murdered an underage white girl.

    This is the type of case that people, particularly the right wing, love to point out as emblematic of whats wrong with socialized medicine and univeral healthcare. And the upshot is that they always advocate tossing out the baby with the bathwater; that if we get healthcare, we’ll all turn into transgendered murderers.

    From what I understand, nearly a third of the population has no insurance. Hell, I work a shitty job in the medical industry and I have no insurance. Whenever I hear about these types of cases I always get the impression that the purpose is to remove the benefits from people like Kosilek, rather than provide for the population at large.

    To clarify, I’m not criticizing Holly for this post, I assume that it is as much about the debate surrounding Kosilek as much as it is the case itself.

    To answer the post’s title question…

    Who deserves health care?

    Everyone. However despicable a person Kosilek is, shouldn’t distract from the basic injustice of the current system.

  17. July 9, 2007 at 12:41 pm

    That may well be, but far too often trans people and our concerns are called “distracting” (from the “real” issues?) and uh, “aberrant”.

  18. July 9, 2007 at 12:47 pm

    You’re making lots of sense, Betsy.

    If we assume that medical care isn’t an unlimited resource, we as a nation have to decide how to decide who gets access to what. Right now, that rationing is mostly based on ability to pay, but if it’s not going to be based on that, it’ll have to be based on something else.

    Basing it on the relative necessity of various procedures in various circumstances makes sense to me, and I don’t claim to know where various transitioning treatments should fall on such a scale.

    I don’t think it’s enough to say that trans healthcare is “medically necessary,” period, or that the decision should always be left up to an individual doctor. It seems to me that it’d be legitimate, for instance, for policymakers to draw distinctions between procedures that are central to transition itself and those that are consider elective and cosmetic within the transition context.

    What doesn’t make sense to me is making medical decisions on the basis of the moral worth of the patient. If a person is under the control of the state, the state has responsibility for that person’s healthcare, it seems to me, and the state has no business saying that a mild-mannered tax cheat should get better care while in prison than a brutal murderer, or that someone in prison should get worse care than someone institutionalized for mental illness.

  19. Tom
    July 9, 2007 at 1:13 pm

    That may well be, but far too often trans people and our concerns are called “distracting” (from the “real” issues?) and uh, “aberrant”.

    I used “aberrant” deliberately, though perhaps not clearly; as far as I can tell, the number of trans people who murder their wives and then get extensive surgeries on the public tab are approximately one (1). I’m assuming this is an aberration even in the transgendered community. So now, “transgendered” and “healthcare” get gleefully conflated with “murderer” and “prisoners getting electrolysis.” Or as Holly put it…

    Seems to me that Kosilek’s case has been the nexus for a whole bunch of different knee-jerk reactions about health care, prisoners, and trans people.

    The transgendered community is not served by this discussion because there’s too much crossfire, too great a likelihood of pandering to bigotries and the basic structure of the argument is “should healthcare be taken from Kosilek” and not “should healthcare be universal.”

    This discussion ends two ways:

    1) Kosilek gets denied healtcare along with one third of the population
    2) Kosilek receives healthcare despite one third of the population being uninsured.

    This is classic divide and conquer. However this case turns out, it will have virtually no effect on the population at large. Which most likely includes large portions of the non-murdering transgendered community.

  20. July 9, 2007 at 1:18 pm

    I agree with babygirl above — “prisoners do deserve health care, but I think allowing this woman to get free electrolysis and a sex change is a bit much. I’d say she deserves whatever medical treatment will keep her physically healthy, but that’s it. I am sure there are plenty of people in prison right now who would benefit from talk therapy who don’t get it.”

    I don’t really know why anyone who believe in universal healthcare would take up this cause, because as tom noted above, catering “to the most exceptional, unlikely, outrageous and non-representative cases” will sour people on the notion of funded health care as a whole. this is NOT a case people will ever get behind, nor should they, really. the government has a responsibility to make sure people in prison stay healthy, not get any elective procedures which they choose, even if there is a medical basis hook you can pin them on.

    and the argument over whether this woman is “despicable/repugnant” or not and whether that is a basis to deny health care seems to me like a deliberate attempt to be distracting, because no one is saying her murderer status should prevent her from recieving basic health care. making the argument that this is NECESSARY and then somehow trying to conflate people saying it’s not with people trying to cherry-pick who is deserving of any healthcare just conflates the issue.

  21. July 9, 2007 at 1:33 pm

    However this case turns out, it will have virtually no effect on the population at large. Which most likely includes large portions of the non-murdering transgendered community.

    This is not true. If her surgery is deemed medically necessary (as it apparently has been), it could be used by other trans people to challenge the exclusion policies of their private health insurances.

    I also don’t understand how, if they’ve deemed her electrolysis and hormones medically necessary, surgery wouldn’t be. clearly that would only be based on cost–which is a really bad indicator of whether something is medically necessary!

    i have private insurance through my partner–private insurance with a clearly detailed exclusion policy towards anything considered sex-reassignment related. I continue to watch this case with interest.

  22. July 9, 2007 at 1:54 pm

    Oddly enough, this is making me think about the grocery store strike we had here in Southern California a few years ago. Most people were supportive of the strikers (I only crossed one picket line, and that was a menstrual emergency), but there were occasional grumblings of, “Why should a grocery store clerk get health insurance when I, a white-collar worker, doesn’t?”

    And that, to me, is the saddest thing about our current system. We’ve been pitted against each other so successfully that we begrudge health care to people we think don’t “deserve” it, whether those people are grocery store clerks or murderers.

  23. July 9, 2007 at 1:55 pm

    Heh. My hypothetical white-collar worker has really bad grammar. “Don’t,” not doesn’t.

  24. Tom
    July 9, 2007 at 2:12 pm

    If her surgery is deemed medically necessary (as it apparently has been), it could be used by other trans people to challenge the exclusion policies of their private health insurances.

    You’re right, of course. I think I originally meant to write it wouldn’t effect the uninsured population. Although at this point, I don’t remember. Damned heat.

  25. July 9, 2007 at 2:25 pm

    Wow.

    It’s posts like this that make me feel fortunate to live in the UK. Access to decent health-care for all people is just unquestioned here, even our scary red-top papers only harp on about it rarely and then are roundly ignored.

    Why should any person, however they have acted, be denied a basic human right? An eye for an eye? Revenge?

    And as for the whole prisoners-get-better-healthcare-than-us thing…

    What’s the name of that English Gitmo prisoner, the one who is imprisoned for praying in the same Mosque as someone else who was imprisoned, who has been denied access to diabetes medication?

  26. eastsidekate
    July 9, 2007 at 2:30 pm

    Mnemosyne: And that, to me, is the saddest thing about our current system. We’ve been pitted against each other so successfully that we begrudge health care to people we think don’t “deserve” it, whether those people are grocery store clerks or murderers.

    I think this brings the tread back to one of Holly’s original points. There are too many debates on access to health care framed in terms of:
    1) the number of people the case will impact
    2) the perceived necessity of the treatment
    3) the perceived morality of the treatment
    4) the perceived morality/worthiness of the patient

    The Kosilek case is one where some people (certainly folks on the right) argue that providing doctor recommended health care is a losing proposition on all four counts. Certainly, this reasoning is common, even among queer people (note the constant struggle for domestic-partner health care benefits, which tends to overlook insurance for trans-medicine, or for other uninsured people).

    Within the context of our current health care system, reviewing these four factors is completely ethical. The problem is, that assumes that our current health care system is the only option available. The only way I see out of this moral dilemma is to give everyone access to health care.

  27. SarahMC
    July 9, 2007 at 2:30 pm

    Does anyone know why healthcare coverage got tied to employment in the US? Or when?
    It’s very troubling to me that one’s job determines his/her access to affordable (or not-so-affordable) healthcare. It’s one of the reasons Universal Healthcare is so appealing to me.

  28. belledame
    July 9, 2007 at 2:32 pm

    It’s posts like this that make me feel fortunate to live in the UK.

    Told y’all.

  29. belledame
    July 9, 2007 at 2:33 pm

    Sarah: Moore goes into the etiology of HMO’s a bit; basically he lays the blame at the feet of Nixon. there’s still a question of what U.S. health care was like -before- that. i’d meant to look into it.

  30. Thomas
    July 9, 2007 at 2:35 pm

    Sarah, it was our post-WWII decision to outsource our welfare state to private enterprise on the assumption of permanent, lifetime industrial employment. Because that would make us different from the damned communists.

  31. Aliem
    July 9, 2007 at 3:37 pm

    Call me simplistic, but it’s my understanding that prison is a punishment of confinement, not a punishment of torture.

    Denying health care to a prisoner for any reason is condoning further punishment. This is the same argument people use to ignore prison rape: “hey, they’re in prison, they deserve whatever they get.”

    If a prisoner is going to be punished past confinement, let’s be honest and upfront about it with phrases like: “I sentence you to six years in prison, with a minimum of thirty instances of rape and seventy beatings.” and ask ourselves “How much violence is enough to inflict on a prisoner?”

    The fact that she’s trans asking for trans-specific health coverage is nothing more than flashpoint sensationalism designed to appeal to the most mean-spirited bigoted traits in all of us. It is irrelevant what sort of medical care she needs. That decision is hers and her doctor’s.

  32. July 9, 2007 at 4:08 pm

    It’s posts like this that make me feel fortunate to live in the UK.

    Told y’all.

    *Facepalm*
    Switch brain on before saying something. I need to go check on the hamster upstairs, I think. I kinda forgot to feed him over the weekend and he just dropped off the wheel…

    Sorry about that…

  33. AB
    July 9, 2007 at 4:14 pm

    Sarah–

    Basically, during WWII employers were very limited in their ability to raise wages to attract workers. Instead, companies began competing on fringe benefits, which were not subject to rationing and high marginal tax rates. One particularly clever company during that time wrote the IRS inquiring whether employer-paid health insurance would be considered part of wages (and thus taxable) or a fringe benefit (and thus non-taxable), and the IRS decided that health insurance benefits were the latter. Voila! Employers could offer something of value to attract workers without having to pay Social Security or other taxes (so ironically, people against reforming the health care system are pro-welfare for white collar workers, who currently receive subsidized coverage through the tax system).

    For a long time, this model worked out really well for companies, who got to dodge some taxes by basically paying their workers in other services or goods (health care, pensions, etc). Now that we’re living in a more globalized economy, this doesn’t work so well. (See GM or any of the legacy airline carriers for good case studies of how it really doesn’t work when your competitors aren’t facing those same legacy costs.)

    However, even though companies are starting to come around, there’s still the question of what the heck we replace this system with. In some ways, I think the comparison to European countries is invalid–it’s kind of like pointing to a successful school district in Vermont and arguing that it should be implemented in NYC. The context, history, and population are totally different, and the solutions don’t transport neatly from one place to another.

  34. evil fizz
    July 9, 2007 at 4:25 pm

    Does anyone know why healthcare coverage got tied to employment in the US? Or when?

    The Internal Revenue Code! In the WWII era and after, there were some significant limits on wages. In order to provide perks for employees who weren’t going to get higher wages, employers offered benefits (as we know know them) instead. Health insurance is a tax-exempt expenditure for employers and employees don’t owe any income tax on it.

  35. Betsy
    July 9, 2007 at 4:25 pm

    Thanks, Brooklynite, for explaining very clearly what I was trying to say!

  36. AB
    July 9, 2007 at 4:31 pm

    And, apologies for the second post, but I think this post just so starkly shows the looming issue for progressives who want universal healthcare: who is going to run this system? I’m totally in favor of reforming the insurance market to open up insurance pools on a different basis than a job; subsidizing/paying for said insurance through progressive taxation; and mandating certain standards of care that all insurance companies have to meet. But it seems that these discussions so often implicitly rely on the idea that we’d all be better off under a single-payer system run by the government (a la the European countries, because insurance companies are TEH DEVIL), and I just have to think that as scary as the prospect of that is for me as a woman, it must be twice as threatening to transpeople.

    If Medicaid is any indication, single-payer universal healthcare will not be including abortion, and probably won’t cover the pill. (I’m *so* looking forward to the Brownback Amendment, let me tell you.) The idea that a healthcare entity run by the same cast of characters that are currently in power would cover the medical costs of transitioning seems… unlikely, to me. Like Betsy pointed out above, someone is going to need to make those unpopular choices about where we draw the line for coverage, because as much as it sucks, resources ain’t infinite. Is there any reason to think that the government is a better decision-maker than insurance companies? How do we figure it out so that the least politically-popular groups don’t end up with the short end of the stick, yet again?

  37. July 9, 2007 at 4:35 pm

    Jumping in, for just a moment, to add some to this bit:

    There has never been a shortage of cultural prejudice and exploitative shock to help insurance administrators out with denying trans health care; it’s often mentioned explicitly in insurance policies, in terms like “any treatment related to change of sex is excluded.” Go check your own policy, and see what kind of creeped-out language some bureaucrat wrote in. to foil us devious trans people from getting any monetary assistance whatsoever!

    My health insurance policy, at a progressive-aligned workplace, in fact words the ‘no trans-related care’ clause in such a way that technically, any claim I make could be denied–any illness could be claimed as related to my being on hormone therapy, and bang, no coverage. A routine checkup at the doctor could be railroaded the same way. In their zeal to not pay for any surgeries I may ever have, they actually worded it so thoroughly that I’m essentially, but for blunt-force-trauma accidents, uninsurable.
    To add insult to injury, they categorize transgenderism as a ‘paraphilia.’ That is, a disordered sexual obession like compulsive necrophilia, pedophilia, or bestiality. Whee! I don’t believe that’s actually even complain with the current DSM standards, in fact.

  38. July 9, 2007 at 4:47 pm

    I don’t know if they have an official policy, but I have heard of people on medicaid who have had hormone medication, blood work/labs, therapy, and surgery paid for. I don’t know how medicaid works, but i feel some of the discrepancy must be a state-by-state thing.

    A big part of the problem is how the trans-care giving establishment has conceptualized and codified transsexuality.

  39. July 9, 2007 at 4:49 pm

    In my moderated post, that last ‘complain’ should be ‘compliant.’ Hit the button too soon. Anyhow, the point is, those prejudices can operate in such a way that the companies aren’t even complying with current medical diagnostic standards, and get away with it because who’s going to stick up for covering a sex change, heavens-to-Betsy-fer-Pete’s-sake?

  40. nausicaa
    July 9, 2007 at 4:53 pm

    Here’s a way to look at it: if there was universal health care, do you think A) it should extend to sex change operations; or B) sex changes are elective surgery that you should pay for yourself even if there is universal health care?

    If the answer is B (elective surgery), then a prisoner has no rights to a sex change. She gave up the right to elective medical care when she committed her crime and lost her liberty to earn her own extra wages to pay for her optional health care. If the answer is A, then the prisoner must get the sex change because it’s part of the basic standard of medical care.

  41. belledame
    July 9, 2007 at 5:05 pm

    I vote A.

  42. July 9, 2007 at 5:08 pm

    I do think that trans health care should be covered like any care. I think it’s important to note, however, that–regardless of what Michael Moore implies with his little boat-to-Guantanamo stunt–prisoners in America have shitty, shitty health care. Prisoners are frequently denied access to health services, treatment for HIV and Hepatitis C (which they may even contract in prison–a five year sentence can become a death sentence, especially when left untreated), etc.

    All of this, “But she is a murderer” excuse is bullshit. If a traditionally-gendered murderer would have access to health care, why should a transgender murderer be denied that access?

    But it’s faulty to pretend that prison health care in the US is competent or adequate.

  43. July 9, 2007 at 5:12 pm

    Do we really have to say “sex change operation” here? (it’s a misnomer, anyway.) Genital reconstruction surgery is a little less sensational, I think.

    If a universal health care system in the US paid for the medical needs of trans people, we certainly wouldn’t be the first to do this. The UK covers trans medical care under their NHS. Canada does as well (as i think was mentioned), though available procedures vary by province. I believe South Africa covers certain procedures as well.

  44. July 9, 2007 at 5:21 pm

    Another reason that trans inmates NEED medical treatment relates to the fact that prison is a highly gendered place–men and women are separated. In many–if not most–cases, an MTF person would be put with men and an FTM person would be put with women…unless they had undergone genital surgery, which increases the small likelihood of being placed with inmates of a similar gender identification as oneself. It is hard enough–punishment enough–to be in prison without also having to give up one’s identity. Too often it’s not about “you can be yourself, you just can’t have this elective surgery.” It’s about being completely stripped of self.

  45. July 9, 2007 at 5:21 pm

    I don’t know if they have an official policy, but I have heard of people on medicaid who have had hormone medication, blood work/labs, therapy, and surgery paid for. I don’t know how medicaid works, but i feel some of the discrepancy must be a state-by-state thing.

    Medicaid is administered on a state-by-state basis, but in accordance with federal guidelines. There are a lot of trans people around the country who have had various kinds of medical care covered — including hormones and even surgery. But this stuff is tenuous at best, and there’s definitely no guarantee that Medicaid will cover trans health care. I believe there are some legal challenges to Medicaid going on around this too — fighting for poor trans people’s right to coverage. This is an even simpler parallel than Kosilek’s in some ways, since it subtracts out the sensationalistic murderer/prisoner part — would you support a suit brought on behalf of a poor person in order to get Medicaid to cover trans health care, when people who have health insurance can’t get it covered? Again, it illustrates the completely bogus nature of our whole system.

    And yeah, nausicaa: claiming that surgery is “elective” has been the tactic used by the government to deny coverage in pretty much every single one of these cases. The real question boils down to, who are you going to let make this decision, about elective vs. necessary? The judge in Lopez’s case consulted with experts and learned about trans health care, and concluded it’s not elective. The only experts that the state of Massachusetts has been able to dredge up are from the only center providing trans health care that now opposes such health care, which shut itself down 30 years ago after abusing hundreds of trans people. So who, exactly, is qualified to make this kind of decision?

    Is Brooklynite’s suggestion really the right answer?

    I don’t think it’s enough to say that trans healthcare is “medically necessary,” period, or that the decision should always be left up to an individual doctor. It seems to me that it’d be legitimate, for instance, for policymakers to draw distinctions between procedures that are central to transition itself and those that are consider elective and cosmetic within the transition context.

    When confronted with the opinions of experts, people who have been providing health care for trans people, international organizations of doctors and other professionals who set standards about these things, policy makers have had two reactions: they either end up agreeing that some trans health care is medically necessary and not elective (including genital surgery, but not necessarily stuff like electrolysis and facial surgery). Or, they do their best to ignore it — and it’s not hard to understand why. No elected official wants to go down on the record as supporting sex changes, not in this country. Like little light says.

    What doesn’t make sense to me is making medical decisions on the basis of the moral worth of the patient.

    And yet that’s exactly why trans people, specifically, are excluded from health care coverage in both the private and public sectors.

  46. AB
    July 9, 2007 at 5:24 pm

    Jay, I think the real question is not whether it would make sense economically to cover these procedures–obviously, other countries have looked at it and decided that the care is needed and should be covered–but whether the U.S. *would* do so, given where we are now.

    I’m not convinced that medical care has anywhere been quite as politicized as it is in the U.S. And that means that other countries with single-payer healthcare can have these wonderful systems where a bureaucrat sits in the back room and makes clinical, dispassionate decisions about what to cover based on current medical evidence, and as much as that sounds fantastic, I think it’s very dangerous to assume it’d work out like that here. I mean, geez, federal Medicaid funding is disallowed for all abortions unless not having one will kill you, despite the fact that forcing women to have babies if they’re not really ready or able ends up costing tens of thousands of dollars more. That’s ideology trumping medicine and rationality, because we have a political climate in which it’s okay to kick the politically unpopular via the healthcare system. I would not be overly hopeful that transpeople would be treated much better under such a system.

  47. July 9, 2007 at 5:27 pm

    One last comment!!! Then I am truly done!

    All of these arguments (in the comments of this post!) from trans people that “I don’t get my electrolysis covered, so a person in prison shouldn’t either” are so fallacious. The same argument has been made about cable tv–which, granted, is not medically necessary. Prison is not a luxury resort where all’s well, folks!

    Just because I spent years hungry and on the streets doesn’t mean I think that prisoners should be denied food and have to sleep outside. Come on.

    Let’s start talking about human rights for all people instead of the other way around. It seems like we have to fight each other for slim pickings, but we can change shit if we work together.

  48. July 9, 2007 at 5:33 pm

    I would not be overly hopeful that transpeople would be treated much better under such a system.

    Much better than what though, AB? Right now, only a tiny fraction of trans people are covered for any kind of trans-related health care under private insurance.

    The rest are either not covered at all (like me, and most of the other trans people commenting on this thread) and have to pay out of pocket, or are already covered by poorly-run, “kick the politically unpopular” government-operated coverage like Medicaid. Or whatever a prison system decides to allow, or a foster-care system, etc.

    Trans people find ways to get health care anyway because for many of us there’s just no other viable choice. Those of us that aren’t rich (and trans people are disproportionately poor, jobless, and homeless) either find ways to sneak coverage through private or public bureaucracy, or we scrimp and save, or get loans from our families if we’ve been lucky enough not to be rejected. Or for some of us, we turn to survival crimes like prostitution in order to make enough money to pay for health care.

    Not everything is perfect in the UK or Canada, where trans people can get government-operated trans health care. It’s been an uphill battle to get those little bureaucrats in their tiny rooms to put various kinds of trans health care on the list. And then it’s often an individual battle to get through the gender clinics and assert that yes, you do in fact need this controversial, much-maligned, scandalous kind of care. But it’s still better than what’s going on for poor folks in this country.

  49. Tom
    July 9, 2007 at 5:52 pm

    I think people might be more open to the idea of Medicade-funded trans-procedures if there were universal coverage in the first place. As it stands now, the stress, expense and difficulties of the system predispose people to dig in their heels on something like this.

    The philisophical/biological identity issues behind the transgendered are difficult to wrap your head around (or at least mine) and you’re not going to want to bother if you’re in a situation like the woman who lost her son to a tooth infection.

    I hope I didn’t derail the thread earlier. I didn’t intend dismiss the necessity of transgendered healthcare; I was trying to say that in a system where healthcare is not the default, a procedure which most people call a ‘sex change’ is going to be a sticking point that will be exploited by healthcare opponents.

  50. AB
    July 9, 2007 at 6:40 pm

    Much better than what though, AB? Right now, only a tiny fraction of trans people are covered for any kind of trans-related health care under private insurance.

    To be more specific: under an alternative vision of universal healthcare. Perhaps it’s the optimist in me, but I really believe we’re going to start to see some serious movement on the idea of universal healthcare during the next election, and I simply want to point out that the alternatives are more than the current crappy system of only being able to access (tax subsidized!) health insurance through white-collar jobs, or the European/Canadian model of state-run, state-controlled single-payer healthcare.

    Much as Michael Moore has done a great thing by making the movie Sicko and drawing people’s attention to the healthcare crisis, I just can’t help but point out that the straight white male perspective on what healthcare reform should look like might have some gaps in understanding large enough to drive a truck through. Like, how much thought has someone like Michael Moore put into who makes the decision about what’s covered, and who might get shafted under that? What are the dangers we need to pay attention to, based on our knowledge of how this has worked with Medicaid or Tricare or the Indian Health Service or any other healthcare program run by the federal government over the past 30 years?

    I don’t mean to hijack this thread with a boring conversation about the details of universal coverage, but it seems so clear to me that feminists and gays and transpeople need to be thinking about these things and talking/debating these things NOW, when there’s still a chance for the debate to really move in any direction, and not to let guys like Michael Moore (bless him, but he’s myopic on certain issues) make these decisions for us.

  51. July 9, 2007 at 8:53 pm

    I was hesitant at first, but you swayed me. Moral consistency benefits the whole of society, not just specific individuals. In the interests of recognising the wide variation of people who would are affected by universal health care we can’t get sidetracked, stopping to pick and choose who deserves it and who doesn’t, denying it to all because a few unsavory folks would benefit as well. It’s like cutting off the nose to spite the face.

    We need a universal health care system if we intend to remain a major player on the world stage; to allay our slow, agonising slide into despotism.

  52. Deanna
    July 9, 2007 at 9:58 pm

    Universal health care in Canada is not state controlled. Yes, there are laws and regulations, just as there are anywhere, and hospitals may be publically owned (or a public-private partnership) but doctors work for themselves and bill the government (although there is a cap on what they can charge for various services).

    What we have is a [i]single payer[/i] system. The single payer being the government, of course.

    You know how employers can get lower prices from insurance companies because they are insuring a lot of people? Well, we get a better rate because we’re insuring the whole damn country. (In essence, anyway.)

    We’ve got public auto insurance in some provinces too – helps keep insurance rates and profits at a reasonable level. Plus, the insurance profits get plowed back into services – like funding seatbelt or anti-drunk driving education. (Or, in election years, refunds to automobile owners.)

  53. libber
    July 10, 2007 at 2:05 am

    Universal health care in Canada is not state controlled.

    Exactly. If only most of my fellow Americans weren’t so ignorant about universal heath care. That’s at least part of the health care problem in America. Sad but true. the majority really believe ‘universal health care’ means poor care by second-rate doctors which will cost you a lot of tax money and which is available only on an on and off basis (because of waiting lists). Yeah yeah I know, it’s kinda off the topic. But that sort of ignorance makes me so fucking angry.

  54. July 10, 2007 at 3:08 am

    this discussion, i think, boils down to how we define “medically necessary”, and who gets to make that decision.

    in a case where someone has a bleeding open wound, i think most (if not all) of us would agree that it is a medical necessity that the wound get stitched up, the bleeding gets stopped, and that pain relievers, if necessary (there’s that word again) are administered.

    many medcial conditions are not so clear.

    the therapist who treated me during transition likened the medical necessity of transition for someone like me to someone with osteoarthritis who requires arthroplasty (hip replacement surgery). in this kind of medical condition, arthroplasty is indicated when their pain and decreased mobility “interferes with daily activities despite treatment”.

    i’d argue that the degree of immobility and pain that cause an interference with daily activity is contextual. is someone in prison faced with the same interference in their daily activities when suffering from gender identity disorder (or whatever they’re calling it these days) as someone on the outside? at what level is pain considered an interference with daily activities? and how do we measure the level at which the interference of daily activites indicate treatment?

    in the case of hip replacement, i’d argue that if ones pain prevents them from getting out of bed and using the restroom, then replacement is indicated. or if they are unable to get into their car and get to work. are the same parameters valid in the context of prison? and if the arguement is that prison is gendered, would moving trans inmates from gendered space be enough?

    the degree of evaluation experience with hip replacement is rather common when compared with gender identity disorder. part of the problem, i believe, is that transgender people span a wide range of symptoms and treatments. most (some estimate 90%) never have a “sex change operation”. many never have electrolysis. and some never use hormones. these treatments are most often “prescribed” based on the aflicted individual’s self assessment. there are very few physical tests to offer as evidence that these treatements are necessary, unlike hip replacement. a crumbling bone, visible in an x-ray, does wonders for “proving” that surgery is necessary.

    there are no such tests for the degree of transness from which an individual suffers.

  55. Aliem
    July 10, 2007 at 3:46 am

    nexyjo wrote,

    there are no such tests for the degree of transness from which an individual suffers.

    Admittedly, this is sort of a doozy. There are no objective tests because being trans is an entirely subjective experience, as you point out.

    That being said, how does one draw that line? Do we use a pain scale? Subjectively assigning numbers as medical diagnosis works there. Are only people (for example) who suffer at 7 or up to be covered? 6s just need to suffer at 6 and if only they hurt a little tiny bit more they’d be eligible?

    Rather than even try for that sort of test, ‘twould be easier to simply allow the patient and doctor to make the decision. I’d also say the same about your hip replacement scenario; if the doctor and patient agree that it’s for the best… who is anyone else to judge?

    And in this perfect world where American transpeople have relevant health insurance, I’d also like a pony.

  56. July 10, 2007 at 3:49 am

    most (some estimate 90%) never have a “sex change operation”.

    I’d be interested in seeing where a statistic like that comes from. Thing is, no matter what we call it, there isn’t one surgery for either mtf folks or ftm folks that could be considered “the sex change operation”. Not to get gory or overly detailed, but some states require lower/genital surgery to get birth certificates changed, some seem satisfied with chest reconstruction for ftms (if it’s called “irreversible sex reassignment surgery” or something), some seem more interested in reproductive sterility via surgery…some won’t change a birth certificate for anything. I know the birth certificate correction isn’t the be-all end-all, but it’s some sort of measure.

    Even genital surgeries…for trans women there seems to be a standard procedure that varies by surgeon….for trans men there’s at least 3-4 separate types of sex reassigning genital reconstuction.

    Am I getting off topic?
    I also think cost is a huge barrier in those that have to pay out of pocket. Clearly.

    Yet another facet to just the trans health portions of this…would out of country surgeries be covered? Because from my perspective, the best genital surgeries for trans men are currently evolving in Europe.

  57. pwll
    July 10, 2007 at 5:16 am

    All trans women and men, in prison or not, should have access to some level of funded trans-related medical treatment. The fact that they don’t means complications like this case and others do arise.

  58. AB
    July 10, 2007 at 12:14 pm

    Universal health care in Canada is not state controlled.

    Someone is always, in any system, making decisions about what procedures, under which conditions, qualify for coverage. In the United States, our health care is controlled by insurance companies (subject to state and federal law) and by doctors, if you can pay out-of-pocket. In a single-payer system, the single payer controls what they’ll pay for. If you don’t like their decisions about what is covered, then you’re either (1) out of luck, or (2) potentially able to lobby the government to change the policy. If you don’t like what your insurance company decides they’ll cover, you can (1) switch insurance companies, if you are able to get coverage elsewhere; (2) lobby the company, either through their appeals process or through public relations pressure; or (3) lobby the government to change the laws relating to insurance coverage.

    The heart of the issue is exactly what nexyjo said:

    this discussion, i think, boils down to how we define “medically necessary”, and who gets to make that decision.

    With transgenderism, there’s so much bigotry and misinformation out there already, I think we do well to consider whether we’d rather have the decisionmakers be the federal government or a multitude of individual insurance companies (in the context of universal coverage, of course). Neither one is totally palatable, but I think there’s an argument to be made that at least with a bunch of insurance companies, you’d probably have at least a few start popping up that would offer services to transpeople, particularly if you had high-profile advocacy groups (e.g., HRC, NOW) start to apply pressure. As has been pointed out time and again, insurance companies are largely amoral, and that may be a good thing if the alternative is the “family values” morality that keeps getting voted into Congress.

  59. Ursula L
    July 10, 2007 at 2:44 pm

    And it’s not a zero-sum game. Whether I have health insurance shouldn’t be contingent on whether some murdering lunatic also has healthcare.

    It shouldn’t be a zero sum game. But in the context of a prison’s budget, if they have X amount of dollars budgeted for health care, how much would this surgery cost, and what might be the trade off? A court order that orders this treatment, without finding funding, might mean that the prison has to dip deeply into medical funds for this one treatment at the expense of a lot of other prisoners.

    Medically necessary/unnecessary isn’t a binary definition. There are the things where you need immediate treatment or you’ll die, the things where you need immediate treatment or you’ll be permanently injured/crippled, the things where you need reasonably prompt treatment to avoid long term consequences, etc. A continuum. This falls somewhere between, say, surgery for a ruptured appendix (surgery now or your dead in less than a week) and non-reconstructive elective plastic surgery (may improve quality of life, but no significant consequences for not getting it done in most cases.) Exactly where, I’m not sure.

    Whether a prison budget should cover this depends in part, I think, on how well the budget is covering other medical needs. We know prison budgets are stretched just to meet the immediate life-and-death problems. If it’s a trade off between this and other care of the same urgency, that’s one thing. If covering this cuts into care for significantly more urgent conditions, it’s not as reasonable to make the trade.

    The state’s spent an awful lot of money fighting this. If there was some way to look ahead to the money spent for legal costs fighting “unnecessary” treatments and transfer it to health care, it would be ideal. On the other hand, if they spend dollars budgeted for medical care in prisons on things like this without suitably increasing the budget, it may become more of a situation where something potentially high profile and dramatic gets the attention, in order to avoid controversy and the press, while routine but perhaps more urgent needs are neglected.

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