It's debatable if the fiduciary standard is 'higher' than suitability. But the better question might be, who's holding the bar?
Transgender Americans have won major victories in the past year as bans on coverage for gender-confirming surgeries were overturned in five states, in Washington, DC, and federally in the Medicare program. It is time for Washington State to follow suit. These decisions signal an evolution in thinking about gender dysphoria-a medical condition in which patients know their gender to be other than the one they were born with. Nearly every major medical body, including the American Medical Association, has come to describe therapy, hormones, and, for some, surgery as a medically necessary step toward helping transgender individuals lead healthy and happy lives.
But the opposition is fierce-and sometimes vicious.
I recently attended an administrative hearing on removing transgender health-care exclusions in state insurance plans. A dentist sitting on a panel of health-care policy makers who will determine covered benefits asked me how gender dysphoria wasn't like "giving people who want to amputate their limbs access to amputation." I explained that gender-confirmation surgery is "reconstructive, as the end results are functional and healthy." He was not sold, although he later admitted, "The idea of it-just the idea-scares me."
He's hardly alone. Family Research Council president Tony Perkins wrote in the Christian Post this month, "Americans are free to disfigure their bodies-but they aren't free to ask taxpayers to foot the bill." He argued that while transgender people enjoy expensive cosmetic surgeries on the government's dime, veterans were dying for lack of care.
Despite what that dentist or Perkins may think, these interventions help save lives and tax dollars.
According to a study from UCLA'sWilliams Institute that came out this year, 41 percent of transgender people nationally-and 45 percent of transgender Washingtonians-will attempt suicide at some point in their life. Opponents to coverage argue that procedures such as genital reconstructive surgery, mastectomy, and hormone therapy are cosmetic in nature and therefore should not be eligible. But a growing body of research from all over the world has shown that these treatments greatly reduce those suicide rates.
Studies in the Netherlands and Belgium show reduced attempted suicide rates among transgender people after they receive medical assistance: a drop from 30 percent to roughly 4 percent in one study, and 32 percent to 2 percent in another.
Those are better rates than many other mental-health interventions. For example, 20 percent of people with untreated major depressive disorder will attempt suicide, and that drops to only roughly 8 percent even with therapy and antidepressants.
These aren't just abstract statistics for me. During my own transition as a 15-year-old in Portland, Maine, in 1997, this sort of intervention helped save my life. Living in a rural state where there were no physicians nearby who knew how to prescribe cross-gender hormones, I felt desperate and frequently contemplated suicide. I was fortunate to have supportive foster parents who connected me to a psychologist who had recently moved to Maine from Chicago. Dr. Bill Barter helped my primary-care doctor walk through a very slow and age-appropriate gender transition. I credit that experience with saving my life after a suicide attempt only months before when I felt there was no way out.
After coming out as transgender and finally beginning to see myself in the mirror, I felt a huge sense of relief and happiness. I felt free to make close friends, as I was finally living an authentic life. I had nothing to hide. Since the late 1990s, I have worked with thousands of other transgender people as a therapist, activist, and social worker. I have seen my story repeated by countless people.
Beyond being effective, these types of interventions are also incredibly inexpensive when considering the alternatives (suicide attempts, ER visits, lifelong therapy, and antidepressants that won't get at the root problem). Every analysis of the cost, from a UCLA study of the private sector to a California Department of Insurance study, has placed the expense at pennies per person per month-such as making up less than .002 percent of the University of California system's health-care costs.
One big reason transgender health-care exclusions continue to exist is a lack of public understanding, accompanied by a heavy dose of prejudice against transgender individuals.
While we have made huge gains, naysayers continue to ignore the irrefutable evidence provided by the medical and mental-health communities. For some individuals, just hormonereplacement therapy is enough, while others will need surgery to align their bodies with who they know themselves to be-but without a doubt, gender-affirming transition care is life saving.
So how do we end this debate now that the evidence is in?
Hormonal and surgical options must be made available to transgender people, just as they are to everyone else. Policy makers from the Washington State Health Care Authority to the state insurance commissioner must remove these arbitrary exclusions and allow transgender people and their doctors to make the case for the medical necessity of this care. Ultimately, we need to end the anti-transgender stigma that empowers politicians, health-care settings, and insurance companies to deny relatively inexpensive, lifesaving medical treatment.
45 percent of transgender people in this state will attempt suicide at some point. After transgender people receive medical assistance, suicide rates drop dramatically.
DANIELLE ASKINI is a social worker, writer, and activist. She is one of the founders of Gender Justice League.