The following is a paper I wrote as an MSW student at NYU in 2016
Policy Summary
In December 2014, Governor Andrew Cuomo announced that New York State’s Medicaid regulations would be amended to include coverage for expenses related to the treatment of Gender Dysphoria (previously referred to as “Gender Identity Disorder”) for transgender individuals. Gender Dysphoria is a condition marked by a conflict between the gender that one is identified with (by others) at birth and the gender that a person actually identifies as.
The move was prompted in part by a class action lawsuit filed in June 2014 challenging the blanket ban of all such coverage (Leonard, A. Transgender challenge to NYS Medicaid regs survives motion to dismiss. Gay City News, 7/9/2015). Under the new regulation, coverage would be available for anyone 18 years of age and older, and would cover expenses including Hormone Replacement Therapy (HRT) and Gender Reassignment Surgery (GRS),[1] but specifically excluded anything that was considered “cosmetic” and not “medically necessary,” and also excluded surgeries that would “result in sterilization” for anyone between the ages of 18 and 21.
The state removed the latter provision, based largely on the argument that by definition, any transgender woman undergoing GRS was being sterilized, and so all such individuals would be barred from coverage. As a result of a court ruling in July 2016 the exclusion of “cosmetic” procedures was also removed, but a trial will proceed to determine if the exclusion of individuals under the age of 18 is valid (Willkie, 2016), although the New York State Heath Department has issued a new proposed rule that would allow minors who are being treated for Gender Dysphoria to receive Medicaid benefits for pubertal suppressants and cross-sex hormone therapy (McKinley, J. For transgender youths in New York, it would be a health care milestone. The New York Times, 10/5/2016).
The basic human need at issue with this policy is, broadly speaking, the need to be able to feel “complete.” Individuals suffering gender dysphoria experience varying degrees of disconnect between their physical traits and how they feel mentally and emotionally. That disconnect can result in varying degrees of depression and sometimes leads to suicide attempts. There is a need here to address mental health issues, and to allow individuals to fully experience their own humanity.
The specific “item” to be distributed is health care service in the form of various aspects of gender reassignment services and procedures, including HRT, GRS, and other surgeries. The services are provided by health care practitioners and hospitals that provide service through Medicaid, and the funding comes from the Medicaid program.
The recipients are transgender individuals, age 18 or older, who desire these services (not all transgender individuals seek to “transition”). New York State estimates that there are over 600 individuals on Medicaid who have been diagnosed with Gender Dysphoria and estimate that the cost to the system would be approximately $6.7 million (Camponile, 2014).
Basis for Support and Opposition to the Policy
There are a number of intersecting morals and values underlying this policy. Perhaps the most fundamental is a question about what medical resources are people who are receiving government benefits entitled to? In a system of limited resources decisions about allocation are necessary, and some “worthy” recipients may be excluded.
Overlaying that entirely reasonable decision-making process are differing views about the very nature of being transgender. For many, including most medical professionals and organizations, it is an identity that often includes a diagnosis of Gender Dysphoria, a recognized mental health issue with clearly identified forms of treatment. The co-existence of Gender Dysphoria with depression is another reason for their support of this type of policy, along with the related decision by New York State to compel private insurance companies to provide similar coverage. This view is supported by many public officials, including New York City Council Speaker Melissa Mark Viverito and the Council’s LGBT Caucus, who referred to the procedures as “critical and lifesaving health care provisions for the transgender community” (Campanile, 2014).
On the other side are those who believe that being transgender is a mental illness, but not one that can be resolved through transitioning, or that it is simply made-up. Some may cover this hostility by focusing on costs, such as State Senator Martin Golden (R-Brooklyn) who suggested that the 10-year cost would more likely be $100 million rather than the $67 million set forth by the State, and simply dismiss the cost as an “inappropriate use of taxpayer dollars.” (Campanile, 2014). Or Westchester County Executive Rob Astorino, who suggested that Medicaid costs are already resulting in excessive property taxes and that “[p]utting taxpayers on the hook for sex change operations when they often struggle to pay for their own basic health-care needs is ridiculous” (Campanile, 2014). In some cases, the underlying hostility may be exposed by the use, such as with Executive Astorino and the New York Post headline, of the term “sex change operation,” a term that was discarded by the medical and transgender communities years ago as woefully inaccurate.
The intended consequence of the policy, as stated above, is the provision of vital health care services to transgender individuals who are covered under the Medicaid program. An unintended, though wholly expected, consequence would be the increased cost of the program that will likely result from the addition of new areas of coverage. Another unintended but beneficial (depending on your perspective) consequence may be that more transgender individuals will “come out” and begin exploring their own identity, possibly pursuing a transition.
Social Justice Issues
If “social welfare” is defined as “social interventions intended to enhance or maintain the social functioning of human beings” (Dolgoff, 2013) then the policy in question here surely qualifies. By definition “Gender Dysphoria” negatively impacts a person’s social functioning, an issue that can be alleviated if not completely ameliorated by the interventions covered under the new Medicaid standards discussed above.
I believe that as a matter of social justice, this policy is an excellent start, if not a complete answer. On its surface it will provide vital and lifesaving healthcare to people who very likely could not afford it otherwise. As Carl Camponile (2014) observed, GRS costs alone can be between $15,000 and $50,000. That’s an expense that would be hard for many people to afford, and completely out of reach for those who are dependent on the Medicaid program.
This is also another vital step towards “normalizing” transgender identity. By acknowledging the reality of Gender Dysphoria, and supporting the methods available to help many people who suffer from it, the State of New York is helping debunk many of the unfortunate beliefs held on the topic – that it is a mental illness, or simply made up. Both of these arguments were used in the past (and perhaps by some today) with respect to lesbian, gay and bisexual individuals as well to try to oppress those groups. As was the case for those groups, a very simple retort is “Who would choose this? Who would choose to be part of a reviled, oppressed group?”
One criticism of the policy from people supportive of the transgender community is based on the level of social control and to the extent that it seeks to engage in “Direct Behavior Control” (Cowger, 1974). Specifically, the policy sets forth requirements that a person must meet in order to be eligible for the benefit – including one year of HRT, one year of “living in the desired gender,” and two letters from two therapists, at least one of which must be from a Ph.D.-level psychologist or a psychiatrist, supporting the individual’s transition. These can be hefty burdens for individuals, especially those with limited means, to meet. They are largely based on the WPATH standards, a set of standards that is frequently a target of criticism, especially within the transgender community, as being overly-paternalistic.
Notwithstanding that criticism, the policy is an excellent step forward. Some of the criticism mentioned directly above is presumably mitigated by Medicaid covering the expenses involved (for example, it does cover HRT).
Cited References
Campanile, C. (2014, December 17). Medicaid to pay for New Yorkers’ sex-change surgeries. The New York Post. Retrieved from http://www.nypost.com
Cowger, C., & Atherton, C. (1974). Social control: A rationale for social welfare. Social Work, 19, 456-462.
Dolgoff, R., & Feldstein, D. (2013). Chapter 1. In Understanding social welfare: A search for social justice (9th ed.). Boston, MA: Pearson.
Willkie secures landmark victory on behalf of transgender Medicaid recipients in Cruz v.
Zucker. (2016, July 7). Retrieved from http://www.willkie.com
[1] Also referred to as Sex Reassignment Surgery (SRS), this is a blanket term for a series of procedures designed to correct the patient’s genitalia from male to female or female to male.
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