Transgender Vets Want Their Surgeries Covered

If we're going to publicly fund medical treatments, why should there be an exception here?


Credit: DVIDSHUB / photo on flickr

As the Obama administration and the Department of Defense try to hash out a plan to accommodate transgender members in the military, some ex-troops are demanding changes to the way the Department of Veterans Affairs (VA) handles their affairs.

The VA offers a host of medical treatment services to the military. Or at least it's supposed to, given the current scandals about its utter failure to properly care for its customers. While it covers the costs of treatment for counseling and hormone treatments that transgender veterans may seek, it currently does not cover the cost of the actual surgical treatment to alter the body.

The Transgender Law Center and Lambda Legal have filed a petition to argue that the VA should cover the surgery. They're making the argument on behalf of the Transgender American Veterans Association, which counts more than 2,000 members. Katy Steinmetz got the details over at Time:

In the petition, the legal team essentially makes four arguments. The first is that the V.A. already provides transition-related healthcare for transgender people, such as hormone replacement therapy and mental health services, so the ban is "arbitrary," says Lambda Legal's Dru Levasseur. (The V.A. issued a directive in 2011 indicating that staff must provide such care "without discrimination.") The second is that the V.A. covers the same procedures that transgender people are seeking, such as mastectomies, for non-transgender and intersex veterans. The third, says Levasseur, is "the V.A. created this exclusion without examining any relevant data," ignoring the "medical consensus" on the topic.

On that point, the legal team has gathered materials to point to, such as a statement from the American Medical Association that "an established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery" in treating people with gender dysphoria. That's not to say that every transgender person needs or wants surgery, and having had more surgery does not make someone more transgender, cautions the Transgender Law Center's [Sasha] Buchert, but those procedures can be "life-saving" for those who do want them.

They are also following the lead of the Department of Justice and arguing that refusing surgical treatment for transgender vets counts as sex discrimination under a particular interpretation of the Civil Rights Act. That interpretation is based on an expansion of a Supreme Court decision that ruled that discrimination on the basis of whether or not a person behaves according to certain gender stereotypes counts as sex discrimination. There are several federal court rulings that uphold an interpretation that it could also apply to discrimination against transgender people, but it currently lacks a final clarification from the Supreme Court. The fight in North Carolina between the governor and the Department of Justice over its transgender bathroom law could eventually get us there.

It is very easy to reach for an outcome where—if for no reason beyond simple acceptance of human, individual liberty—transgender citizens are perfectly welcome to pursue a surgical solution while at the same time not obligating taxpayers to cover everything. Making it "free" (or really, deflecting the costs onto other people) reduces the incentives for all parties involved to really, truly work through the issues and make sure surgery is the right solution. That sounds paternalistic, but we have ample evidence in the medical field already that professionals, in an environment where the patient is not the actual customer, are quick to order unneeded tests, drugs and treatments. It's unlikely that a transgender person is going to treat such surgery in the same vein as a patient getting an unnecessary EKG, but we should not ignore the changes in financial incentives that would be involved in subsidies. Furthermore, subsidies for gender reassignment surgery will inevitably drive up the cost of treatment. As a result, anybody who actually falls through the cracks might find it even harder to save up to pay for it on his or her own.

But there is another issue here, which is that Americans, regardless of political affiliation, have generally accepted and embraced publicly funded medical services to veterans as a benefit for those who have been willing to put their lives on the line for the sake of the country. And that promise has not typically been connected to illnesses or issues that are just the result of military service. That gender dysphoria is obviously not an issue caused by military service isn't relevant to the decision to not cover it. Rather, it has been lumped in with a disparate collection of uncovered medical procedures like abortion, plastic surgery (except when ruled "medically necessary"), and in-vitro fertilization.

The surface argument is that these are not "necessary" procedures, but clearly not everybody agrees, and by "everybody," that includes medical professionals. These are politically unpalatable medical procedures that some Americans don't want their tax dollars spent on. So, medical treatment for veterans has become a politicized process that either bends to the will of experts, who have their own agendas and biases, or to democracy, where people are often selfish jerks. Neither solution seems all that responsive to the patient's decisions about what he or she needs, which sounds about right for the VA's reputation.

This fight is a good reminder that when healthcare is in government's hands, citizens have less and less control over their own well-being and are left having to prove to bureaucrats that their medical needs are actually "real." Bureaucracy moves slowly. Ask British men trying in vain to get access to an HIV-prevention treatment that has become more and more widely available in the United States.