HRC: What the Fuck?

In the USA, the Human Rights Campaign, or HRC, is the leading gay rights group, at least in terms of how much airtime and money they manage to get. They currently claim to be trans-inclusive, and to support transgender rights, although they have a history of fucking up in many ways. But their mission statement includes, “The Human Rights Campaign is organized and will be operated for the promotion of the social welfare of the lesbian, gay, bisexual and transgender community.”

Every few years, I try to give them the benefit of the doubt, that they aren’t just a self-serving part of the charity-industrial complex focused more on donations than actual work. And they always, consistently demonstrate they are unworthy of it.

Their flagship “product” is the Corporate Equality Index. This index is intended to encourage companies to treat LGBT people as, oh, human beings.  Companies are rated based on a bunch of criteria, such as having non-discrimination policies, and, importantly in 2015, whether or not they provided health care benefits that included benefits transsexual employees require. It gets a lot of attention and does generate real change. But it has some problems.

Some companies got a perfect score, like United Health Care. These companies are supposed to be the models of LGBT inclusion – they have good policies and practices, and are good corporate citizens when it comes to LGBT issues. In fact, they are perfect!

Other companies, such as Exxon, do much worse.  Exxon received -25 – yes, negative 25 (the link to their database indicates “0” points, but their actual score is listed, along with reasoning, in the HRC full report).  You can read more about why here.

When looking at my own employer (which I will not name here out of concerns for my privacy), I note that my company did not achieve a perfect score in part because they lack trans-inclusive health care benefits. Fair enough, they should rightfully get dinged for that, and it’s great that HRC is looking for trans-inclusion – hopefully it pushes my employer and other companies towards finding better options for health care.

But here is my gripe…

My employer is not perfect, certainly. They rightfully get dinged for not providing trans-inclusive benefits. But the reason they don’t provide those benefits is that they use a health insurance company that HRC ranked as a ‘perfect’ company.

In this case, my employer uses United Health Care (UHC), who achieved a perfect score because they provide their own employees with health insurance that includes trans-inclusive benefits. But many, if not most, of UHC’s health care plans have an explicit anti-trans statement in them.

Transsexual health care is an a life and death issue. It’s not about cosmetic surgery. It’s not experimental or unproven. For many people, appropriate medical care, which might include sex reassignment surgery (SRS) or other procedures, is an appropriate medical treatment. After surgery, people who sought SRS report significantly higher happiness and significantly lower suicide attempts. The American Medical Association, in 2008, passed a resolution that appropriate medical care should be provided to those who need it. The cost of such care is, roughly, 11 cents per year per insured person for a corporate health plan (from the link in the prior sentence; note that this does not include cost savings that are related to reducing prescription drug costs post-surgery or reduced mental health costs post-surgery – in balance, SRS actually saves money).

From some health care provider information UHC provides on Gender Dysphoria:

SURGICAL TREATMENT FOR GENDER DYSPHORIA

Most plans exclude coverage for surgical treatment for gender dysphoria.

This is evidenced by examining certificates of coverage and evidence of insurance.  For instance, one of Tulane University’s 2015 plans, provided by UHC, contains the following, starting on page 25:

Benefit Limitations

M. Procedures and Treatments

7. Sex transformation operations.

That’s pretty clear.  And that’s not unusual (by UHC’s own admissions).

So, basically, UHC, a company with a “perfect” HRC record for LGBT rights, can offer a plan that rejects the medical judgement of the American Medical Association (and others) for some transgender people, simply because that is a medical treatment that some transgender people require. In fact, Medicare covers SRS (thanks to this decision in 2014, which, rightly, pointed out that you can’t deny a treatment that is proven to be medically necessary, effective, and safe simply because it’s socially controversial).

To put this in simpler form, a company can get a perfect score on the HRC equality index even when they:

  • Actively discriminate against some transgender people (If your medical condition is directly related to being transsexual, we choose not to cover some medical treatment, despite clear and convincing evidence as to medical necessity)
  • Provide products that exclude some trans people (this would be similar to a company providing a “Man and Woman Health Plan” that provided coverage for married straight couples but not for married gay couples)
  • Engage in actions that increase depression, poor quality of life, and suicide attempts among transgender people
  • Is making decisions that greatly harm some transsexual people based on inaccurate and non-scientific rationale (similar to how gays were considered to need reparative therapy, UHC often will pay for counseling – presumably to “learn to live with” the wrong genitals – but not surgery).

In other words, a company that is contributing to the death of transsexual people by their choice to not cover the surgery (despite the extremely low cost, and even cost savings when lifetime mental health costs are considered).

Now UHC is not the only insurer to do this, nor are they the only company with a perfect score on the HRC Equality Index that do this. It’s a major problem throughout the insurance industry. Sometimes, when you ask if things are covered by a company, you’ll hear terms like “experimental” and “cosmetic” to describe surgery (this is inaccurate and not based on the modern science, according to respected groups like the American Psychological Association, American Medical Association, and WPATH). Other times they won’t give a reason. And, often, you’ll hear the most disingenuous response: “We offer many plans that provide coverage for these procedures.”  UHC and other insurance companies do have good plans that do not have this exclusion – but in general, most plans have it, and the only times that plans won’t have this exclusion is when there is outside pressure (“Our Fortune 500 company is unwilling to purchase insurance that doesn’t cover this” or “The State requires us to offer this”) – and then it only applies to the specific cases where this pressure was applied, not to other plans. And, since most people get insurance through an employer (either their own or a relative’s), there is a significant financial cost of seeking a different plan if the employer-provided plan doesn’t provide coverage.

As an example, Aetna actually tries to say that they don’t cover trans-related surgeries because of insurance regulations – it would involve changing plans that have been approved by state insurance commissions. Apparently, they want people to think that insurance companies frequently face regulatory sanction because they cover something extra – this is obviously not a particularly credible argument, although I welcome the insurance industry to respond by comment giving case information for when a state went after an insurance company for providing a little more than they said they would.

Moving to include gender reassignment procedures in our plans is consistent with other changes we have made to better serve the needs of the LGBT community,” Aetna said in a written response to The Denver Post. “In 2015, Aetna started covering gender reassignment surgeries for our 33 Aetna plans offered to federal employees. … Aetna also is expanding coverage of gender reassignment surgery in many of our fully insured commercial plans … and will continue to roll (such plans) out over the next couple of years as we refile our plans with the states. We will be introducing the product in West Virginia, Utah, Idaho, Missouri, Wyoming, Nebraska, Iowa, Louisiana, South Carolina (for our fully insured plans) this year.

The above is from a Denver Post article that is quoting a statement from the insurance company. They also told the post they support the LGBT community, which is interesting considering they are actively refusing to provide some treatments when people need them because they are T.  Perhaps Aetna should refine their statement to say they support the LGB community. Aetna is meanwhile merging with Cigna – Cigna has some of the strongest anti-trans exclusions in the industry, with plans even prohibiting hormones for trans people.

Who can you support, if not HRC?

I encourage people who might want to support the LGBT community to support organizations that do not reward companies that are actively discriminating.

In particular, you may look into the Transgender Legal Defense and Education Fund. Another worthy cause is the True Colors Fund (they fight LGBT youth homelessness). You also should look both locally (your local transgender support organization almost certainly can benefit from any help you can provide) and in places in the country where trans people face particular prejudice and where your time or money may make a huge difference (for instance, the midwest or deep south). Trust me, there are plenty of pro-T groups that you can support without needing to send money to HRC. The need is far greater than any of our pocketbooks or volunteer schedules.

A Footnote

As an aside, I would implore others concerned about the coverage of SRS and any other treatments to be very careful in how they approach de-medicalization of transsexualism (which is one specific category of trans people). There are many trans people who do not need medical treatment, and it is important to recognize that many trans people do not have a medical condition, nor do they need or benefit from medical treatment. But it is also important to recognize that other trans people do have a medical condition that is treatable medically – and this is not mere personal choice or desire. In this way, some transsexual people differ from gay people – there is no medical treatment that is appropriate or needed for homosexuality, and homosexuality is not a medical condition, but there are various medical treatments that are medically appropriate and necessary for some transsexuals.

Not all trans people want or need certain surgeries. There is tremendous variation among trans people. Some may identify as neither gender, both genders, or third gender. Others may strongly identify as one gender, but are comfortable having sex organs that typically are associated with another gender. As always, this should be respected, and when I talk about medical necessity, I am not referring to the people who do not need or desire a particular procedure.

Is Sex Reassignment Surgery a Right?

Just recently, the US First Circuit Appeals Court of appeals ruled that a prisoner’s rights were being violated because she was denied medically necessary sex reassignment surgery (SRS) [I use the term SRS rather than gender reassignment surgery because the surgery doesn’t impact gender identity or expression, but it changes things associated with biological sex, like breasts or genitals]. This violated the prisoner’s 8th Amendment right to be free from cruel and unusual punishment.

This is one of the first federal cases in the United States that has recognized that SRS is medically necessary.  This is a major win for the trans community.  And the advocates of the community understand this.

We expect the bigotrs to hate this. They don’t believe surgery is needed for anyone, much less a prisoner. “Let her rot.” Actually, they’d say, “Let HIM rot.” They don’t believe trans people exist, after all. But that’s not what annoys me.

However, what’s the response from the trans community as a whole? Basically the same as 2012, when she won a different case.  You can find comments online like, “I for one am infuriated by this. The inmate is a murderer serving life… Normal people can’t get this covered yet I can go kill some one and then someone will pay for my SRS? Ugh…..”

Or, “Although, I completely agree on a person’s need for GRS/SRS. I do not believe this person is entitled anything from the state. This person committed MURDER and they will now be rewarded with free medical anything from honest TAX PAYERS.”

These arguments are – pardon this language – bull shit.

First, the 8th Amendment, just like the 1st or the 2nd, is still in force. It is illegal to have cruel and unusual punishment. Even for someone sentenced to life. Even for a murderer. The US constitution is supposed to put us above abuse of prisoners. Even when the prisoners are bad people. Especially when we think the prisoners are bad people.

But, beyond that, we don’t have this standard for other treatments. We don’t say, “Oh, no defibrillator for you, no ambulance ride to the hospital. Die of the heart attack. You’re a prisoner. We don’t want to pay for you.”

We don’t say, “You can’t get cancer treatment. You’re a bad person. Too bad. We don’t want to pay for you.”

Yet, with SRS, apparently the standard from many members of the transgender community is two-fold: First, it’s not actually a right, it’s just a right for non-prisoners. Second, no prisoners get rights before get my rights. And even more critically, “This isn’t really medically necessary.

Well, rights don’t work that way. The prisoner is not keeping you from getting SRS. Maybe society is, and quite possibly your rights are being violated! That doesn’t change whether or not the prisoner gets SRS. Either way, your rights being violated don’t mean that someone else’s rights weren’t violated. Seriously, this is a basic concept! Once you bring your own rights into a discussion about someone else’s rights, that’s a problem. Let’s talk about your rights, and make sure you get what you need – and, yes, health care is a human right, and you should be getting it, even if some in our political system disagree. And it’s going to help you when a court recognizes it as a right. Really.

Second, SRS is a life-saving medical procedure for many. This prisoner was sentenced to life in prison. LIFE in prison, not death in prison! Yes, it sucks that sometimes prisoners get better medical care than non-prisoners. Perhaps the solution of that problem isn’t to take away the prisoner’s health care and violate their rights, but to make sure the rest of us also get medical care. Taking away their medical care won’t help those of us outside of prison have medical care!

It sickens me to hear the same arguments used against gay marriage to express disagreement that someone has a right to SRS. The gay marriage opponents’ argument is, essentially, “If someone else has a right, that hurts me.” That’s not cool. No, gay marriage doesn’t hurt straight people. It just helps gays. You can help someone without hurting someone else. The same goes for SRS for prisoners – you can help a prisoner, and live up to our constitutional obligations – even when that prisoner is a bad person – without hurting someone who isn’t a prisoner.

Yes, we need to fight for peoples’ rights to have SRS. That means we need to fight for prisoners to have that right. And for people who aren’t prisoners. It’s a human right, not just a non-incarcerated right. People are sorely mistaken if they believe throwing some trans people under the bus and saying they don’t have a right to SRS will help those who aren’t in that group. You’re just proving the point of the bigots: that SRS is not actually medically necessary. Yes, it is medically necessary for those who need it. And these people for whom it is necessary – like anyone else – may even be in prison. THAT is what needs to be fought for. Not the right for some people to have SRS, as that will only prove that SRS isn’t truly needed. Medical care is a human right. Let’s not forget that.

The Connection Between Military Service and Trans People

320px-Marine_RPD_machine_gunA recent study (focused on the USA) talked about, among other things, how trans people were more than twice as likely to have served in the military than non-trans people.  It talked about a lot of other things, only some of which I will talk about here, as some of it is truly horrible – the likelihood of being a rape victim, for instance, is particularly high among closeted trans people serving in the military.

Today’s policy in the US armed forces is that someone with gender identity disorder is mentally ill and thus should be discharged as unfit for duty.  The same goes for intersex soldiers.  Being open about your gender identity, even after the repeal of Don’t Ask, Don’t Tell (DADT), is not acceptable and will get you kicked out.  There is no apparent plans to change that.

Of course it doesn’t have to be that way – Canada has allowed trans people to serve, and even provided SRS (sex reassignment surgery) under the military health coverage.  So does Israel.  And the best speech ever by a military officer about treating people decently (specifically after a sex scandal) was written by the Australian General’s speech writer, a transgender Lt. Colonel.

But, back to the study…the study found there are tons more military veterans among the trans community than among the non-trans community.  Why?  They cited an earlier study which found many trans people, particularly transwomen (that is, people who initially had an “M” on their birth certificate but are women), undergo what the researchers described as a “flight into hypermasculinity.”  I believe, based on stories I know of transsexual people, that this is both real and common, and have a thoughts as to why.  First, this “flight” usually seems to occur in early adulthood.  This is a time of tons of changes, such as brain maturation, physical maturation, and leaving home (for many).  People are trying to find themselves, trying to figure out where they belong.  To find acceptance and peace, obviously it would be easier if one were living according to society’s expectations on gender.  So people try.  I think this is one reason why so many transwomen have done very masculine things in their teen and early adult lives, whether it’s being the high school football star, being part of the hyper-masculine Seal Team 6, or a motorcycle racer.  Now, I’m not saying women can’t do these things, but they are traditionally very masculine jobs.

I think the flight into hyper-masculinity may be similar to a may man who has internalized prejudice and marries a woman – only to have a broken marriage years later.  It doesn’t turn out to work.  He’s still gay.  And, likewise, the transwoman is still a woman.  Yet, there is an attraction for both the gay man and the trans woman – if only they could live as society expects, life would be much, much easier (and likely better).  They can’t, because they aren’t what society expects, and trying to live that life leads to death.

It’s unfortunate that the Veteran’s Affairs (VA) health system (the medical system that provides medical care for veterans in the US) leaves transgender people out in several ways.  Now, it’s not all bad – overall, the official policies of the VA are actually relatively decent compared to most health care.  But there are three big gotcha’s in the policy and implementation.  First, good policy, alone, is insufficient if people providing care don’t get it.  And that’s sure to happen in a health system as large as the VA.  It’s inexcusable to treat a veteran in need of medical care in a way that humiliates or demeans, but sadly it does happen.  Second, the policy itself prohibits sex reassignment surgery.  The VA, like many health care providers, consider this surgery to be primarily cosmetic, while at the same time recognizing that gender dysphoria is real (and has a surgical cure, for transsexuals, particularly transsexual women).  In addition to these two problems, the third is a problem of access – many trans people are discharged non-favorably from the military, in which case they may not qualify for VA health benefits, even if they otherwise qualify (for instance, an honorably discharged veteran who served in combat within 5 years would qualify for a time).  For instance, cross dressing is against military justice code, and can cause a dishonorable discharge – which results in no veterans’ benefits.

So, the next time you hear news of gay veterans, think of the transgender military members – there’s plenty of them and they are, sadly, at risk of dishonorable discharge or worse (suicide is very common among trans people trying to live as a gender they are not).  And then, when discharged, think how the system we’ve set up to ensure our veterans are healthy and can adjust back into society fails someone on this most personal and important aspect of their being.  We have work to do.