A young man sat in my office in Tucson, Arizona a few weeks ago to discuss his hysterectomy. He was 18 years old and had recently started testosterone to begin his gender transition. He had many questions about the procedure: Will you need to make a big incision? Should I remove my ovaries and when? (Yes, unless you might want to harvest eggs later) Will my insurance cover my hysterectomy? The answer to this one is “I just don’t know.” The hysterectomy might be deemed medically necessary and get covered. However, Arizona is one of 10 states that prohibits Medicaid coverage for sex-reassignment surgery.
In Wisconsin this week two transgender residents filed a federal lawsuit against the state. They contended that contending their denials of service are discriminatory and violate the federal health care law. They also argue that there is no medical or scientific support for Wisconsin's contention that transition-related health care for transgender people with gender dysphoria is “medically unnecessary.”
Transgender people don’t access the health-care system as much as other people. In its most recent report, the National Center for Transgender Equality found that 23 percent of respondents avoided going to the doctor because they feared discrimination; one-third had at least one negative experience with their provider.
When they do come to clinic they encounter insensitivity and discrimination from the front office all the way to the physician. The challenges of insurance and payment are an added barrier to transgender people receiving quality health care. I have had patients whose insurance companies will not recognize their gender transition in paperwork. This require them to jump through multiple hoops to receive their hormone therapy, or deny their hysterectomy just days or hours before their surgery is scheduled.
Hysterectomy is a medically necessary component of gender affirming surgical therapy. Additionally, there are health consequences for not removing the uterus and ovaries in somebody taking large doses of testosterone. Testosterone is converted to estrogen in the body and elevated estrogen levels can lead to uterine pre-cancer and cancer. They can also suffer from irregular and sometimes heavy bleeding.
Testosterone also might aggravate a problem of the ovaries called polycystic ovarian syndrome, a syndrome that includes excessive weight gain and diabetes. Most importantly, people with ovaries who are taking testosterone to masculinize have to take higher doses when their ovaries are in place to overcome the estrogen they are making. Removing the ovaries could lead to lower doses of testosterone.
Trans people, especially those who have been alienated from the health care system have other health issues. Transmen are at risk for sexually transmitted infections including hepatitis, HIV and HPV, the virus that causes cervical cancer.
Over 40 percent of trans or gender nonconforming people have experienced depression or attempted suicide. Often, when they are forced to languish in the in-between of genders without the necessary care they desire and need to be healthy and whole, their symptoms are aggravated.
I have received many years of medical training and am regularly frustrated when a bureaucrat or politician tells me how to practice medicine. That young man from a few weeks ago told me that starting his transition made him the happiest he had ever been, and I believe him. I can’t imagine the feeling of wearing the wrong skin; and he shouldn’t have to. I certainly don’t have the surgical skills to offer all the sex-confirmation surgeries the two Wisconsin residents so desperately want and need.
But, as a specialist in female pelvic surgery and reproductive medicine, I am exceedingly qualified to offer my male patients many of the services and procedures they need to continue their transition. Asking them to prove that this care is medically necessary and worthy of payment is not just offensive and discriminatory but also heartless and inhumane.
Ilana Addis MD, MPH, is an ob-gyn who has worked with transgender patients. She is a former chairwoman of the Arizona Section of the American College of Obstetricians and Gynecologists. Follow her on Twitter: @iaddis.