Posts Tagged ‘ surgery ’

Nova Scotia Extends Health Care Coverage for Reassignment Surgery

After originally saying that it would not fund genital reassignment surgery, the Nova Scotia government has now said that it would extend health care funding coverage for the procedure.

Health Minister Dave Wilson is quoted as saying, “This is the right thing to do.”

I’ve written previously about why GRS is recognized as being medically necessary by medical experts, specialists in trans health, social agencies and human rights organizations.  Here is a snippet:

… There is more. Current legislation asserts that most forms of identification and legal documentation can only be changed to reflect one’s new gender after surgery has been verified. Without GRS, many pre-operative transsexuals experience severe limitations on employment, travel beyond Canada’s border, and treatment in medical, legal and social settings in which verifying ID is necessary. Prior to GRS surgery, transsexuals also face limitations on where they can go (i.e. the spa or gym, or anywhere that involves changing clothes) and difficulties in establishing relationships — as well as being in that “iffy” area where human rights are assumed to be protected, but have not yet been specifically established as such in policies and legislation. In hospitals, prisons and such, they are housed by physical sex rather than their gender identity, creating potentially risky situations, unless the authorities directly involved choose to keep them in isolation instead. And at the end of the day, without GRS surgery, one’s gender is always subject to being challenged or stubbornly unacknowledged by those who don’t realize that a transsexual’s gender identity was not a matter of choice. There is also an extremely high risk of violence faced upon the accidental discovery that one’s genitalia does not match their presentation.  No other supposedly “cosmetic” issue so completely affects a persons rights, citizenship and safety…

This is the fulfillment of several years of work for Nova Scotian trans people.  While details of the program are not yet known, the community had been advocating for comprehensive trans health coverage:

This points to a trans* health care model that includes, but is not exclusively reliant upon, SRS; that is driven by the individual and their particular requirements; that serves all of the trans* community, including those who do and those who do not seek SRS. This is exactly the kind of culturally competent, patient driven, community health care model that both Minister Wilson and his predecessor, the Hon. Maureen MacDonald, have been advocating for Nova Scotians. This is exactly the model that we, as a community, should be asking for.

Nova Scotia also recently added trans people to that province’s human rights legislation.

In a note on Facebook, Kevin Kindred and the Nova Scotia Rainbow Action Project are encouraging people to contact their MLA and send letters of thanks and support.

Most Canadian provinces provide some form of funding for GRS, now (albeit sometimes imperfect) — only New Brunswick and PEI do not.  Attempts to defund GRS have been met with sustained pressure from the public and human rights complaints, with Ontario delisting coverage in 1998 (restoring it ten years later), and Alberta delisting funding in 2009 (restoring it in 2012).

(Crossposted to Rabble.ca)

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The non-operative word is not “sorry.”

I’m going to be writing about transition regrets and/or reversal of transition (sometimes from folks who remain trans-identified).  Before I do, though, it seemed necessary to finish and put this article out there, as it lays the groundwork.  I’d written about the decision to be non-operative previously, and had intended to leave it at that, but it remains one of the most hotly-contested and misunderstood subjects that I touch upon.

When it comes to genital reassignment, the non-operative word among trans people should not be “sorry.”

That’s not a very popular statement in transsexual communities.  But as much as I don’t like “rules” for being trans, I have arrived at one guideline:

Do as much or as little as you need to achieve the peace that you need.

It’s not quite that clear and simple, of course, especially given the pressures to conform and integrate as either male or female, which have been idealized as binary opposites in society.  Trans (that is to say, both transitioning from one sex to another and/or living between genders) challenges those absolutes, but it’s also a lot to ask, for someone to remain a life-long challenge to society.  And phrasing it as a “pressure to conform” oversimplifies something that also includes fears about going swimming or to public places of semi-nudity, going through airport scanners and traveling internationally, being in sex-segregated spaces like homeless shelters or correctional facilities, or the possibility of being challenged in a public restroom.

Relationships can also factor into the equation.  Genital reassignment surgery is inevitably going to change a dynamic within intimate relationships, and raise questions about our sexualities and those of our partners.  While the decision for or against GRS shouldn’t be dictated or coerced by our partners, when we love someone, it’s inevitably going to be on our minds.  Some individuals will be able to consider foregoing surgery as an act of love and sacrifice, while for others it would be far too much to ask — we’ll see why, shortly.

Another factor that blurs the lines is the fact that we live in a nation where our enfranchisement in society is largely affected by our identity documents.  In Canada, only the Province of Ontario has a provision to change a birth certificate without multiple verifications of surgery — and in many provinces, the same is true of lesser documents like driver’s licenses.  While our Social Insurance card does not display a gender marker, potential employers can do an S.I.N. check which displays a gender marker in the resulting report — and that, too, cannot be changed without a new or amended birth certificate.  When our ID is incongruent, it potentially exposes us to harm and/or discrimination when we’re carded, and at many other stages of just trying to live and work and access services.  At no other time is a person’s enfranchisement in society dependent on them having surgery.  But because that is the status quo in Canada and most parts of the U.S., it will inevitably be a point of consideration, for the time being.

Medical issues can also be factors affecting whether one can or can’t obtain surgery.  This might take the form of a serious health condition that precludes undergoing other procedures (some of these — such as diabetes or HIV — can be worked around by finding surgeons with better hospital access, but other conditions can be completely prohibitive).  It might also refer to fear of undergoing a major invasive surgery, an aversion to the medical process overall, a desire to wait until techniques improve, or living in a province where GRS is not funded and not being able to afford it.  Occasionally, health care funding is an influence for GRS, such as situations where vaginaplasty or phalloplasty are funded by insurance while orchiectomy, metoidioplasty or other options are not.

But for the moment, let’s put all of these things — health, cost, relationships, social pressures, legal identification and enfranchisement — aside.  In an ideal world, the decision to have surgery should hinge on an individual’s needs and the advice of their doctor.

This may seem a little confusing for people who have read my writing about surgery being a medical necessity.  I still maintain that its availability is, and that when surgery is necessary for an individual, it is an absolute necessity.   Relationships and legal enfranchisement obviously underscore this need, and there is also an economic benefit to resolving gender identity conflicts, so that a person is better-able to function and be productive.  But it’s also important to remember what GRS is designed to do:  alleviate distress.

Gender dysphoria encompasses a number of aspects: body dysphoria (in which genital configuration causes anxiety, revulsion, discomfort, or simply unease), social dysphoria (in which the social dynamic that we experience with people is ill-fitting), and self-identification (the inner core of who we are and the face we need to present to the world).  Each of those can vary in degree, and trans individuals can experience an emotional, psychological and/or even physical distress and anxiety about their body.  Living as the gender we identify with will often alleviate the social dysphoria and self-identification conflicts… only surgery addresses the body squick.

Body dysphoria is not always a conscious thing, but can be experienced as a discomfort or aversion to the genitalia, or a sense that those parts are out of place and don’t make sense to be there.  At the most extreme, this aversion becomes even violent, driving a person toward self-harm or self-destructive behaviour.  For people who experience it less severely, it can be a discomfort toward sexual intimacy in general, or a feeling of being out of place, without being completely clear on why.  Obviously, in these situations, it makes sense to align the body with what a person understands that they need to be.

At the lower end, the stress may not be as urgent, although a sense of closure might still be needed.

Not everyone experiences this.  Sometimes transition alone, minus surgery, is enough to resolve a person’s dysphoria, while other factors pose more significant reasons not to have surgery.

Non-operative trans women are sometimes considered button-pushing because they challenge the traditional trans narrative (there is often an exception made for trans men because of the limitations of phalloplasty and metoidioplasty procedures), in the same way that some bisexual people are unfairly seen as a challenge to the “born this way” narrative of sexual orientation.  The idea that we are fixing a predominantly medical condition seems undermined by the existence of people who don’t want to completely “fix” their bodies through surgery.  And yet, individuals exist who genuinely need to transition and live as their identified sex, but don’t urgently need or want GRS.

In transsexual culture, there seems to be this perspective that all roads lead to the holy grail of GRS, and that after one has the surgery, one has “arrived.”  Part of the reason that so many post-operative trans women and trans men leave the community is because once they’ve reached that point, the weighty discussion about GRS is no longer relevant to them.  The GRS-heavy direction has also tended to exclude non-operative and other trans people, because of the implication (intended or not) that they “must not be real” if they choose not to pursue surgical methods.

Yet GRS was only ever supposed to be one step toward self-resolution.  It’s neither all-completing, nor is it always a final endpoint (and this calls for a discussion of post-traumatic / minority stress), although it does have the ability to bring closure when that body distress exists.  By comparison, cissexual (non-trans) women never stop discovering what it means to them to be a woman; cissexual men likewise.  One does not “arrive” simply from the flick of a scalpel.

The basic reality of the trans condition is that our bodies do not define us.  If we allowed that to happen, we’d have never been able to start a transition — we would still be living in the misery and shame of having to live up to everyone else’s expectations.

The trouble with a heavy (or exclusive) focus on GRS as the “endpoint” of our transition is that we can become so intent on becoming “wholly” female or “wholly” male that we abandon, hide or feel ashamed of characteristics and histories which make us truly unique, perhaps instead embracing stereotypes.  It’s important that surgery does not become a case of simply trading one mask for another.

The overarching focus on surgery also does people an injustice, as it means that we fail to talk about bodies, hygiene issues, sex, the down-sides of post-operative care, and those things that we fear might cause a person to stray from the One True Path™ of GRS, or have doubts.

And sometimes –oh, not for everyone, but sometimes — non-operative-by-choice trans people arrive at a point of personal resolution from transition alone, and find that they can take pride in how unique they’ve become.  That perspective is hard-won.  It’s a shame to bury it.  Once in awhile, it’s important to embrace one’s uniqueness, and take pride in it.

Anyone who fails to understand this needs to take themselves out of the comfort zone of their own experiences, for a moment, to remember that one size rarely fits all.  Because the non-operative word is not “sorry.”

In the end, we are who we need to be.  Nothing else matters.

(As I was wrapping this up to post, Helen at en|Gender pointed to Non-Op.  For those who want to know more, it looks like an interesting resource.)

(Crossposted to The Bilerico Project)

Alberta reinstates funding for Sex Reassignment Surgery

The Alberta Government has announced that it will be reinstating health care funding for sex reassignment surgery (often called gender reassignment surgery, and abbreviated as GRS by the province and its clinicians), effective June 15th.

In the recent provincial election, Premier Alison Redford was returned to power by an electorate that appears to have been hoping her government would track back toward progressive politics.  Albertans have been watching to see if her government would indeed follow through, and in what manner.  An Angus Reid poll placed Ms. Redford as the second most popular Premier currently in power.

The province had cut funding in 2009 as a “cost savings measure” — however, the $700,000 savings (provided for approximately 16 people per year) wasn’t even a sliver of the provincial health budget.  Since then, the Province has been on shaky legal ground with the funding cut, since human rights tribunals have typically recognized the procedure as being medically necessary.  It was for this reason that the Province of Ontario ultimately reinstated funding, and B.C. abandoned an attempt to defund the surgery.  Judicial court rulings (eg.) in Canadian case law also indicated a likelihood that the medical necessity of GRS would be upheld.

The Trans Equality Society of Alberta responded to the announcement with a media release:

We are pleased that the current administration sees value in caring for all Albertan’s needs, enabling them to live happy, fulfilled lives.  The return of this coverage, who’s removal only saved Albertan’s $0.18 each annually, will give hope to those for whom GRS was previously out of reach.  While there are many other issues facing Trans-identified Albertans, this is a huge step in the direction of respect and dignity for the Trans Community by the Alberta Government. Thank you for taking this important first step.

The American Psychiatric Association and American Medical Association both stress that sex reassignment surgery is a medical necessity, and a 2008 resolution by the AMA emphasized that insurance companies should cover the procedure.

Most Canadian provinces have some form of coverage for GRS, although some have problematic quirks of process or costs that can create barriers to obtaining the procedure, and some still do not fund sex reassignment procedures for trans men.  In 2008, Nova Scotia’s Liberal Party added working toward GRS funding inclusion to their political platform, although it has not yet been accomplished in that province.

Internationally, several nations have also added coverage to their public health insurance programs over the past couple of years, including Cuba, Brazil, and Chile.  Argentina recently passed the most comprehensive policies on trans enfranchisement, which included GRS funding, new name change guidelines, anti-discrimination inclusion in their human rights code, and legal protections from hate crimes.  A number of Australian provinces are under renewed pressure to provide funding after an incident of attempted self-performed surgery in an act of desperation.  There have been (trigger warning) at least three other major self-mutilation incidents reported in international media in the past year, including one person in China who self-castrated and then jumped to their death because they couldn’t deal with the pain.  Although not all trans people decide that they require surgery, for those who do, it can be an absolute necessity.

Corporations have also been rapidly adding health plan coverage to their benefits programs, including Apple, Chevron, General Mills, Dow Chemical, Chubb, American Airlines, Kellogg, Sprint, Levi Strauss, Eli Lilly, Best Buy, Nordstrom, Volkswagen’s U.S. division, the University of Pennsylvania, Whirlpool, Xerox, Raytheon and Office Depot (note: some of these may not apply in Canada).  According to the Human Rights Campaign’s Corporate Equality Index (CEI), over 200 major U.S. businesses now include trans-inclusive health care coverage featuring surgical transition-related care, including 50% of Fortune 500 companies — an increase of over 1500% in that group since 2002.

Alberta’s 2009 announcement was followed by a mass filing of human rights complaints.  Due to changes in grandfather-through decisions, some of those complaints were negated when funding was given, and others are still in process.  Due to the backlash at the time of the announcement, the province had eventually conceded to provide funding for people already in transition prior to the cut, to a maximum of 20 per year.  A number of others who had not qualified for the “Phase Out” program (usually because of the timing of their first medical appointment after starting transition) had been typically offered GRS funding as part of a settlement during negotiation stages of their human rights complaints, but have not spoken to media due to confidentiality requirements.

Although this victory is huge, some concerns about medical access remain.  It can be difficult or near impossible to find trans-friendly (let alone trans-aware) medical practitioners in several regions of the province. This can make it hard to even find general practitioners willing to treat people for medical issues that are not trans-related.  For transition care, there is one clinic in Edmonton (therapy only, currently with an 18+ month waiting list) — in Calgary, there is also a once-a-month trans health clinic operated by a psychologist and a family doctor who’ve teamed up to try to help, but the need is one that is difficult to fill with a once-a-month model.  The previous Stelmach government had shut out attempts by the trans community to speak about these matters, and advocates are hopeful that this can now change.

On Wednesday, the Federal government voted to allow a human rights bill proposing protections for transsexual and transgender Canadians to committee for review and possible changes, toward a final vote.  The bill had passed in the previous Parliament, but died in the Senate upon the election call.

(Here is a full backgrounder on why GRS is medically necessary.  It is also available as a trifold brochure)

(Crossposted to The Bilerico Project Dented Blue Mercedes and Rabble.ca)