New Policy Covers Transgender Health

(Part II of this story appeared on March 11, 2010.)

Gregory M. Sensing works at the Harvard School of Public Health. He goes to work, he goes home, he decides what to make for dinner and when to do the laundry. But for most of his life, he’s faced a struggle that something internal does not seem quite right.

“I don’t have any sort of debilitating disease or disorder that keeps me from moving through life, but there’s always this underlying static hum every minute of every day, saying that this is not my body.”

Sensing was born female but has been living as a man for six years. Although he is taking sex hormones and plans on getting sex reassignment surgery, not all transgender people approach the process of transition in the same way, and some decide not to make medical changes at all. For many, finding a way to pay for medical treatment is a hindrance in their transition, but the increasing visibility of the transgender community in the United States has brought issues of discrimination, medical care, and compassion into the public eye.

As transgender people struggle to pay the bills and feel comfortable in their own skin, institutions are working to address their needs. In the continuing effort to create an equitable and inclusive campus, Harvard University Health Services modified its insurance policy last fall to cover top surgery for transgender people covered by the University’s Blue Cross Blue Shield health insurance.

EXCLUDING EXCLUSIONS

At Harvard’s behest, Blue Cross Blue Shield modified their University-specific policy on transgender services. Employee coverage went into effect on Jan. 1, and student coverage will begin on Aug. 1, 2010.

Blue Cross developed a policy outlining generic medical coverage criteria for both top and bottom surgeries. However, Harvard has decided to remove the exclusion only for top surgeries—that is, breast augmentation and mastectomies—for now, as the possibility of covering genital surgeries is still being investigated.

“One concern they have is with the lack of qualified local providers,” says Noah E. Lewis, staff attorney for the Transgender Legal Defense and Education Fund and a 2005 graduate of Harvard Law School. “Which, of course, is the result of insurance exclusions in the first place.”

Prior to the modification, Harvard subscribed to a standard plan from Blue Cross that specifically excluded “services and supplies that are related to sex change surgery or to the reversal of a sex change.”

According to Lewis, the UHS exclusion forced transgender people to pay the same insurance premiums as other members of the Harvard community, without receiving equal benefits in return.

“The exclusion for transgender services stuck out like a sore thumb,” he says. “If transgender health care were not explicitly singled out for exclusion, these services would be covered, as would any other medically necessary drug or surgery.”

Lewis says that such insurance exclusions reflect outdated prejudices against transgender people.

The new policy states that “gender reassignment surgery is one treatment option for Gender Identity Disorder, a condition in which a person feels a strong and persistent identification with the opposite gender accompanied by a strong sense of discomfort with their own gender.”

While members of the transgender community dispute the label of a “disorder,” most are hopeful that this is the first step in a more inclusive policy of medical treatment.

FROM POLICY TO PRACTICE

The change in insurance coverage is in keeping with Harvard’s non-discrimination policy, which states that any form of discrimination based on race, religion, sex, political beliefs, and other categories contradicts the principles and policies of the University. This list was modified in July 2006 to include gender identity.

“Putting the insurance policy in line with Harvard’s goals of equity and inclusion goes along with the non-discrimination statement,” says Eva B. Rosenberg ’10, chair of Harvard Transgender Task Force. She says that the University is working to find places where policies or practices may be discriminatory and trying to change those behaviors.

“A lot of people don’t realize that using a bathroom or checking off gender on a form can be stressful to gender nonconforming people,” she says. “Some of the discrimination that goes on is just unconscious or routine rather than in the form of harassment or outright malice.”

While part of the changed insurance policy came from attempts to adhere to the university’s non-discrimination policy, the removal of the exclusion of coverage for the surgery has been years in the making. UHS agreed to cover sex hormones when the new policy was adopted in 2006, but the transgender community continued to fight for other necessary surgeries and cosmetic changes necessary in the process of sexual realignment.

ENSURING COVERAGE

Ultimately, a combination of pressure from within UHS, TTF, and other transgender individuals studying or working at the University contributed to the most recent change.

“TTF is very lucky that there is a core group of mental health professionals and administrators who understand where we’re coming from and act as our allies,” says Morgan L. Haven-Tietze ’10, a member of TTF. “TTF used to have to sift for understanding people in the administration, and now there are people who speak persuasively on our behalf.”

One such spokesperson has been Sara Kimmel, a psychologist at UHS. Kimmel consulted many members of Harvard’s transgender community and advocated against the discriminatory policy. She wrote in an e-mail that a team of medical experts examined the safety and efficacy of the related procedures while deliberating on the policy changes, and determined that top surgeries for gender confirming purposes are often medically necessary for transgender individuals hoping to pursue medical transitioning treatment options.

“For students and employees who have a medical need for the procedures that are now covered, it is an important increase in accessibility to surgeries that significantly improve one’s quality of life and often are necessary for ensuring safety,” she wrote.

Recognizing transgender as a medical need was another reason for removing the exclusion.Many transgender people experience discomfort and depression because of the incongruence between body and mind, a sentiment that is becoming more widely accepted as constituting a medical need and a right to treatment.

In June of 2008, the American Medical Association resolved as an association to “support public and private health insurance coverage for treatment of gender identity disorder as recommended by the patient’s physician.”

THE BATTLE ISN’T OVER

Students and employees are hopeful that the remaining exclusions will be removed in the near future.

“As further medical technology develops there’ll be further discussion about removing exemptions; I am hopeful they can be removed soon, and I don’t think we should feel content until they are,” says Rosenberg, who says the battle is not over yet.

“Say your insurance covers chemotherapy and you don’t have cancer but someone else does,” she posited. “That’s why it’s called insurance—it’s supposed to cover you for many conditions you never have and some you might have someday.”

Sensing, who is planning on having the surgery within the next few months, uses similar logic.

“I wouldn’t object if I were asked to pay a few cents extra for someone else’s need to have insurance cover something like prenatal care or a prostate exam, or some other procedure not applicable to me,” he says. “If it helps someone in my community have a healthier and saner life, the extra cost is a non-issue. It’s just the right thing to do.”

“There’s still a long list of things that aren’t covered, and it’s unclear to me why some things are covered and some aren’t.” he added. “If you’re going to cover two, why stop there?”

—Staff Writer Alice E.M. Underwood can be reached at aeunderw@fas.harvard.edu.