Treating Transgender Needs

(Part I of this story appeared on March 10, 2010.)

In an effort to foster a more inclusive campus community, Harvard is actively putting its policy into practice.

In accordance with the University’s non-discrimination policy, which was modified in 2006 to include gender identity, University Health Services decided to address the medical needs of transgender people with more equitable insurance coverage.

Each transgender person experiences the process of transition in a different manner—some prefer to avoid medical intervention and others seek the full range of possible treatments, from genital reconstruction to hair removal.

While Harvard’s insurance plan has covered sex hormones since 2006, a new policy adopted in January incorporates coverage for top surgery, meaning mastectomies for transgender men (women transitioning to men) and breast augmentation for transgender women (men transitioning to women).

While the change is greatly appreciated within Harvard’s transgender community, finding full treatment and acceptance from others remain significant challenges.

A HUGE EXPENSE

Prior to the change in the insurance policy, BlueCross BlueShield of Massachusetts—the supplementary health insurance plan for most Harvard affiliates—did not cover sex reassignment surgeries, even with a doctor’s recommendation.

“It’s a huge expense to try to come up with the money to afford surgery, so to have it covered through insurance is a big deal,” says Iain M. Stanford, who is working on a doctoral dissertation in queer theology at the Harvard Divinity School. “Personally, I could not think about surgery unless it were covered by insurance.”

Noah E. Lewis—a staff attorney for the Transgender Legal Defense and Education Fund who has been deliberating with UHS and the insurance company on the inclusion of transgender surgeries in Harvard policies—says that the previous exclusion meant that only the most economically privileged people could access these treatments.

“Transgender exclusions therefore deny medical coverage to the people who need it the most—people who are unable to afford care on their own,” says Lewis, a 2005 graduate of Harvard Law School.

A senior who identifies as a transgender man and asked to remain anonymous says he would not have been able to afford top surgery for several years without insurance coverage, so he did not feel it was worthwhile to begin treatment with the available hormones.

“For me, having top surgery is the key to being able to be perceived as the gender that I am; I could take hormones that would masculinize my face and my voice, but I still wouldn’t pass in public without the top surgery,” he says. “I thought I would have to delay changing my physical body until after I graduate and pay off my student loans, and that was really disheartening.”

Although he will graduate before the insurance begins coverage for students on Aug. 1 of this year, he says that he is thrilled that treatment for transgender people will now be covered.

“It’s going to make a real positive difference for students who come after me,” he says.

COMFORT AT LAST

Lewis, who began working with UHS during his final year of law school, says that he has pushed for further coverage because he knows first-hand the effects of being denied these services and the drastic improvement in health and well-being following treatment.

“The improvement in my health following surgery and hormones was like night and day,” he says. “The way my brain experienced my body finally matched my physical body.”

Lewis says he believes that no one should be denied medical care out of ignorance and outdated prejudice.

“For those who want them, hormones and surgery allow transsexual people to feel comfortable in their bodies for the first time,” he says.

Gregory M. Sensing, who has lived as a man for six years and is awaiting a surgery date in the near future, says he believes that these treatments are medically necessary.

“It’s stressful to go through every day of your life with this conflict of body and mind,” he says. “I’ve become very skilled at disconnecting with my body, and having that one less thing to worry about will make day-to-day life so much easier.”

While members of the transgender community at Harvard are happy that top surgery will now be covered, many agree that the change should have been made long ago.

“This is overdue,” says the senior. “People need access to medical supplies to feel whole, and Harvard is finally catching up in acknowledging that people who identify as trans have medical needs, and they’re meeting those needs.”

PATHOLOGY OR IDENTITY

Although designating this “conflict of body and mind” as a medical condition is necessary to receive medical treatment, many transgender people are uncomfortable that this conflict is classified as a disorder in the most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders.

While the APA is currently considering a proposal to change the classification of “gender identity disorder” to “gender incongruence” in the next edition of the manual—which will be published in May 2013—most insurance policies still classify being transgender as a disorder.

Consequently, UHS’ new policy stipulates that prior to getting the surgery, individuals must consult a behavioral health professional to evaluate their needs.

“They expect a certain narrative of ‘I’ve always known I’m the other gender and I’m in the wrong body,’” says Stanford, in reference to the requirement of speaking with a psychiatrist before receiving treatment. “There are things we give medical service to but don’t or shouldn’t pathologize.”

Stanford says it would be ideal if people could have access to transgender health services without the associated stigma of transgender as a psychological disorder.

“Having access to medical services is important for our ability to live with integrity, and, at times, it is also a matter of our safety in the world,” he says.

While Sensing also agrees that transgender should not be classified as a disorder, he says that having access to the coverage is more important than the terminology used to describe it.

“Right now I’m concerned with being healthy and being able to afford my healthcare, and this insurance coverage goes a really long way in helping me toward that goal,” he says. “If for the sake of insurance I need to be labeled as having a disorder in order to get the healthcare I need, that’s a small price to pay right now.”

ACCEPTANCE THROUGH EDUCATION

While Sensing says he will tolerate the “disorder” classification since it allows for medical treatment, he says he hopes that this is not a label transgender people will have to carry forever.

“As more people become more enlightened about what it means, they’ll find another way to define it that doesn’t involve stamping us with a disorder,” he says.

Sensing, as well as many other members of the transgender community, are counting on education to spread awareness of transgender issues.

“In some contexts, I’ve seen a lack of acceptance just because there’s not any education or visibility,” Sensing says. “You don’t think something is an issue if you never see it.”

Eva B. Rosenberg ’10, chair of Harvard Transgender Task Force, agrees that the lack of visibility can lead to unintentional discrimination, not only in the search for medical treatment, but also in day-to-day issues such as checking a male/female box on a form, changing one’s name, or using gender-specific restrooms.

“Many individuals and offices across the university are open to transgender issues and learning more about what they can do,” Rosenberg says. “But maybe some employers don’t think they have any trans employees or don’t consider the ways in which their everyday practices could make life harder for gender non-conforming individuals in general.”

While Stanford University is also in the process of developing an insurance policy covering sex reassignment surgery, Harvard is the first Ivy League school to offer coverage for any form of sex reassignment surgery. Members of the transgender community are hopeful that the initiative to be more inclusive of transgender medical needs will spread to other campuses.

“Other institutions look to Harvard and the Ivy Leagues to follow their lead, so I think it’s good that Harvard is doing this now,” says the senior, who hopes to seek sex reassignment surgery within the next few years. “It would’ve been great if they’d been doing it earlier, but it’s still praiseworthy that they’re making this change. This explicitly makes Harvard a more trans-accepting place.”

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