Author: rormsby

I was asked to post this to the blog so that access would be available to more than those on the librarian’s  email list.

A student asked for help at the reference desk  in locating the number of people in the U.S., compared with Europe, who have had sexual reassignment surgery.

While working with the student at the  reference desk, the best we could locate is an estimate of the number of transgendered people in the U.S.  (The Williams Institute, at UCLA, estimates about 700,000, according to a report issued last year, http://williamsinstitute.law.ucla.edu/research/census-lgbt-demographics-studies/how-many-people-are-lesbian-gay-bisexual-and-transgender/.) .  (The Williams Institute is among many organizations providing information and research.)

Realizing that this estimate didn’t address the student’s question,  I took the student’s contact information and told the student I would look into the question further.  After consulting with Mike Waldman for some suggested sources; checking on a number of possible sources, and reading a number of articles, and  websites, I have concluded that there’s no source to answer the student’s question.    (I failed to inquire if the student was interested in a specific age range as I have realized that some sexual reassignment surgeries are done shortly after birth.)  I also learned, through reading, that worldwide many people travel outside their home country for these surgeries, and Thailand is often chosen because of the lower cost.  (The Williams Institute is among many organizations providing information and research.)

The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7^th version., by The World Professional Association for Transgender Health, http://www.wpath.org/documents/Standards%20of%20Care_FullBook_1g-1.pdf,  recognizes that health is dependent upon not only good clinical care but also social and political climates through public policies and legal reforms that promote tolerance and equity for gender and sexual diversity and that eliminate prejudice, discrimination and stigma.   Page 5 of the standards notes, “ Some people experience gender dysphoria at such a level that the distress meets criteria for a formal diagnosis that might be classified as a mental disorder.  Such a diagnosis is not a license for stigmatization or for the deprivation of civil and human rights.”    It’s understandable that anyone could be reluctant to share any type of health or medical information, but especially when, as the standards point out, “in most countries, crossing normative gender boundaries generates moral censure rather than compassion.”

On pages 5-6, of the standards, it is noted that no formal epidemiologic studies on transsexualism specifically or transgender identities have been done.   On page 7, citations to  studies undertaken of those who came for gender-transition-related care at specialist gender clinics in Sweden, the United Kingdom, the Netherlands, Germany, Belgium and Singapore, ranging from 1968 to 2007 are given.  A citation is also provided that De Cuypere and colleagues reviewed these studies and conducted their own, in 2007, and  this review can be found in Principles of Transgender Medicine and Surgery, edited by Randy Ettner.  (Not available within CUNY, but found in WorldCat, the catalog of library catalogs.)

The Standards of Care notes that direct comparisons of these studies are impossible because each used different data collection methods and differed in criteria for documenting a person as transsexual (for example, whether or not a person had undergone genital reconstruction, versus initiating hormone therapy, or seeking medically-supervised transition services.)

I also learned that there are many issues surrounding private pay and Medicaid/Medicare insurance coverage of sexual reassignment surgeries, hormone treatment and other care.

There’s a system of diagnostic codes for procedures, and I learned  ICD-9-CM Code 64.5 “operations for sexual transformation, not elsewhere classified,” is on the list of “never covered” procedures for Medicare. (Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/downloads//cms1428f_i.pdf)

While some states permit Medicaid to pay for sexual reassignment surgery, New York State does not permit this. There are efforts to have this changed by the state legislature. (Source:   http://www.prideagenda.org/Issues-Explained/Transgender-Equality-and-Justice/Medicaid-Coverage-of-Transgender-Healthcare.aspx)

Today, a New Jersey woman, who is transgender, was able to get Aetna Insurance to reverse its earlier decision to deny a claim for a mammogram that was done at a doctor’s recommendation: http://www.glaad.org/blog/tldef-secures-policy-change-aetna-health-care-coverage-transgender-people.  Aetna has announced some changes in coverage for others it insures.

I also think perhaps in the future that the Internal Revenue Service might be a possible source of information on totals of people seeking medical expense deductions for sexual reassignment surgery because of an important 2010 decision  in Rhiannon G. O’Donnabhain v. Commissioner, 134 TC 34.   O’Donnabhain underwent sex reassignment surgery, including breast augmentation surgery, in 2001.    The tax court found that the transgendered taxpayer’s gender identity disorder (GID) qualified as a “disease” for the IRS’s definition of medical expenses, and allowed deductions for hormone therapy and sexual reassignment surgery.  But, breast augmentation surgery, was found to be a nondeductible cosmetic surgery in this case.   The 61-page decision in this case makes many references to the World Professional Association for Transgender Health’s standards of case.  (You can find the decision on RIA Checkpoint or CCH Intelliconnect, available through the Newman Library’s databases.  There are many news stories about it.)

Although there are many possible resources, I found two recent articles on SSRN that provide some information:

LGBT Taxpayers: A Collision of ‘Others’, Anthony C. Infanti, University of Pittsburgh-School of Law Georgetown Journal of Gender and the Law, Forthcoming, University of Pittsburgh Legal Studies Research Paper, No. 2011-11.  This comments on the O’Donnabhain v. Commissioner decision.

Removing the Constraints to Coverage of Gender-Confirming Healthcare by State Medicaid Programs
Iowa Law Review, Vol. 97, No. 4, 2012
Nicole Marie True
Iowa Law Review

The True article provides the states, including New York State, that do not allow Medicaid to cover sexual reassignment surgery for transgendered and makes references to the previous mentioned Dutch and Belgium studies providing an estimate of people in The Netherlands and in Belgium who have undergone sexual reassignment surgery.

I’ll show my age but more than 30 years ago, when I was an undergraduate at the University of Iowa, the first “sex change” operation done at the University of Iowa Hospital was headline news.  I thought of this when I thought of how easily the student approached me with the reference question seeking comparative data.  I thought it would be available, but for all kinds of reasons, from personal to policy,  it isn’t.

While much progress has been made, much remains to be made in providing health care for all.  I hope this information is helpful.