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Sandra Fluke -- the Georgetown University law student and women's rights activist who was excluded from the congressional hearing on access to contraception and then was labelled a "slut," "whore" and more by Rush Limbaugh following her talk to Democratic members of the House of Representatives -- is now being characterized as "a liberal activist pushing some rather radical ideas" for advocacy she has done for health care coverage of genital reassignment surgery for transsexual men and women... as if that would somehow make the epithets acceptable.

I wrote about this in 2009, but it's worth repeating.  Because Fluke's position on that subject is not a "radical liberal idea," but rather the prevailing position of the medical establishment.  Here's why.

Popular opinion has it that Gender Reassignment Surgery (GRS, often popularly nicknamed "sex change surgery") is a cosmetic issue and motivated by a simple "want" to be female or male, by someone who was not born as such. However, extensive medical research into transsexuality dating as far back as the 1920s and continuing through modern studies have demonstrated otherwise, and consequently, medical standards of care have included GRS as a necessary procedure for decades. In order to understand this, people will honestly need to put aside preconceptions for a moment -- and also realize at the same time that most transsexuals would rather see a health system in which preventative and quality-of-life treatments were uniformly covered, rather than one in which someone's eye surgery or tendon issues are not, thus creating fighting amongst people in simultaneous need.

The experience of being transsexual involves one's entire identity. They attempt to hide who they are, living a lie that feels unnatural in order to live up to others' expectations, the hiding driven by a spiralling sense of shame and self-loathing, until it becomes an experience many liken to "suffocating," or vents itself in an explosion of frustration. Transsexuals are unable to explain why they feel that their gender should be something different than their birth sex, and sometimes spend years attempting to mask themselves, to "pass" as the gender that society expects them to be. This restricts their ability to function socially, emotionally, psychically, spiritually, economically (it’s hard to be productive while constantly feeling out of one’s element and/or “backwards”), maybe sexually, and leaves them often suicidal as a result. If this continues into later adulthood, often a crisis point is reached in which the person suffers a complete emotional collapse.

“Gender Dysphoria” is the name for this condition, and treatment follows the standards of care established by the World Professional Association of Transgender Health (WPATH, formerly HBIGDA), which includes GRS. No less than the American Medical Association has stepped forward advocating the necessity of surgery and its coverage. In fact, like the AMA, the American Psychiatric Association and their Canadian counterparts support GRS as a medically necessary part of treatment. It was partly for this reason that the Ontario Human Rights Commission ruled in 2008 that that Province should restore coverage of the procedure.

Treatment of Gender Dysphoria encorporates surgical and endocrine intervention, because analytical and aversion therapies have historically proven damaging. As much as mainstream society would like to believe that electroshock therapy, anti-psychotic drugs or conversion ("ex-gay") therapy would help transsexuals “just get over it,” modern medicine has realized that this approach simply does not work, and usually results in suppression, suicide or extreme anti-social behaviour. Aligning body to mind, however, has enabled transsexuals to become valued and successful people in society. There are, in fact, a few transsexuals who feel that they can live without having GRS, but they are the exception and not the rule.

Gender Dysphoria (sometimes called "Gender Identity Disorder," or GID) is currently listed as a mental health issue, but ongoing study of both genetic ”brain sex” and Endocrine Disrupting Chemicals (EDCs) show the possibility of some biological causal factor. In a study released in October 2003, UCLA researchers identified 54 genes in male and female mouse brains that led to measurable differences by gender, and went on to indicate the possibility of a brain being gendered differently to one's physical sex. Studies of EDCs show another, possibly concurrent potential that exposure to chemicals that simulate hormone characteristics -- particularly between the third and eighth week of pregnancy -- can affect the signals sent out to determine psychological gender and biological sex, which appear to develop at different times during gestation. In all fairness, nothing is conclusively proven at this point, and there is not a lot of research money being put into further study, as most pharmaceutical companies do not yet see a payoff from doing so. But the anecdotal and observational data from EDC and brain studies of human and animal populations would tend to support an innate origin or component of transsexuality, and coincides with transsexuals' convictions that they "just knew" that they were female (in the case of male-to-female transsexuals) or male (in the case of female-to-males).

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.

Transsexuality is not widely known or understood in mainstream society, and should not be confused with other aspects of the larger transgender (an umbrella term) culture. Although much sensationalism can be made of something like medical coverage of Gender Reassignment Surgery, the realities paint a very different story.


Equality Matters has some additional information.  

Previously published in 2009 at The Bilerico Project and Dented Blue Mercedes, and on my behalf at DailyKos.

Originally posted to DentedBlue on Wed Mar 07, 2012 at 10:42 AM PST.

Also republished by LGBT Kos Community and TransAction.

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Comment Preferences

  •  thanks for this!!! (6+ / 0-)

    you have a great voice and thank you for adding it to our common well being

  •  Recc'ed in the hopes that this gets the eyes it (4+ / 0-)
    Recommended by:
    jessical, Deep Texan, DvCM, MercuryX23


    Is it true? Is it kind? Is it necessary? . . . and respect the dignity of every human being.

    by Wee Mama on Wed Mar 07, 2012 at 11:04:40 AM PST

  •  Recc'ed and republished (3+ / 0-)
    Recommended by:
    jessical, DvCM, MercuryX23

    Because people who don't have this issue don't think about it at all, never mind enough, and we should!

    All it takes is security in your own civil rights to make you complacent.

    by Dave in Northridge on Wed Mar 07, 2012 at 11:11:11 AM PST

  •  oh my (4+ / 0-)
    Recommended by:
    FogCityJohn, Deep Texan, DvCM, MercuryX23

    I'll try to come back to this today.  Thanks for writing it and good luck.

    Here's a little underview, for those who may be new to the subject...

    1. Not all trans people need or desire surgery.  This is important.
    2. Trans people take hormones.  In the case of MTF trans people, surgery is more than about body shape -- it is also about hormonal profile over the course of one's life, and health.  
    3. GRS is only one quality of life medical intervention important to trans people.  In the more enlightend european states, facial and other surgeries necessary to living an ordinary life are -- to a limited but nontrivial degree -- also covered.  Having a life that doesn't suck is a medical issue.

    It is worth noting that this is a very very difficult discussion to have.  I expect most commenters will be either strongly supportive or downright nasty.  My experience with this subject on here is largely of the form -- never has popcorn tasted so bitter.  

    It is also worth noting that GRS is a set peice, per costs.  It compares favorably to a year of an expensive medication, and improves the lot of those who desire it and undergo it in myriad ways.  There are not very many of us.  If one wants to have a fight about medical costs, there are many better bones to pick.

    ...j'ai découvert que tout le malheur des hommes vient d'une seule chose, qui est de ne savoir pas demeurer en repos dans une chambre.

    by jessical on Wed Mar 07, 2012 at 11:18:17 AM PST

    •  Yes, (4+ / 0-)
      Recommended by:
      Deep Texan, jessical, DvCM, MercuryX23

      Not everyone is able or willing to undergo a major medical procedure.  I myself lived as decidedly non-operative for a number of years before coming to realize that I personally needed surgery in order to achieve closure.

      This can be a complex discussion of its own, which is why I didn't get too far into it here.  However, for those who might be looking to resolve how this can be, there can be a few different factors at play.

      The most obvious factor is the body "squick" (i.e. revulsion) that transsexual individuals often (but not always) feel about their existing genitalia.  For some, this can be severe, to the point where a person becomes tempted to self-harm -- for these folks, GRS becomes an absolute necessity.  For others, this feeling might not be as strong, and sometimes not present in any conscious or life-affecting way.

      Another main factor is related to identification (discussed above), and the ability to move on from trans-anything to achieve full closure.  This is one of the main values of GRS: to enable an individual to enter a productive life where trans issues aren't a distraction or source of anxiety.

      And while transsexuality isn't about the act of sex, a transsexed person's partner's preference can sometimes be a factor in a decision about surgery.

      Feel free to add if there's anything relevant I missed.

    •  Should all body image surgery be covered? (0+ / 0-)

      Would this extend to plastic surgery of a more general nature?

      If we're going to mandate coverage of "quality of life" surgeries, surely at the very least liposuction for the obese and/or stomach rings should be covered.

      It just seems like a very slippery slope.

      •  See the phrase "more than"? (2+ / 0-)
        Recommended by:
        DvCM, jessical
        In the case of MTF trans people, surgery is more than about body shape
      •  here we go... (0+ / 0-)

        you're poking to make your point, and I'm responding, which isn't good.  

        But here goes.  How about a little common sense?  If someone is going to be a laugingstock because of how they look, then medical insurance should -- if it is reasonable, for a cost that is not obscene, and within the bounds of a humane person's good sense -- cover helping out.  

        If someone is so heavy that they can't get a job or function in society, and there are deep issues which prevent them from fixing it by other means,  then you bet it should be covered.  Enough to make everything nifty for everyone?  No.  Enough that people can simply function in society, to the view of a reasonable observer?  Yes.  That's how the richer nations of the EU handle it.  

        But you aren't arguing about that, I think.  

        ...j'ai découvert que tout le malheur des hommes vient d'une seule chose, qui est de ne savoir pas demeurer en repos dans une chambre.

        by jessical on Wed Mar 07, 2012 at 04:51:53 PM PST

        [ Parent ]

        •  So what wouldn't be covered? (0+ / 0-)

          Only ineffective surgeries?

          What I'm kind of dancing around is this issue is going to come up, and legally, they're going to be difficult to distinguish.

          •  What you are actually doing (1+ / 0-)
            Recommended by:

            Is attempting to negate the very real and necessary reasons for providing access to SRS by conflating the surgery with a cosmetic procedure.

            I'll tell you what I tell anyone who says this to me. I am grateful that you do not suffer from what I do. That you do not know the pain...the anguish of having a physical sex that does not match up with the way your brain perceives it should. That you cannot understand that even for a trans person living full time in the gender role that matches your brain, it does not change the fact that there is still an ever present physical indicator, a cruel reminder that your body sex does not align with your brain sex. And that it is so painful that you consider ending things because it is often too much to bear.

            I am grateful that you do not suffer as I do. Nobody should.

            "And every wave is tidal, if you hang around you're going to get wet." - Elliott Smith

            by MercuryX23 on Thu Mar 08, 2012 at 05:14:41 AM PST

            [ Parent ]

            •  ...right. (0+ / 0-)

              I can see myself getting that exact same speech with a few minor details changed from an Anorexia Nervosa sufferer.

              •  And so... (1+ / 0-)
                Recommended by:

                You really don't understand a thing, then.

                "And every wave is tidal, if you hang around you're going to get wet." - Elliott Smith

                by MercuryX23 on Thu Mar 08, 2012 at 08:21:23 AM PST

                [ Parent ]

                •  I think... (1+ / 0-)
                  Recommended by:

                  ...that in my earlier years of participation on this site, I learned just how completely many people conflate trans with simple mental illness and delusion, and how deeply some people enjoy the fact we put ourselves out there on subjects like this, because it lets them make their point over and over.  I chose to play, my bad.  

                  I think the respondent understands full well what he (I presume he) is saying: that trans people are asking for a medical procedure to mask a mental illness, and gender is an immutable gift of god/biology/his brother fred.  There isn't any winning, and arguing with folks like that will just lead to an excess of stomach acid and an early grave.  

                  It was useful to find out on here how many people think that way though.  I don't know if that is a good thing to know or not.  It has informed my life, and not in a good way.  There are ways in which being online here has given me broader and more interesting perspectives on what it means to be a person, which is why I'm still online.  And I'm grateful for that.  And there are ways in which I've learned that a significant proportion of the body politic regards us as simply insane and grotesque and contemptible.  I think I'm poorer for that, and less kind to myself and others.

                  ...j'ai découvert que tout le malheur des hommes vient d'une seule chose, qui est de ne savoir pas demeurer en repos dans une chambre.

                  by jessical on Thu Mar 08, 2012 at 02:49:29 PM PST

                  [ Parent ]

  •  The Catholic press (0+ / 0-)

    thinks we are so far beyond the pale that Ms. Fluke is discredited advocating insurance inclusion for us.

    It's not bad enough that these over-educated "co-eds" (and who uses the word "co-ed" anymore?) want to control their own bodies -- when we all know that the GodFather and His holy spokesMEN are supposed to do that. They also want people to control what sex they are.

    That would bring down the patriarchal temple. Your sex is a life sentence direct from the GodFather. You are not supposed to be able to break out of His jail.

    If the spokesMEN of the GodFather allowed that, the next thing you know women would be demanding the Church return all the sacred places of the Goddess they stole to build their cathedrals on....

    They sure aren't making the new generation of feminists like the old one... Janice Raymond fully agreed with the Holy SpokeMEN of the GodFather and got us denied insurance coverage. Probably no one still remembers that except for those of us who tried to transition before the Internet created DoItYourselfHRT and affordable Thai surgery...

  •  By the way, (1+ / 0-)
    Recommended by:

    ... portions of this article are available as a trifold brochure, to use in educating people on the subject.

  •  Thank you for this... (0+ / 0-)

    As a woman of transsexual history, I appreciate this brilliant article, and it's support for Sandra Fluke's lesser known, but no less important activism.
    Now, more than ever, she is a hero to me.

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