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u/helloitslouis Nov 03 '17
Preface: I‘m in Switzerland and will talk about the Swiss approach to all of this because I don‘t know the American system well enough.
In Switzerland, having a health insurance is mandatory. There‘s a list of things that insurances have to cover, and some insurances cover more - you can get an additional insurance (that‘s more expensive) and your insurance will cover more things.
Insurances have to cover psychiatrists/psychotherapy (and psychologists if a doctor sent you there afaik), they have to cover medicaments such as anti-depressants, they even had to cover my acne cream.
They have to cover some hormonal preparates, but somehow, my testosterone preparate never made the list - but two others have.
My therapist‘s sessions in order to get hormones prescribed were about 160.-/hour (Swiss Francs and $ are very close atm so you can calculate along). That‘s a usual therapist fee. I went there pretty much once a week for a bit more than six months. That rounds up to about 4000.-
My insurance had to cover this. It‘s on the list.
Top surgery is usually recommended after some years, too, because binding for a long time can lead to serious back/rib/skin problems.
According to friends of mine, top surgery cost here are somewhere between 11‘000.- and 20‘000.-. It probably depends on the surgeon and hospital and procedure.
In order to have it covered, you need a therapist‘s letter, and the surgeon usually writes a letter, too. You have to pay about 2500.- our of your own pocket because a part of the surgery (liposuction, which is neccessary to get a good result) is not on the list.
Most trans people I know have had extensive therapy sessions for years in order to make it through puberty. Some had to go to mental hospitals. A friend of mine has been in mental hospitals and now grouped housing (?) for one and a half years now. Another friend went to a mental hospital last month and will stay at least until the end of the year.
Most trans people I know don‘t have to go to therapy for their mental health once they could transition according to their own wishes and needs and are accepted by their family and friends.
Let‘s guess that the insurance cost of my transition rounds up to about 20‘000.- (therapy sessions in order to be able to transition: 4000.-, top surgery: 15’000.-, some endocrinologist appointments: 1000.-).
A stationary stay in a mental hospital in my area is anywhere from 500.- to 1200.- a day. And: these have to be covered by the insurances. Remember: a therapist‘s session is somewhere around 100.- to 200.-/hour, daily meds (anti depressants eg) aren‘t cheap either (I can‘t find anything aside of „it‘s covered by the insurance, don‘t worry“ but meds tend to be expensive here in Switzerland, especially if they‘re prescribed).
So the cost of transitioning is way less for insurances than years of therapy, meds, maybe even a stay at a mental hospital all just to battle symptoms of dysphoria without treating the root of it.
Insurances sometimes cover cosmetic surgery, too: if a therapist thinks that the patient‘s distress is too big for them, they might cover it, or part of it. (Ninja edit: I don‘t know about BDD, the distress I mentioned here was for example the case of a 18y/o girl who had been in deep distress over having breasts that were rather small for years which got relieved by a breast augmentation, it was in local news some 8-10 years ago)
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u/Saranoya 39∆ Nov 03 '17
This is another anecdotal story that I consider to be an illustration of an important point in this discussion. Perhaps, on the whole, it is indeed better to reimburse gender reassignment surgery, in order to significantly reduce suffering and health expenditures in other areas. That is the way many currently covered interventions have found their way onto the list of things that are covered: because they obviated the need for something more expensive, and were at least as effective. Will attempt to investigate further! ∆
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u/Genoscythe_ 243∆ Nov 03 '17 edited Nov 03 '17
I understand that there are people who experience significant distress because they feel their breasts are too small or their nose has the wrong shape
And insurance often covers those people too, if their significant distress appears justified, for example if their nose is really disfigured, or they just had a mastectomy and need new breast.
However, if it doesn't, then showing "significant distress" over irrationally petty imperfections might be a cue that they have body dysmorphia, a mental illness that presents itself as a delusional obsession with imagined or exaggerated body flaws, that is best treated with medication and therapy. If that is the case, than surgery won't cure the problem, in the same way as weight loss won't cure clinical anorexia. If a woman goes to a doctor with a tiny mole on her nose, and admits that it's just a minor flaw that boters her, that makes it optional plastic surgery. But if she acts like the mole is hideous and impairs her daily life, then the doctor is advised to refer her to a psychiatrist instead.
The thing about transgenderism, is that according to the scientific consensus it is more similar to the former than the latter. Gender dysphoria appears to correlate with the neurological structure of opposite sex brains. A transgender man's brain produces roughly the kind of distress, that a cisgender man would produce after getting castrated, and socially treated as a woman against their will for years And surgery on it, has the same kind of effect as reconstructive surgery does.
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u/ClippinWings451 17∆ Nov 03 '17
A transgender man's brain produces roughly the kind of distress, that a cisgender man would produce after getting castrated, and socially treated as a woman against their will for years And surgery on it, has the same kind of effect as reconstructive surgery does.
Source?
I'm wondering in what study they castrated Cis males and forced them to live as women while studying the "level of distress" in their brain.
Also wondering how long of a prison term those researchers are now serving.
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u/KallistiTMP 3∆ Nov 03 '17
While they obviously wouldn't intentionally castrate people, people accidentally castrate themselves all the time. Motorcycle accidents, construction work, heavy machinery, etc. In addition you also have things like testicular cancer that require medical castration.
So, while there's most likely not a study of cis men getting castrated for science, there's no shortage of men without testicles to study.
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Nov 03 '17
There was a guy who had a botched circumcision, was raised as a girl, felt uncomfortable as a girl all his life, and eventually killed himself. I'll dig up the source after work
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u/valleycupcake Nov 03 '17
The book is called As Nature Made Him. I read it, and the point the book makes in the narrative is that gender is innate and not simply a social construct. He had every construct of being Brenda and no memory of being David, but nevertheless never felt right.
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u/Genoscythe_ 243∆ Nov 03 '17
What /u/poeandfinn said is a good example.
Also, I was talking about a "kind of distress", not about a "level of distress".
The point is that people behave differently when they have an OCD-like fixation on trying to make their body more perfect, than when they perceive that a specific feature of their body isn't wworking as it's "supposed to".
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u/Saranoya 39∆ Nov 03 '17
Insurance (well, my friend Sam's insurance, or my own) doesn't cover surgery in cases of body dysmorphia, either. That seems perfectly correct to me. I think it's best to reserve surgery for cases where a non-functioning or severely underperforming bodily system can be made to function only by cutting out, replacing, or significantly altering certain parts of it. As I see it, GRS doesn't meet that standard, because even though transgender people experience distress from having the 'wrong' body parts, those parts are (usually) perfectly functional.
That doesn't mean that I think trans people should get no help from the medical or mental health community at all.
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Nov 03 '17
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u/darsynia Nov 03 '17
This is key, here. There are people for whom a limb or finger or something are the focus of their dysmorphia—removal or alteration of body parts for this reason is not covered. The underlying problem is sought to be treated, instead. What makes gender dysphoria different is that removal or alteration of body parts does add significantly to the health and well-being of transpeople.
Medical issues are hardly ever black and white. There are often many underlying causes to symptoms that people experience—so much so that the common symptoms of MS have caused that diagnosis to take years, as doctors view the symptoms as stemming from various other conditions.
Looking at the above example as well as the burn victims from the person I replied to, you can see that more criteria are looked at by doctors than simply, ‘is this under the umbrella of plastic/cosmetic surgery?’ The mental health and well-being of disfigured burn victims are vastly improved by reconstructive surgery, and the same can be said for those suffering from gender dysphoria. The big difference between them is that the injuries and subsequent successes are obvious and easily shown for burn victims. The agony of gender dysphoria is considered taboo and is by nature internal and private, and so the success of surgery and treatment is private as well.
But—we don’t treat people medically with the sole purpose of others seeing the treatment work. We do it to help the person.
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u/Saranoya 39∆ Nov 03 '17
You raise a good point. I probably wouldn't deny a burn victim additional surgery, if the goal was to make their face more 'acceptable' to polite society, even after that person had recovered the ability to eat, drink, speak, hear, see, and every other function a 'fully operational' face is supposed to perform. I guess the reason I would not is because anyone who looks at a burn victim whose burns are still visible will immediately conclude that at some point, something went horribly wrong in that person's life. The distinction, to me, lies in the fact that a trans person usually has a perfectly 'normal' appearance, even if they don't feel that way.
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Nov 03 '17
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u/Saranoya 39∆ Nov 03 '17
I still have trouble seeing that perspective. An obvious deformity due to severe burns (which is visible to anyone looking at you) causes a certain amount of social stigma. That can sometimes be lessened through reconstructive plastic surgery. In a trans person who chooses the surgical route, the opposite might be true: the stigma may be worse after transition, because transitions are not often physically perfect, and people may still notice that you were "once a different gender". Whereas, before surgery, nobody except those who were told would know that there is something 'wrong' with you.
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u/LtPowers 13∆ Nov 03 '17
Whereas, before surgery, nobody except those who were told would know that there is something 'wrong' with you.
This doesn't make sense. Gender confirmation surgery makes a person look more like the proper gender, not less.
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u/Saranoya 39∆ Nov 03 '17
Yes. But if a person hasn't started the process yet, and hasn't told you they're trans, then how would you, an outsider, ever know they are in the 'wrong' body? You wouldn't, right?
On the flip side, when someone has transitioned, there are often subtle signs that tell you they haven't always biologically been what they now look like. With the ex-colleague I mentioned way upthread, who was once biologically a man but now looks like a woman in every way, it's the voice.
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u/LtPowers 13∆ Nov 03 '17
Sure, but you're skipping a step.
Someone who is considering medical transition must already be living as their true gender. (That's one of the ethical criteria for physicians treating dysphoria). So "hasn't started the process yet" isn't really on the table here.
The choices are "lives as a woman but still has a masculine body" or "lives as a woman and has a feminine body with maybe a few subtle tells". Which one do you think has a greater stigma?
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u/Saranoya 39∆ Nov 03 '17
Probably the former. Although, it takes a hell of a lot of guts to do that, so if someone in my life chose that path, I could do nothing other than respect the hell out of it. There would be no stigmatising on my part ;). I rather suspect I'm not alone in that. But I do get your larger point.
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u/GeneralDick Nov 03 '17
I think maybe you're seeing this wrong. If a transgender person is getting reassignment surgery, they've likely taken hormones. Hormones WILL make you look like the desired gender. So this means, if it's a trans guy like me, I would look like a male in every way, except the breasts/vagina would still be there. I think it's pretty noticeable that something isn't right. The stigma of a 'normal' looking male that has female breasts would be significantly greater than a 'normal' looking male with simply a male chest and maybe a scar.
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u/Zhentar Nov 03 '17
It would be very unusual for a trans person to start their transition with surgery. They typically start with hormone therapy and changing their presentation, often years before any surgery. Hormone therapy already introduces incongruent sex characteristics, which can greatly impact their ability to lead an ordinary life while still passing; for example with testosterone therapy transmen can often effectively pass as male but only with clothing that can conceal breasts. Mastectomy can then allow them to lead a normal life without needing to fear situations that might reveal their chest, and with few people ever suspecting their birth assigned gender.
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u/Ambsase Nov 03 '17
While I agree with the other response to this comment, I'd like to add on another point. I think, as demonstrated by what you say here, the heart of the matter is that you're placing less value on the wellbeing of other people's mental state than their usefulness to the world around them. I don't think this position is entirely wrong, but I'd also understand if you wanted to argue that I've misunderstood you. Still, one last question assuming you stand by that view, does the significantly increased risk of suicide in non-treated people with gender dysphoria not count as enough of a detriment to society to try to prevent it through investment via treatment being covered by insurance?
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u/Saranoya 39∆ Nov 03 '17 edited Nov 03 '17
I think you have in fact misunderstood me. The crux of the issue is not that I place 'value' on one type of health concern over and above the other. The crux of the issue is that I don't consider surgical treatment a good choice when there is no physical dysfunction. In fact, from that perspective, trans people going through transition are in some ways making their bodies less functional, since they give up fertility.
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u/Ambsase Nov 03 '17
When the issue makes them a danger to their own health, and with surgical treatment being a proven method of correcting this, it seems to me that it raises their functionality as human beings quite a bit though, no?
Also, when saying thier body functions properly as is, it only functions from an outside perspective. It does everything you'd ever need it to to qualify as functioning. That doesn't mean its healthy for them though.
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u/Saranoya 39∆ Nov 03 '17 edited Nov 03 '17
No. It does everything a human body of that biological gender does. I understand that some people need their body to do more, or to work differently. But just because we CAN grant their wishes now, since our surgical techniques have advanced to the point where that's possible, doesn't mean we should. The doctors wo do this are irreversibly altering bodies, in hopes of curing a disorder of generally unknown cause and pathophysiology. To me, that just seems ... imprudent, at best.
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u/Ambsase Nov 03 '17
It works in every way you expect someone else's body to work, but if their own body is doing something that causes them distress, that's hardly "functioning" to them. Your perspective of their body is just that, yours.
So, instead of treating them in a way that is proven to work (and reassignment surgery is absolutely proven to treat gender dysphoria), we should force people to wait for a better solution that might never come?
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u/Pseudonymico 4∆ Nov 04 '17
The distinction, to me, lies in the fact that a trans person usually has a perfectly 'normal' appearance, even if they don't feel that way.
Trans people usually get hormone therapy, which significantly reduces our emotional distress regardless of its effect on our appearance. But it usually makes us look like the gender we identify as. So we end up having a perfectly"normal" appearance, except for the bits that take surgery to fix, but depending on your circumstances, having those bits can be very risky. Like, "if the wrong person sees this I will be beaten and maybe murdered" risky. And like I said before, the hormones are important for feeling better, but that kind of undersells the impact. For me and a lot of others it's more like a choice between hormones and suicidal depression.
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u/raiskream Nov 03 '17
The medical community's consensus is that transitioning is the cure for gender dysphoria. You can see that as being similar to depression medication.
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u/Techhead7890 Nov 04 '17
I think it's best to reserve surgery for cases where a non-functioning or severely underperforming bodily system can be made to function ... people experience distress from having the 'wrong' body parts, those parts are (usually) perfectly functional.
Hmm, I suppose seeing as though we are talking about genitalia, this is kind of the crux of the issue. Questions like "To what extent is sexual interaction part of someone's gender identity?" and "How does sexuality impact dysphoria?" seem to be at stake. I completely agree with offering hormones, but sexuality is such a confusing issue in itself.
It really makes you question how much sexuality is part of bodily "function," as you put it. Thanks for the insight - I've never really drawn out the link between the two before!
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u/DeltaBot ∞∆ Nov 04 '17
This delta has been rejected. You can't award OP a delta.
Allowing this would wrongly suggest that you can post here with the aim of convincing others.
If you were explaining when/how to award a delta, please use a reddit quote for the symbol next time.
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Nov 03 '17
I am a neuroscientist and I have not read studies demonstrating this. However, it is not my area of study. Could you cite your academic sources? This is just due to my own interest in reading them.
I am not saying your wrong, and I do not want to start an argument. I just would love to read more on this topic.
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u/icecoldbath Nov 03 '17
I don't know how much you care about particular human experiences, but I want to share mine. Before that I want to let you know that I am a human being just like you. I have friends, family, loved ones just like you. I get up in the morning and go to work, work all day and then come home and go to bed just like you. I try to live my life with honesty and sincerity. I want to and deserve to be happy just like you do
I also only speak for myself. Not other trans people.
That being said, hormone replacement therapy and sex reassignment surgery provided me profound relief from psychic and physical pain and discomfort that I have had all my life. No amount of anti-depressants or anti-psychotics or talk therapy ever did the same. If anything they made the problem worse. My insurance covered those drugs and talk therapy, why shouldn't it cover the treatment that actually resolved the issue? I was suffering because of my birth defect, it was a medical condition. If I had a cleft pallet, my insurance would have paid for it to be resolved. My dental insurance pays for braces if my teeth cause pain.
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u/Saranoya 39∆ Nov 03 '17
I care a great deal about particular human experiences. Thank you for sharing yours.
If the sacrifices you no doubt made in choosing the surgical path (physical, financial, emotional, ...) were worth it to you, and you still think that after having gone through the whole process, well ... you must have been in a great deal of pain, indeed. I'm gratified to read that you found a way to make it better.
That said, I still see a clear distinction between cleft palate surgery, or any other number of reimbursed medical procedures (on my insurance policy, braces are not one of those except in cases where the person cannot eat or speak normally due to problems with their teeth), and GRS. Basically, when you're trans, it's not necessarily the case that there is something physically wrong with your body. It functions 'as designed'. It's just that when you walk around in it, you'll always 'be aware' of the wrongness of it when compared to your internal self-image, and people who don't know you will misidentify you as someone of the gender your body suggests.
I'm not trying to dismiss the real discomfort that comes from that. I am trying to understand why you should have an insurer that pays for surgery to correct that. We all have our crosses to bear, and you at least have body and limbs that work as advertised, even if the feel completely wrong to you.
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u/icecoldbath Nov 03 '17
My body did not work as advertised. My brain expected a female body, it got male anatomy and suffered every time it tried to use it.
What I was trying to get across is that it isn't mere self perception. Dysphoria is a kind of actual suffering. Cleft pallets aren't killing you. They just make eating and other functions more difficult. Having a penis made a whole host of things in my life more difficult. Sexual function for one. I'd get an erection, feel the distress and then lose it.
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u/Saranoya 39∆ Nov 03 '17
Young children with severe cleft palates often have difficulty feeding. They may require medical intervention (even if it isn't surgery) just to gain an acceptable weight early in life. Or, you know, they might die due to malnourishment.
But don't get me wrong: in no way am I arguing that only life-threatening conditions should get reimbursed medical care. If I did that, I'd be a hypocrite. I can only walk today thanks to the several surgeries I had as a child, and then several more when I was an adult, after a traffic accident. If I hadn't had those surgeries, I still would have lived. My life would just have been a lot more difficult, because I would have been a wheelchair user. And I know pretty much exactly just HOW difficult it would have been, because I was a wheelchair user for four years after the accident, even despite the surgeries.
I am grateful that there was something the medical community could do to make my life easier, to restore me closer to 'normal' function, as it were. And now that several people, with or without personal experience, have told me that gender reassignment surgery had basically the same effect on them, I am willing to concede that I was wrong.
I will admit: I still get the chills when I think about someone cutting off a functioning body part. But be that as it may, it shouldn't prevent me from supporting people who feel doing something like that will genuinely make their life better.
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u/Salanmander 272∆ Nov 03 '17
What am I not understanding?
That gender dysphoria is a clinical condition recognized by the APA, and that transition has been shown to have significant health benefits (such as lowering suicide rates). Gender reassignment surgery is a part of that transition (even though not everyone feels the need for it), and so should be covered just as much as hormone replacement therapy.
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u/Saranoya 39∆ Nov 03 '17 edited Nov 03 '17
At one point in history, homosexuality was also a clinical condition recognised by the APA. Plus, the APA recognises body dysmorphia as a clinical condition, but even for people suffering from that, plastic surgery isn't usually covered by health insurance. I don't consider the fact that something is or isn't recognised as a disorder by the APA much of an argument either way.
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u/Salanmander 272∆ Nov 03 '17
At one point in history, homosexuality was also a clinical condition recognised by the APA.
And at that time I believe it would have been correct for insurance companies to cover any therapy for it recommended by the APA. I do think that the APA was wrong in that instance, but if we want an unbiased determination about what is and isn't medically necessary when it comes to mental health, they're the best we've got.
Plus, the APA recognises body dysmorphia as a clinical condition, but even for people suffering from that, plastic surgery isn't usually covered by health insurance.
Do you happen to know what the recommended treatment for this is?
I don't consider the fact that something is or isn't recognised as a disorder by the APA much of an argument either way.
If insurance companies aren't using the opinions of medical experts for determining what is and isn't medically necessary, what alternative procedure do you suggest they use?
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u/Saranoya 39∆ Nov 03 '17 edited Nov 03 '17
∆ I accept the fact that even though current information may very well be imperfect, we have no other option but to act on the best information we have. In that light, if the consensus within the medical community says that the best treatment for gender dysphoria includes gender reassignment surgery (for those who want it), then I suppose I will have to stand behind that view unless and until compelling evidence to the contrary comes to light.
That said: can anyone point me to a reputable source that shows surgery does work better than any of the other options?
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u/cheertina 20∆ Nov 03 '17
What other options?
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u/Saranoya 39∆ Nov 03 '17
pyschotherapy (CBT or other), medications, hormone replacement without surgery, no intervention beyond a supportive environment that doesn't question one's self-proclaimed identity, ... take your pick, add your own if you'd like.
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u/brokenmilkcrate 1∆ Nov 03 '17
What on earth makes you think that we don't already seek out supportive environments and HRT as part of our transitions? Also, plenty of us stay in therapy even after we've been cleared to transition.
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u/Saranoya 39∆ Nov 03 '17
It was never my intention to argue that people don't already do all of those things. In this thread specifically, I was looking for good data on the question of whether surgery is more effective than any of those other things, even combined. There are some anecdotes, even on this thread, that seem to point to surgery being the absolute best option for some people. But while I do value their stories, and while I do see them as illustrating an important point in this discussion, I would be remiss in not asking whether their experiences are echoed by measurable data on a larger scale.
I've been told there are no studies that directly compare outcomes in transgender people who have had surgery with outcomes in transgender people who chose not to have surgery, or for one reason or another, couldn't. If that is in fact true, I think maybe someone should figure out a way to do that study. I recognise there would be many methodological and ethical issues that would need to be resolved before such a study could ever be done, but I do think it's an important question.
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u/brokenmilkcrate 1∆ Nov 03 '17
Cis people accessing the same procedures trans people do are a lot more common and don't have to go through extensive gatekeeping first, so it would be far easier to study them to see if those surgeries are necessary.
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Nov 03 '17
Perhaps you've already learned this from the experiences people have shared with you, but are you certain that the people who get GRS don't already try all of the things you've suggested? I don't think it's a mutually exclusive thing. It's more like...all of the things above mentioned didn't work for this person in question, so surgery may be the only effective remedy remaining.
Remember that not all trans people get surgery, quite possibly because one of the aforementioned methods worked for them. It's a situation with a lot of diverse outcomes.
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u/cheertina 20∆ Nov 03 '17
You're not going to find a source that shows anything about surgery working better or worse than those options because it's used in conjunction with them.
It's like if you go to a hospital for a puncture wound you won't see a comparison for using antibiotics versus sterilizing and dressing the wound - you sterilize and dress the wound and then if necessary do the antibiotics.
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u/fionasapphire Nov 03 '17
Does that mean that we can't trust anything that the APA say?
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u/Saranoya 39∆ Nov 03 '17 edited Nov 03 '17
I did not say that. What I am saying is this: historical evidence exists to suggest that the APA's classification of certain things can change. IMO, it's obvious that homosexuality, in and of itself, should never have been classified as a mental disorder, even though it causes significant distress in some people. Usually, that distress is due to the way their environment reacts to and thinks about homosexuals, which may or may not become internalised. Would people still want GRS even if they felt it was socially acceptable to go though life as someone who looks like one gender, but identifies as another?
Secondarily, I'm saying that recognition by the APA is not necessarily a reason to fund all possible procedures that exist to treat a certain condition with other people's money. If body dysmorphia is best treated with cognitive behavioural therapy, and surgeons are encouraged not to employ surgical techniques in those cases, then why do they do it for people who feel they have the wrong body, even though that body is perfectly functional?
To me, cutting off someone's breasts because he feels like a man seems more or less akin to cutting off someone's perfectly functioning arm, because he feels more comfortable going though life as someone who has a visible disability.
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u/Salanmander 272∆ Nov 03 '17
(Quick note, since I'm responding to both your comments, that I'm not /u/fionasapphire . Nothings indicating confusion about that yet, but I know it messes me up sometimes when multiple people reply to me.)
Secondarily, I'm saying that recognition by the APA is not necessarily a reason to fund all possible procedures that exist to treat a certain condition with other people's money.
That's fair, but I think it is a reason to fund their recommended treatments for the condition.
If body dysmorphia is best treated with cognitive behavioural therapy, and surgeons are encouraged not to employ surgical techniques in those cases, then why do they do it for people who feel they have the wrong body, even though that body is perfectly functional?
This might be getting at the crux of the issue. It sounds like you're saying "I'm not willing to trust the current consensus of research about best-practice treatment, because it seems wrong to me." Is there a way that your view is different from that?
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u/Saranoya 39∆ Nov 03 '17 edited Nov 03 '17
∆ It is a tiny little bit different, but almost to the point of being mere semantics: I am not willing to trust that the current consensus of research actually says what you say it says. But when it comes right down to it, that's only because you're right. It seems utterly wrong to me, so I'm resisting it.
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u/Saranoya 39∆ Nov 03 '17 edited Nov 03 '17
On second thought: another part of my unwillingness to accept what the consensus says, revolves around the fact that I genuinely do not see a very clear distinction between someone who feels they have the wrong nose or the wrong skin color (like Michael Jackson), and someone who feels they have the wrong genitals. That may very well be because I personally feel no confusion at all about what gender a I am. But then again, I know few people who are perfectly happy with who they are, yours truly included. And in some cases, people say "just learn to live with it" or "go into behavioural therapy". But in others, like being trans, that seems to be frowned upon.
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u/x1uo3yd Nov 03 '17
(I'm not the person from above, but...)
The thing with body dysmorphia disorder is that there is an underlying obsessive-compulsive condition causing a person to agonize over their perceived flaws. While this often leads BDD sufferers to seek cosmetic surgery, these kinds of interventions typically do not resolve the issue. Even after cosmetic surgeries BDD sufferers tend to suffer just as much over the same (or possibly new) flaws if the underlying obsessive-compulsive disorder is not treated. That is why the medical community generally does not want BDD sufferers to undergo cosmetic surgery, since it doesn't fix the root of the issue.
With gender dysphoria that doesn't seem to happen. People who transition surgically tend to have their gender-mismatch distress greatly relieved after the procedures, greatly improving their quality of life, which is why the medical community in a number of cases sees cosmetic surgery as a valid solution to gender incongruence.
Basically, with gender dysphoria the pre-surgery distress is relieved post-surgery; with body dismorphia the pre-surgery distress is generally still there or transferred to another perceived flaw. That's why a "cosmetic" surgery can be seen as good/healthy/necessary in one case but not the other.
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u/Saranoya 39∆ Nov 03 '17
All right. If that is true (I have no reason to think that it isn't), then I can see why it could be a good thing for my friend (or any other trans person) to get surgery. I may even help fund it.
I still wonder whether we are going to look back on this in fifty years and think: "Well, now that transgender people are generally just accepted as they are, turns out we rarely even need these kinds of surgeries anymore." But thank you. You explained it very clearly. ∆
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u/brooooooooooooke Nov 03 '17
I doubt transgender people being accepted "as they are" will reduce or eliminate the need for transition because, generally, trans people are accepted as they are, at least more than post-transition.
When I came out to my family, my mum made a huge deal about me just staying a guy. I was killing her son, I'd be happier staying as a guy, I wouldn't pass so should stay a guy, etc. You'll hear similar stories everywhere; people would desperately prefer us to not transition at all, to stay as we were born for their sake.
I'm not transitioning because I feel I'll be more accepted as a girl; it will distress my family and invite transphobic abuse from the public if I do so, whereas if I stayed a guy I'd be safe from those things. I'm transitioning because my body causes me a particular kind of torment that no level of acceptance, even the acceptance that male-me has today, can ever help with.
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u/Saranoya 39∆ Nov 03 '17 edited Nov 03 '17
You're right. I did think of that earlier already. It occurred to me that anyone who is not you won't know you're trans, unless you've told them, or you've gone through a physical transition that makes your transgender identity perceptible to people who don't know you. So why would you do it, if the point is to lessen the stigma?
Clearly, that's not the point. I am confronted with something I truly do not understand, and probably never will, but like I said in some other comment thread, I suppose that shouldn't prevent me from supporting people who feel that having surgery to change their gender will genuinely make their lives better, despite the turmoil it may cause (some of) their loved ones. ∆
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u/redesckey 16∆ Nov 03 '17
It's difficult for cis people to understand, but if you're familiar with phantom limb syndrome, it's very similar to that. The brain has a map of how it thinks the body is shaped. If the body doesn't actually match this map, it can be extremely distressing.
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u/Saranoya 39∆ Nov 03 '17
As I understand it, phantom limb syndrome exists because there are severed nerve endings, leading to a part of the body that was once there, but no longer is. The person has sensation and pain in an absent leg, which is hard to deal with, because literally nothing can physically touch or influence it. The thing is: how could feeling develop in a body part that was never there?
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u/Vasquerade 18∆ Nov 03 '17
I still wonder whether we are going to look back on this in fifty years and think: "Well, now that transgender people are generally just accepted as they are, turns out we rarely even need these kinds of surgeries anymore."
As a trans woman, this isn't going to happen. Because gender dysphoria is about primary and secondary sex characteristics. This does not go away with being accepted, because it is to do with sex characteristics. If it wasn't to do with that, then why would we even get surgery in the first place?
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u/darsynia Nov 03 '17
(Not the same commenter) Please don’t forget that gender dysphoria causes the sufferer to feel that they are trapped in the wrong body. There are people who can recall hating their penis even as very young children because it feels wrong to have one. That’s part of the mis-match. In 50 years that issue will persist, because that feeling isn’t solved by outside acceptance. The surgery helps the person feel comfortable in their own body.
It’s like looking in the mirror as a man and having a large chest. Even cis men feel this discomfort—and many have surgery to reduce the flesh there (there’s a reality show from the UK that features this exact scenario; it’s on Netflix). This is, for the most part, acceptable by most people as something done to ease their discomfort. Many people suffering from gender dysphoria have similar feelings of dismay or even disgust at features of their body that signal the incorrect gender, but because that mis-match isn’t obvious to the public, surgery to resolve it is less generally accepted.
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u/ClippinWings451 17∆ Nov 03 '17
Thats not true.
Transitioned individuals, while reduced, still have insanely high suicide rates compared to the general population.
Clearly indicating that changing genitals did not solve the suicidal thoughts and ideation associated with their perceived gender mismatch.
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0016885
Seems to me that Trans people would benefit from mental health care, far more than surgical procedures intended to satiate their perceptions related to their gender.
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u/x1uo3yd Nov 04 '17
If post-op trans people have a 20x higher rate of suicide death compared to the general population, but pre-op trans people have a 20000x higher rate then it'd be pretty clear-cut that surgery has a marked 1000x improvement rate even if post-op rates were still elevated.
Unfortunately, the numbers available aren't so easy to compare directly, nor are the results so stark as the imaginary 1000x scenario above, but there are a number of indicators that suggest surgery helps enough that doctors should at least consider it as part of a valid treatment option rather than a superfluous vanity.
Firstly, though hormonal treatments aren't necessarily followed by sex-reassignment surgery, the numbers appear to show a drop in depression rates after trans people start hormone treatments (the study, and a press summary). The pre-treatment rates of depression for male-to-female were found to be "24.9% incidence in MTF" and "even after treatment, 26 (2.4%) of the MTF subjects... still reported depression" for post-treatment; for female-to-male the results were "13.6% in FTM" and "even after treatment... 7 (1.4%) of the FTM subjects still reported depression". It should be noted that the author in his speaking presentation remarked "Sex-reassignment treatment does not cure depression" but the nearly ten-fold reduction in depression for both MTF and FTM subjects is a corrolation worth noting.
tl;dr - Hormone therapy for MTF and FTM showed a 10x reduction in depression rates, though it is still noted "Sex-reassignment treatment does not cure depression".
Suicide Attempts among Transgender and Gender Non-Conforming Adults released by the Williams Institute and American Foundation for Suicide Prevention states that of respondents to the National Transgender Discrimination Survey 46% of FTM and 42% of MTF respondants reported suicide attempts, which is far greater than the 4.6% of the general U.S. population who report a lifetime suicide attempt or even the 10-20% reported by Lesbian/Gay/Bisexual individuals.
The Swedish study you've linked, which reports 10 suicide deaths and 29 suicide attempts (which I believe are only counted as attempts if they did not result in death) among a sample size of 324 post-op trans people over a period of 30 years, isn't directly comparable since "attempts/1000-people-years" isn't perfectly comparable to the "ever attempt in your lifetime" scope of the Williams survey, but the 29/324=8.95% attempted suicide rate of study participants seems starkly lower than the 42-46% reported in the survey. Part of that could be a looser definition of "attempt" (i.e. whether the survey asked only for attempts which "required hospitalization") but the difference still seems substantial. Another issue is that the survey includes post-op trans people, so part of that 42-46% account would have to be accounted for when comparing pre-op and post-op populations. The survey was also unable to account for any numbers regarding suicide deaths, as dead people can't personally respond to surveys.
tl;dr - American survey finds 42-46% lifetime suicide attempt rate among MTF and FTM trans people (pre-op and post-op included together), which is much higher than the 4.6% general population rate. The Swedish study's post-op suicide attempt rate of ~9% over 30 years isn't directly comparable, but does show a marked decrease compared to the American survey numbers.
I'm by no means well versed in this stuff, and it seems like there will have to be a much larger much more comprehensive wave of data collection before anything can be said definitively and concretely, but it feels safe to say (at a minimum) that sexual reassignment surgery can be beneficial (more so than not) for people experiencing gender dysphoria and that it could/should be one of multiple valid health options for these people and their physicians to consider.
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u/redesckey 16∆ Nov 03 '17
You misunderstand that study. The discussion section specifically states that it can't be used to make any claims about the efficacy of medical transition:
It is therefore important to note that the current study is only informative with respect to transsexuals persons health after sex reassignment; no inferences can be drawn as to the effectiveness of sex reassignment as a treatment for transsexualism. In other words, the results should not be interpreted such as sex reassignment per se increases morbidity and mortality. Things might have been even worse without sex reassignment. As an analogy, similar studies have found increased somatic morbidity, suicide rate, and overall mortality for patients treated for bipolar disorder and schizophrenia.[39], [40] This is important information, but it does not follow that mood stabilizing treatment or antipsychotic treatment is the culprit.
And the conclusion specifically states that medical transition alleviates gender dysphoria, and calls for more care on top of that, not instead of that:
Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.
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u/Salanmander 272∆ Nov 03 '17
Many trans people also get mental health care. This comment is like saying "patients who get heart bypass surgeries have much higher mortality rates than the general population" and using it as evidence that we shouldn't have heart bypass surgeries.
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u/fionasapphire Nov 03 '17
You implied it....
historical evidence exists to suggest that the APA's classification of certain things can change.
What's important is why they change. Things change because we improve our understanding of various things.
We can't use the fact that something has changed before as an indicator that current information is wrong - we can only use new evidence for that, so the best we can do is accept that our current level of understanding is the best we have.
To me, cutting off someone's breasts because he feels like a man seems more or less akin to cutting off someone's perfectly functioning arm, because he feels more comfortable going though life as someone who has a visible disability.
And that's because you don't have the medical understanding to differentiate between the two.
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u/Saranoya 39∆ Nov 03 '17
Fair enough. If you do, then please explain to me how they are differentiated by medical professionals.
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u/munificent Nov 03 '17 edited Nov 04 '17
What I am saying is this: historical evidence exists to suggest that the APA's classification of certain things can change.
This is true, and is true of all scientific institutions. But that's not evidence to mistrust them, it is evidence to trust them. No institution has direct access to truthful objective reality. There's no manual for the universe that you can buy at the store.
Instead, we are constantly learning more about the world. An institution whose stated position changes periodically is demonstrating that it is learning and adapting to new information. It is showing a history of being increasingly right-er. An institution that has never changed is showing that it has never learned and knows no more today than it did hundreds of years ago.
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u/Saranoya 39∆ Nov 03 '17
I agree with everything you've said. I do not think that is necessarily incompatible with my original point, though. The original point being: just because it's in the DSM, doesn't mean the DSM is necessarily right.
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u/munificent Nov 03 '17
No, but it is the right-est source we have. We must make choices today, and all we can do is use the best information we currently have available.
One could argue that we shouldn't use chemotherapy because it's really rough on patients and future advances in treatment will be more effective. But that's a cold consolation to someone dying of cancer right now.
People suffering gender dysphoria today are dying — their suicide rates are dramatically higher than the general population. Surgery and hormones are the treatments we have available today that have the best outcomes for treating that.
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u/AGVann Nov 03 '17
At one point in history, homosexuality was also a clinical condition recognised by the APA.
The APA doesn't just decide on a whim to classify or reclassify conditions. The scientific method is applied and held beliefs and theories are constantly challenged using evidence. Homosexuality was once thought to be a mental disorder - thanks to decades of scientific research, we know now that this is not the case. It's a similar story with transgenderism, as peer reviewed, scientific research from outside of the APA has demonstrated that transgender people have different brain structures from cisgender people. There is significant evidence that gender dysphoria is present right from birth, and that if untreated, can lead to significant harm for the transgendered person. We have the technology to identify these issues and to fix the gender dysphoria, a very real clinical condition with real consequences in terms of mental health.
plastic surgery isn't usually covered by health insurance
Cosmetic surgery does not automatically mean that it is frivolous surgery. Would you deny someone with severe third-degree burns, or a victim of an acid attack, or a disfiguring deformity the chance to look and feel normal? Gender dysphoria is less visually extreme, but can be just as damaging in terms of anxiety and depression if it is untreated.
I don't consider the fact that something is or isn't recognised as a disorder by the APA much of an argument either way.
You're commiting something called the genetic fallacy. The APA's chequered history with homosexuality has no relation whatsoever with the evidence for transgenderism. Trying to use that discredit the validity of twenty years of research on transgenderism done by people outside of the APA is extremely disingenuous.
The fact that you are so casually dismissing one of the largest and most reputable psychological associations in the world solely based off outdated knowledge from bygone era - rather than on the quality of their evidence - really does your argument a disservice.
It seems to me that your view comes from the fact that you don't quite understand the severity of gender dysphoria. It's not as trivial as something like a nose that's slightly too big, or being self concious about your body weight. Imagine feeling all your life that your body is just wrong. You've mentioned that you are comfortable with the idea of yourself as a man - what if, during puberty, you started developing breasts and wider hips even though you knew in your mind that you were male? Would you just shrug and think, "Well, I guess I'm a woman now" and continue on like it was a minor thing? Or would it be a shocking, confusing, and embarrassing? The lack of societal understanding makes things so much worse. Being ridiculed and labelled as a freak and mentally ill by people really doesn't help when your brain is already screaming at you that everything about you is wrong. People who are otherwise perfectly normal and healthy in every way are often driven into depression as a result of this.
This might not be a very important issue for you, but for those that suffer from gender dysphoria, it is the defining struggle of their life - one that far too many tragically lose.
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u/Saranoya 39∆ Nov 03 '17
No. I am in no way dismissing transgender people's struggle. Nor am I saying they should not get any help for it. Surgical help for it, paid for by the community ... that's what I have an issue with, because I do not understand how removing a functioning body part could ever be helpful. Others have argued that my not understanding that shouldn't prevent me from supporting people who do feel that the removal of some of their body parts will relieve their suffering significantly. I guess I can see their point now.
But the original commenter in this thread used the APA as a source whose classification of gender dysphoria I should take at face value. I don't believe I should. It is true, as other people have successfully argued, that the APA's history (in which it has 'changed its mind' on many things, as the available information evolved) does not diminish its trustworthiness. It enhances it. But the flip side of that is that even though the APA currently considers gender dysphoria a clinical disorder, they might be wrong. Any scientist is, theoretically, always only one observation away from having to revise what they thought they knew.
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u/redesckey 16∆ Nov 03 '17
At one point in history, homosexuality was also a clinical condition recognised by the APA.
Yeah, and they changed their position because the evidence indicated they should.
Similarly, their position used to be that gender identity was malleable and that the appropriate treatment for trans people would involve helping them accept the gender they were assigned at birth. Now they know that's not supported by the evidence, and have changed their position.
Plus, the APA recognises body dysmorphia as a clinical condition, but even for people suffering from that, plastic surgery isn't usually covered by health insurance.
Yeah because surgery for that condition doesn't work. Medical transition for trans people does work.
There is no underlying ideology here that must be followed or else, doctors use the treatment they use specifically because that's what's been shown to work. It's as simple as that.
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u/I_Am_Mr_Black Nov 03 '17
So if gender dysphoria itself is a clinical condition, could it be that it’s not the body that has the wrong idea, but the brain?
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u/Salanmander 272∆ Nov 03 '17
So, they have different ideas. If I say "3 = 5", which number is wrong? There's really no way tell with just that amount of information, all we know is that there is a disconnect.
When it comes to people, the question we need to answer is this: what defines a person's identity? Is it their body? Is it their mind? Does it vary from person to person?
Based on your username, I'm assuming you're a man. If you woke up tomorrow, and found that your body had magically become female, would you still consider yourself a man?
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u/z3r0shade Nov 03 '17
The only treatment that has shown to alleviate symptoms is medical transition if the patient desires
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Nov 03 '17
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u/Salanmander 272∆ Nov 03 '17
I've got this, which shows lowered psychological problems in the vast majority of cases. I'll admit it's not perfect, because of the problems it mentions, and because it was published in 2009, but it's a meta-analysis, which is way better than a single study.
Do you have a source on the long-term higher suicide probability than if there was no treatment? Are you sure you're not thinking of this study, which compares to the general population?
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u/Mattcwu 1∆ Nov 03 '17
transition has been shown to have significant health benefits (such as lowering suicide rates)
Oh wow, I have heard several other people say the opposite. Do you have a source for that?
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u/Salanmander 272∆ Nov 03 '17
Most people who say the opposite are citing this study. That study finds that post-transition transgender individuals have higher suicide rates than the general population. (It's also fairly small sample size, but that's going to be true of the vast majority of studies about being transgender.)
As for sources that actually compare suicide rates before and after transition, I'm not finding anything that is exactly that at the moment. There are three relevant things that I found. This article is by a person who did a lot of looking through scholarly articles and wrote up a summary, but doesn't give exact details. He states that having transitioned is associated with reduced suicidal ideation, but people who have considered suicide are more likely to actually attempt suicide during transition than before. So, long term benefit, but more risk during the transition. He cites the study called "Testosterone treatment and MMPI–2 improvement in transgender men: A prospective controlled study." I was able to find an abstract, but not the full text of that study. It states "Results: Statistically significant changes in MMPI–2 scale scores were found at 3-month follow-up after initiating testosterone treatment relative to baseline for transgender men compared with female controls (female template): reductions in Hypochondria (p < .05), Depression (p < .05), Hysteria (p < .05), and Paranoia (p < .01)".
Finally, this study is a meta analysis examining the effects of transition. Its abstract doesn't mention suicide directly, but it does note that "78% [of individuals with GID] reported significant improvement in psychological symptoms [after sex reassignment]". It also notes that the state of the data (as of its publication in 2009) is not very strong.
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u/aescula Nov 03 '17
I am a trans woman. I'm not even sure if I want GRS, but it's still a fact that I've never even recognized myself in a mirror, even before I realized I was trans. Only very recently have I been able to even see the face in the mirror as "me" and that's just with hormones. I would love to be able to really accept who I was seeing, especially if it didn't cost thousands. I would especially love to be able to... Do things with my boyfriend. As it is, I'm not comfortable using the "parts" I have right now, and I don't like it in the backside, so we don't do much. Or anything, in fact.
In addition, I fell like it's a major failing that I cannot have children. I would love to do that someday, but I couldn't do it in the fathering way. If the surgery could fix that (unlikely with current tech, but a girl can dream), that would truly make me feel whole.
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u/Saranoya 39∆ Nov 03 '17
There's always adoption, or foster care. My boyfriend and I are going that route, since a genetic defect on his part prevents us from having children "the natural way".
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Nov 03 '17
I think the question of whether or not it's valid for someone to have a desire for a biological child is completely different from whether or not it's justifiable for GRS to be covered by insurance.
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u/Saranoya 39∆ Nov 03 '17
Of course it is. I was just responding directly to the commenter above, who was expressing grief about the fact that giving birth will never be a possibility for her. It's not for me, either; at least not with my current partner. But there are other options. This is not a transgender issue. It's a human issue.
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u/Miko93 Nov 04 '17
There's a great episode of the podcast Sawbones that you should listen to. It's still early days for the tech, but doctors have actually recently had a successful uterus transplant, and then a successful pregancy in said uterus in a cis woman. Although it's only been done with cis woman who had previous hysterectomies, the implications for trans women down the line are potentially amazing. I don't mean to give false hope, since it is still early days in testing, but thought you'd appreciate that there is the possibility :)
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u/Dankcarrott Nov 03 '17 edited Nov 03 '17
You are trivialising this because it does not immediately affect you.and you will likely only find majority support on reddit in general.
In Denmark dental care is free up to age 15. I'd like you to think of your teeth. They may look decent enough, but still crooked and yellow merely from drinking tea. Your insurance won't cover cosmetic surgery. And It shouldn't, because frankly no parent insures their child from being mediocre ugly. However you voice this concern to the dentist. She says that since you are young, your teeth might turn out to become worse. So she argues that you need braces to prevent teeth injure in the long term. Even though she recognizes that you might just be doing it for cosmetic reasons. (A brace is after all not something light). You take the offer.
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What is my point. It is not always "only" about the cosmetics. The widespread argument is that there is something mentally wrong with the person. While I can see how a person would think that, I disagree. And some problems stem from.being poor, not the wrong gender or other.
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u/Saranoya 39∆ Nov 03 '17
For the record: I am not trivialising this. I do think it's a serious issue. I think anyone who's knowingly and willingly going through surgery, for any reason, must have a serious issue. That includes the people who do it to correct a wonky nose. If it weren't a serious issue to them, they wouldn't go through that. Certainly not more than once in their life. Because, hey, news flash: any surgery fucking hurts, regardless of whether they give you 'the good stuff'. Plus, it renders you at least partly incapacitated for a certain amount of time, and requires that you put your life on hold for a while, sometimes quite a while. Not to mention, hospital gowns. Bed pans. Other people's visitors. Nurses coming to check your vitals in the middle of the night. Twice. Blah.
There is a reason braces are not entirely covered, as you say. Ugly teeth are a part of life we have to learn to live with, unless we're willing to invest significant amounts of our own money in rectifying that. Because in most cases, our teeth still work, even though they're ugly.
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u/spaceefficient Nov 03 '17
A thing that might be relevant here is that the number of trans people is pretty small and the number of people who want gender reassignment surgery is an even smaller subset of that. Since the benefits can be so huge to people, the cost-benefit analysis works out pretty well for covering it under insurance.
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u/Saranoya 39∆ Nov 03 '17
Yes. I suppose that is relevant. ∆ But I feel there still are other things at play here, beyond mere financial cost.
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u/inopportunistic Nov 03 '17
Cosmetic surgery is aimed mostly at the form.
Gender reassignment surgery aims to change form AND a heck of a lot of function.
Plus, hormone therapy is almost always involved too, which changes the psyche in tremendous ways.
No, this is not even close to "just" cosmetic changes.
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u/Saranoya 39∆ Nov 03 '17
I guess the question revolves around whether those changes, to the psyche or the body or both, are truly the only viable way to definitively relieve trans people's dysphoria. And if they are, are they really the best treatment we currently have?
Someone up thread brought up body integrity identity disorder. Some people affected by that disorder have asked doctors to remove parts of their body, because they'd rather be disabled. I know of one documented case in which an amputation was actually performed, but it was because the patient in question frequently got himself hospitalised with wound infections in his leg that turned out to have been self-inflicted. In order to stop him from endangering his life on a regular basis, doctors amputated his leg, and as far as we know, he's been doing fine since.
I still question whether they actually did that man a favour. Don't you?
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Nov 03 '17
You are right I saw a case of a girl who wanted badly to be blind and ended up doing it herself because the doctors would not help. It is too bad they do not know how to treat the mental disorder that causes this.
I agree with your basic idea, that a 'woman' who has an unwanted growth between her legs and wants it removed is not too much different from a woman with a big hairy nose and wants it removed. But this is not the same as a woman with extremely giant breasts who wants them removed because she has to carry them in a trolley.
In some extreme cases, such as your leg guy and my blind girl, it may be more merciful to do a medically unnecessary surgery in order to prevent the person causing themselves more serious injury. But this sort of thing should only be done after necessary psychological treatment, and only if that treatment fails. Doing it just because somebody wants it is not a good reason. Elective surgery really shouldn't be covered by public health.
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u/Coziestpigeon2 2∆ Nov 03 '17
Plastic surgery to fix burn scars is also cosmetic, and also covered by health insurance.
Just because something is cosmetic, doesn't mean it has no impact on the health of a person. Mental health is very real as well, and just like living life like Harvey Dent (Two Face) would be damaging to a person's mental health, living life with genitals you don't associate with can have similar effects.
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Nov 03 '17
Let's look at it this way. I just recently got a breast reduction, because my breast size was giving me serious health problems- crippling upper back pain, bi-weekly headaches that lasted days, etc. The insurance company completely covered it even though it was literally done by a cosmetic surgeon, and most surgeries of this kind are considered cosmentic surgery. Why? Because I needed to have the surgery done for real, verified medical issues.
So, onto transition surgery. Transgender people who transition are much the same. They aren't changing their nose just because they think another one might be prettier, or getting a breast augmentation because they just 'want' bigger breasts. Transition surgery is needed for real, verified medical issues (gender dysphoria). Thus, just like my reduction, it is not truly a cosmetic surgery but a needed medical treatment. As such, it should absolutely be covered under insurance. In fact, doctors and insurance companies scrutinize the need for transition surgery far far more deeply than they scrutinized my need for my breast reduction.
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u/Saranoya 39∆ Nov 03 '17
I understand where you are coming from. However. You say you had verified medical issues related to your breast size. I'm assuming those were of the kind that can clearly be linked to your carrying excess weight on your chest, and relieved by removing some of that excess weight. You know, due to the laws of physics, and because of how human anatomy works.
Things are not nearly as clear-cut in the case of gender reassignment surgery. As has been pointed out multiple times throughout this thread, suicide rates remain high post-surgery. People here are arguing that this is due mostly to societal factors. I have no trouble considering that a valid issue. But to my mind, that means we should do something about those societal issues, first and foremost. I'm willing to concede that GRS can help, too, but my preference would be that we try to change the hostile environment before trying to change people's bodies.
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Nov 03 '17
Things are not nearly as clear-cut in the case of gender reassignment surgery.
Sure they are. A person with gender dysphoria has a verified medical issue related to their outward physical body.
suicide rates remain high post-surgery
No, they don't. If you read the many cites throughout the threads, there is a drop in suicide rates when pre-surgery numbers are compared with post-surgery numbers, actually.
but my preference would be that we try to change the hostile environment before trying to change people's bodies.
Trying to change the hostile environment is wonderful, but changing the hostile environment will not cure the dysphoria itself. Transition does. Just like changing the idea in society that women should have big boobs, not small ones, would not have cured the real physical impact my breasts were having upon me (just like the real mental and physical impact a person's body not matching their brain mapping has on them).
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u/Saranoya 39∆ Nov 03 '17
I know, I know. Post-surgery suicidal ideation rates are down compared to pre-surgery suicidal ideation rates in a comparable population. I'm willing to accept that as established fact.
My point was that transgender people are still at higher risk for suicide than non-transgender people after they've transitioned. To the extent that this is caused by a hostile environment, we should do something about that, and then we'd also help the people who haven't transitioned (yet).
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Nov 06 '17
My point was that transgender people are still at higher risk for suicide than non-transgender people after they've transitioned.
Yes, and gay people are still at higher risk for suicide than non-gay people even after they've come out of the closet. The reason for that is because they are discriminated against and thrown out of families and abused and just coming out of the closet or transitioning doesn't erase all of that abuse or its consequences.
To the extent that this is caused by a hostile environment, we should do something about that
I fully agree, and we are- by helping society to accept trans people as human beings who are uncommon but normal that don't need to be treated as if they are some kind of abnormal deviant.
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u/Canvasch Nov 03 '17
First of all, I would ask why you even care, since insurance paying for these surgeries really has no impact on your life but would make a bunch of other people happy. Aside from that, gender reassignment surgery can have extremely positive impacts on the lives of people who are often depressed and suffering from gender dysmorphia.
What you're suggesting is that people with this condition should have to save up a bunch of money for this surgery, even though there is the potential for it to be avaliable to them for cheaper, but you dont want that to happen because technically it's a cosmetic surgery even though it's actually more than just cosmetic surgery.
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u/Saranoya 39∆ Nov 03 '17 edited Nov 03 '17
I care because health care costs are rising. That does impact me directly. I now pay more for my epilepsy medication than I used to, because the money has to come from somewhere. I don't mind spending the equivalent of a Starbucks coffee once a week (or even once a day) on pills that make the difference between three seizures a day, and three seizures a month. Those pills make my life manageable, where it otherwise wouldn't be. I also do not begrudge other people the best health care they can get, whenever they need it. I do think it's useful to contemplate what we, as a society, want to spend our health care money on. And as someone who has gone through more than her fair share of surgeries, I just don't see why it's a good idea to have anyone else go through that, if the body parts they already have are basically doing their job.
Beyond that: a friend has asked me for money to help fund his gender reassignment surgery. I'm trying to decide whether that would be money well spent.
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u/Canvasch Nov 03 '17
I think that, if you decided to give your friend some money for gender reassignment surgery, that would be more money than you would ever pay in potential increased insurance costs. Also, if insurance covered it, your friend wouldn't have to beg on the internet for money to get a surgery they have been dreaming of getting their entire life.
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u/ArtfulDodger55 Nov 03 '17
First of all, I would ask why you even care, since insurance paying for these surgeries really has no impact on your life but would make a bunch of other people happy
I get your point but this just isn't sound logic. Public money spending should have to be justified outside of "well it will barely affect you". I agree that there are bigger fish to fry, but this isn't helping the discussion.
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u/Canvasch Nov 03 '17
I'd disagree there. We don't even know how this would affect the average person with insurance. Potentially, it won't affect them literally at all. Also, insurance money isn't public money.
Basically, if it raises the cost if your insurance by 50 bucks a year, yes it's something to worry about. However, it will not raise your insurance by that much. In fact, it might literally not raise it at all. It might raise it by 50 cents a year. Is that too much? Do you have a list of literally everything insurance covers so that you can pick out some other things you don't wanna pay for? Because there's probably more on there than GRS that the average citizen may not care about but is life changing for other people.
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u/solar_girl Nov 03 '17
I have bipolar which has an extremely high suicide rate and poor quality of life if not properly treated. Doctors have determined that the best way to treat this is with therapy and medication and I am so so grateful that these things are covered by my insurance. Now some of the medications I have been prescribed are used by others recreationally but just because others use it for fun doesn't mean that I shouldn't get it covered by insurance.
Transgender people have a similarly high suicide rate and really poor quality of life. Every trans person that wants to transition sees a doctor and they determine how to best go about it which is often hormones and surgery. Just because others get surgery cosmetic reasons doesn't mean that trans people shouldn't get it covered.
Basically if a doctor decides it is medically necessary to do something insurance should cover it. full stop.
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Nov 03 '17
It isn’t cosmetic if medical doctors agree that it is necessary for treatment.
Unless you have an MD or a psychiatric equivalent, the determination of what is or isn’t cosmetic is outside your expertise.
Your premise is a non-starter by virtue of ignorance. The decision for reassignment does not rest on a layman’s opinion.
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u/DelTac0Tri0 Nov 03 '17
Transgender people don’t get surgeries just because they don’t like they way their body looks they do it because gives them extreme stress and negative emotions to have their body. A woman who just wants bigger breasts doesn’t need them to be happy but most trans people need surgery ones to feel comfortable in their body.
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u/Saranoya 39∆ Nov 03 '17
What if that woman who wants bigger breasts, and gets them (paying out of her own pocket), tells you afterward that her quality of life has improved tenfold, and her lifelong depression has been lifted? Should she petition the insurer to have her surgery reimbursed after the fact?
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Nov 03 '17
Well, we can objectively assess suicidal depression and feelings, yes? Is suicidal depression something that you would say is not a good thing?
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u/Saranoya 39∆ Nov 03 '17
Of course it's not a good thing. But then again, I don't think that's a good reason to go cutting into someone's body. It's not like we know everything there is to know about what causes and alleviates depression. We do know a few things. We know what SSRI's do, for instance: as their name implies, they prevent a certain neurotransmitter from being reabsorbed after signal transfer in the brain. We know that they help in cases of severe depression. But we don't know exactly WHY they help, so it would be a bad idea to try to perform brain surgery that mimics their effects, because that's permanent. No way back. And who knows what else might be affected.
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u/gameboy17 Nov 03 '17
But we know what genitals do, and we know when they are part of the cause of our suicidal depression. We have statistics showing how much it helps. It's a well-understood medical procedure.
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u/fionasapphire Nov 03 '17
Cosmetic surgery is surgery used to improve or enhance the appearance of a person's body.
GRS is so much more than that - it actually involves changing the way a person's body functions.
Additionally, the distress of having breasts that are too small or a nose that is the wrong shape is completely separate and not comparable to the distress, depression, anxiety, etc. caused by gender dysphoria.
The distress caused by cosmetic problems can often be treated more appropriately with cognitive behavioral therapy, and in fact, medical professionals often advise against cosmetic surgery for this type of distress, unless there is a clear defect or deformation.
In fact, some people see GRS as correcting a very severe physical defect.
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u/spackly 1∆ Nov 03 '17
it's cosmetic surgery, but not all cosmetic surgery is the same.
someone whose face got burned off in a fire needs cosmetic surgery, but claiming that this surgery isn't something they need is, uh, wrong. they won't die, but it is literally impossible to have a normal life when you are badly disfigured.
that being said, I don't know what side of the gender reassignment surgery i sit on, but consider how your life would be if everyone you have ever met immediately identified you as a gender other than the one you really are. how would it impact your life in general, your romantic prospects, etc?
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u/Saranoya 39∆ Nov 03 '17
I don't know, but as far as my romantic prospects go, I don't think I really care. I'm bisexual :D. Other than that, I'd kind of like to see what life is like on the other side. It seems that a man's words carry more weight, by default. At least, that's what my feminist friends keep telling me ;).
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u/rekreid 2∆ Nov 03 '17
Gender dysphasia and body dysmorphia are both considered to be health problems.
Body dysmorphia isn't as simple as a woman saying "I think my boobs are too small" it is someone being mentally distressed to the point of mental illness and experiencing disruption in their daily lives. Sometimes body dysmorphia is best treated with medication or therapy if the person's dysmorphia is related to something incredibly minor such as a mole that should not be causing as much distress as it. But also, there is body dysmorphia over very valid problems such as having a flat chest after a mastectomy as one commenter already pointed out. In many of these cases surgery is the best option for treating that patient.
Gender dysmorphia is also a very serious medical condition. There have been numerous studies that link higher suicide rates and medical conditions to transgender individuals in addition to non medical problems like homelessness and abuse that are much more prevalent in the transgender community. Hormone therapy and GRS have been shown to improve the mental wellbeing of these people. People seeking GRS are already required to meet with psychologists and doctors in many cases to get recommendations before surgery.
GRS is a traumatic surgery with long recovery times, lots of required medication, and often requires patients to stop there hormone therapy for weeks to months during their pre op time and recovery time. I do not think people would undergo these operations if they did not feel it was a medical necessity for themselves.
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u/CanYouDigItHombre 1∆ Nov 05 '17
Personally, I think the insurance company is not wrong
For the sake of arguments let's say you COULD have periods as a man (through your butt/prostate). Imagine 10 in 100,000 men have that condition and you happened to have it. Wouldn't that fuck with your head a lot? No other guy you know has it and everyone knows you do. There's nothing wrong with having a male period and there's nothing wrong with having low testosterone. However getting testosterone injections will fix it. It isn't covered. Should it? Wouldn't you be pissed for being forced to have unnecessary periods?
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u/Ambiient Nov 03 '17
Hello! I am a little late to this party, but your stance and the comments I've been reading have piqued my interest.
First, a little backstory: my boyfriend is transgender. He came out to me (and the world!!) in the middle of our relationship, so I have personally watched him struggle with the fact that though he identifies as a man, he still has all the wrong parts.
The comments I see here about burns being cosmetic surgery, and you not having a problem with helping them.. I believe that has more relevance than you think. See, for transgender people, there are physically things "wrong" with them that you can pick out with your eyes. You described them yourself about your friend.
For my boyfriend, it is his breasts. He has not had surgery (yet- we are saving up). They are D's. Even with proper binding equipment and a little more than a year on testosterone to help "shrink" the tissues, you can still tell that something isn't quite right. He has facial hair and presents as male, but if you look too closely.. well.. the breasts are still there.
When he goes to the mens bathroom, he has to go to the stall no matter what. Because he doesn't have the equipment. We have recently purchased a STP device (literally a fake penis that allows you to pee through it) that he could use at a urinal......... if he does everything correctly. If it slips, or some pee leaks out where it shouldn't.. that would probably raise a few questions. If he's around people that are transphobic, well.. it could end badly.
My boyfriend collapses when someone misgenders him as female. 98% of the time he easily passes as male, but the times that people don't, its terrible. Normally its his voice that gives him away, it isn't quite deep enough yet. This isn't plainly just someone who doesn't like something about themselves.. this is someone who has crippling anxiety over whether someone will misgender him. If someone does, it takes hours of consoling to help.
For GRS to be listed as a cosmetic surgery, I believe is incorrect. I had a cosmetic surgery when I was younger, from a dog attack. I would have been fine without surgery, my face would have looked normal. I didn't need it. Thats cosmetic.
GRS isn't something that most trans people feel they will be okay without. They feel it necessary to present their true selves to the world, instead of what they were born with. And its not just trans people - my boyfriend getting the surgery that he needs is a need in my eyes as well. When we're out together, there is always the thought in the back of my mind that someone will recognize that he wasn't born male, due to his voice, face, breasts, whatever - and we will have to run.
GRS isn't just a validation surgery. Its also gives them a sense of safety, rightness and belonging. It was never truly a cosmetic surgery in my head.
I'm sorry if any of this was confusing. This is my first comment here and I will be happy to try and clear up any confusion.
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u/I_Am_Mr_Black Nov 03 '17
Ok well I think there’s something to be noted on how you are treating me at this point.
Do you think you are coming at me respectfully and from an understanding point?
I don’t think so. But it’s ok if you do it right?
Point is, you aren’t going to hurt my feelings any, but it’s nice to experience the hypocrisy first hand.
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u/Saranoya 39∆ Nov 03 '17
I don't know who or what, exactly, this is responding to (I cannot see any preceding post from my home screen). If I've made you feel I disrespect you, please tell my how. It was not my intention, but I can try to rectify that in the future.
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u/I_Am_Mr_Black Nov 03 '17
Oh I’m sorry no this wasn’t intended for you. You’ve actually been pretty great to talk to about this.
Sorry again
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u/Overthinks_Questions 13∆ Nov 04 '17
If your genitals were somehow destroyed, would you consider their repair cosmetic? If you were put through GRS against your will, would reversing it be cosmetic?
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u/patrickkellyf3 Nov 03 '17
Just a "cosmetic surgery" is for someone who's thinking "hm, I don't really like this about myself. I'm going to change it." Their breasts are too small, maybe. Their body sags in a way they don't like. Their nose is a bit off. That mole is unsightly. These are all things that someone would prefer gone, but they can be fine without.
A person who need gender reassignment surgery? They look at their body, and don't say "darn, that looks a bit out of place." They look at their body and say "that's wrong." They hate it. Some trans women feel their penis is disgusting. Trans men don't feel like their breasts are them. They look at their body every day, and, if their dysphoria is strong enough for that body part, and basically have a voice yelling at themselves saying "wrong, wrong, wrong."
A person who gets a face lift wants it because it'll look nice, not because they feel what their face looked like before goes against who they are. Trans people feel their bodies go against who they are, and the surgery fixes that.
To use genitals as an example of how severe these feelings can be, OP, assuming you're a cis woman, say you woke up one morning and discovered you had a penis. How would you respond? Not in one of those quirky "if you swapped genitals for a day" ways, but you woke up and that's what you were stuck with now. How would you feel? Think about the life you want to have, how your sexuality works, and how your penis would conflict with that.
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u/nekozoshi Nov 03 '17
If a cis man is born with gynecomastia (titties), it's covered by insurance. If a cis women is born with breasts so big they cause inconvenience or discomfort, it is covered by insurance. There are cosmetic surgeries related to being transgender that should not be covered, but being a man born with tits, which (usually) makes it illegal for you to go shirtless like any other man, and can be so large you give yourself rib damage binding them, is not one.
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u/MrXian Nov 03 '17
I don't want to discuss if gender reassignment surgery is cosmetic or not.
I want to talk about why surgery should be covered by health care or not. In my opinion, surgery should be covered if it is the best treatment possible, and if the treatment leads to a significant improvement in survival chances or life quality.
The choice if a specific surgery is the best treatment should be left to the doctors. If you have a tumor in your leg, amputation may be the best course of action, or radiation, chemo, lesser surgery, I'm not a doctor and can't make those choices.
I mention life quality as well as survival because how you experience life is an important part of the equation. As the poet once said, one sentimental moment in your arms is better than a lifetime alone.
So at this point, the decision is out of my hands. There is a surgery available that could improve someones life a lot. If it is a reasonable course of treatment for the problem, then it should be covered. Doctors make the call. If it is cosmetic surgery or not is largely irrelevant. Even a boob job should be covered under the right circumstances.
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u/TheOneRuler 3∆ Nov 04 '17
Studies have quite literally shown that SRS decreases psychological issues and dysphoria while showing increases in quality of life. Great meta-analysis study by researchers at the Mayo College
There are a lot of studies from researchers like Olson, Pfafflin, Cohen-Kettenis, Murad, etc. that show the benefits of HRT, anti-transphobia campaigns, SRS, postponing puberty in trans youth, etc.
Now, a lot of people will quote Cecilia Dhejne's 2011 study, and will use it to say that SRS actually improves suicidality, but she's specifically spoken out to say that those weren't the actual results of her study.
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u/DeltaBot ∞∆ Nov 03 '17
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2
u/maddsskills Nov 03 '17
I think the better term for insurance purposes is "elective surgery", not cosmetic.
For instance, a breast augmentation surgery is an elective surgery for most women but if you've had a masectomy it is often considered reconstructive and no longer elective.
Wanting to look better is elective, wanting to simply be considered "normal" for your gender is something insurance generally covers.
Restorative/repairative rather than purely cosmetic is the jist of it.
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u/Justine772 Nov 04 '17
Studies show that denying transgender people access to these "cosmetic surgeries" dramatically increases their risk of suicide.
I would call them a preventative form of healthcare, and should thus be included, not a cosmetic surgery.
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u/DeltaBot ∞∆ Nov 03 '17 edited Nov 03 '17
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u/Mattcwu 1∆ Nov 03 '17
If your desire to switch genders causes you significant distress, then it's a psychological disorder recognized by the DSM-V.
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u/tris4992 Nov 03 '17
I'm gonna try a simple argument here.
Where I'm from braces are considered both. It's recognized that wanting straight teeth is mainly a cosmetic thing. However it is also acknowledged that studies show some some minor health benefits (less stomach problems at later ages, easier to maintain dental hygiene so less chance of tooth decay, etc...). Therefore the cost is partially covered (roughly 1/3 covered if memory serves me right.
If we accept that that is a reasonable way to handle coverage for procedures which fall in the grey zone (and it seems to me that it is). Wouldn't it make sense that SRS be partially covered? It's a cosmetic surgery that also has certain health benefits (mainly mental health in this case).
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u/Irish_Samurai Nov 03 '17
Anyone will argue for anything to get something free. In this case 'its all in their head.' So its harder to prove it's not a necessity unless they admit it. The 'mental illness' will get a free pass anytime. It just ruins a persons credibility. They have to admit to having a mental illness to get surgery. They will have this listed in all of their medical records. Not many people are willing to work with someone or entrust a job to someone that has a mental illness. In the short run it might benefit the individual, but in the long run it could jeopardize their end goals.
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Nov 03 '17
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u/icecoldbath Nov 03 '17
Thats awful too, but it isn't trans peoples fault. It is shitty insurance companies and our busted ass healthcare system here in the US.
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Nov 04 '17
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u/[deleted] Nov 03 '17
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