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Alberta reinstates funding for sex reassignment surgery (plus, why it's necessary)

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The Alberta Government has announced that it will be reinstating health-care funding for sex reassignment surgery (often called gender reassignment surgery, and abbreviated as GRS by the province and its clinicians), effective June 15.

In the recent provincial election, Premier Alison Redford was returned to power by an electorate that appears to have been hoping her government would track back toward progressive politics. Albertans have been watching to see if her government would indeed follow through, and in what manner. An Angus Reid poll placed Ms. Redford as the second most popular premier currently in power.

The province had cut funding in 2009 as a "cost savings measure" -- however, the $700,000 savings (provided for approximately 16 people per year) wasn't even a sliver of the provincial health budget. Since then, the province has been on shaky legal ground with the funding cut, since human rights tribunals have typically recognized the procedure as being medically necessary. It was for this reason that the Province of Ontario ultimately reinstated funding, and B.C. abandoned an attempt to defund the surgery. Judicial court rulings (eg.) in Canadian case law also indicated a likelihood that the medical necessity of GRS would be upheld.

The Trans Equality Society of Alberta responded to the announcement with a media release:

We are pleased that the current administration sees value in caring for all Albertan’s needs, enabling them to live happy, fulfilled lives. The return of this coverage, who’s removal only saved Albertan’s $0.18 each annually, will give hope to those for whom GRS was previously out of reach. While there are many other issues facing Trans-identified Albertans, this is a huge step in the direction of respect and dignity for the Trans Community by the Alberta Government. Thank you for taking this important first step.

The American Psychiatric Association and American Medical Association both stress that sex reassignment surgery is a medical necessity, and a 2008 resolution by the AMA emphasized that insurance companies should cover the procedure.

Most Canadian provinces have some form of coverage for GRS, although some have problematic quirks of process or costs that can create barriers to obtaining the procedure, and some still do not fund sex reassignment procedures for trans men. In 2008, Nova Scotia's Liberal Party added working toward GRS funding inclusion to their political platform, although it has not yet been accomplished in that province.

Internationally, several nations have also added coverage to their public health insurance programs over the past couple of years, including Cuba, Brazil, and Chile. Argentina recently passed the most comprehensive policies on trans enfranchisement, which included GRS funding, new name change guidelines, anti-discrimination inclusion in their human rights code, and legal protections from hate crimes. A number of Australian provinces are under renewed pressure to provide funding after an incident of attempted self-performed surgery in an act of desperation. There have been (trigger warning) at least three other major self-mutilation incidents reported in international media in the past year, including one person in China who self-castrated and then jumped to their death because they couldn't deal with the pain. Although not all trans people decide that they require surgery, for those who do, it can be an absolute necessity.

Corporations have also been rapidly adding health-plan coverage to their benefits programs, including Apple, Chevron, General Mills, Dow Chemical, Chubb, American Airlines, Kellogg, Sprint, Levi Strauss, Eli Lilly, Best Buy, Nordstrom, Volkswagen's U.S. division, the University of Pennsylvania, Whirlpool, Xerox, Raytheon and Office Depot (note: some of these may not apply in Canada). According to the Human Rights Campaign's Corporate Equality Index (CEI), over 200 major U.S. businesses now include trans-inclusive health-care coverage featuring surgical transition-related care, including 50 per cent of Fortune 500 companies -- an increase of over 1,500 per cent in that group since 2002.

Alberta's 2009 announcement was followed by a mass filing of human-rights complaints. Due to changes in grandfather-through decisions, some of those complaints were negated when funding was given, and others are still in process. Due to the backlash at the time of the announcement, the province had eventually conceded to provide funding for people already in transition prior to the cut, to a maximum of 20 per year. A number of others who had not qualified for the "Phase Out" program (usually because of the timing of their first medical appointment after starting transition) had been typically offered GRS funding as part of a settlement during negotiation stages of their human-rights complaints, but have not spoken to media due to confidentiality requirements.

Although this victory is huge, some concerns about medical access remain. It can be difficult or near impossible to find trans-friendly (let alone trans-aware) medical practitioners in several regions of the province. This can make it hard to even find general practitioners willing to treat people for medical issues that are not trans-related. For transition care, there is one clinic in Edmonton (therapy only, currently with an 18+ month waiting list) -- in Calgary, there is also a once-a-month trans health clinic operated by a psychologist and a family doctor who've teamed up to try to help, but the need is one that is difficult to fill with a once-a-month model. The previous Stelmach government had shut out attempts by the trans community to speak about these matters, and advocates are hopeful that this can now change.

On Wednesday, the federal government voted to allow a human-rights bill proposing protections for transsexual and transgender Canadians to committee for review and possible changes, toward a final vote. The bill had passed in the previous Parliament, but died in the Senate upon the election call.

(Here is a full backgrounder on why GRS is medically necessary. It is also available as a trifold brochure)

(Crossposted to The Bilerico Project and Dented Blue Mercedes)

(At this point, I've also included a 2009 article which provides background on the significance of the surgery and its coverage)

Why "Sex Change" Surgery is Medically Necessary (previously published at Dented Blue Mercedes)

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

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

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

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

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

There is more. Current legislation asserts that most forms of identification and legal documentation can only be changed to reflect one's new gender after surgery has been verified. Without GRS, many pre-operative transsexuals experience severe limitations on employment, travel beyond Canada's border, and treatment in medical, legal and social settings in which verifying ID is necessary. Prior to GRS surgery, transsexuals also face limitations on where they can go (i.e. the spa or gym, or anywhere that involves changing clothes) and difficulties in establishing relationships -- as well as being in that "iffy" area where human rights are assumed to be protected, but have not yet been specifically established as such in policies and legislation. In hospitals, prisons and such, they are housed by physical sex rather than their gender identity, creating potentially risky situations, unless the authorities directly involved choose to keep them in isolation instead. And at the end of the day, without GRS surgery, one's gender is always subject to being challenged or stubbornly unacknowledged by those who don't realize that a transsexual's gender identity was not a matter of choice. There is also an extremely high risk of violence faced upon the accidental discovery that one's genitalia does not match their presentation. No other supposedly "cosmetic" issue so completely affects a persons rights, citizenship and safety.

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

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