Sunday, March 5, 2017

A Red State is "Detransitioning" State Employees--Like Me

It's been close to a decade since I legally gender transitioned.

While it was a great relief to finally live authentically in the gender I knew myself to be, transitioning was a process both challenging and tedious. I needed to have my name and gender marker changed in so many databases. This meant awkward interpersonal interactions. (For example, when I went to get a driver's license issued with my new name and gender marker, the person staffing the front desk at the DMV, apparently seeing me as insufficiently manly looking after just a few months on testosterone, responded by exclaiming in front of the crowd waiting in line, "What are you, some kind of pre-op?!").  It meant educating and cajoling and placating administrators of multiple bureaucracies who had never personally changed anyone's gender marker in whatever system they administrated, and were disconcerted to be asked to do so. It meant presenting my court order of name change and state ID showing my "M" marker over and over again.

Running the gauntlet of getting my gender transition acknowledged and implemented took months. It was tiresome. But I managed it, and moved on with my life. As my appearance shifted under the influence of hormone therapy and most people got used to addressing me as "he," the levels of stress involved in just living my life as myself slowly dropped. There were ongoing battles that remained, like my fight against the ban on insurance coverage for transition-related care in the policies offered to Wisconsin state employees, but the legal hassles seemed mostly behind me. I could mostly breathe free and just go about my business.

And for a brief moment, things really started to look up. After eight years of fighting with no success for insurance coverage for the trans care my wife and I required, policy directives under Obamacare forced my state to say it would lift the ban on transition care. The exclusion was to be lifted on January 1, 2017. But in November of 2016, Donald Trump won the presidential election, promising to repeal Obamacare and produce a total change in federal regulations. Now, my Republican governor and state legislature felt empowered to enact transpohobic policies. In December, the "Employee Trust Fund" or ETF--the agency administering all benefits programs for Wisconsin state employees--directed all insurers providing coverage to state employees to reinstate the ban on coverage for trans care.

For a family like mine, with two gender transitioners who had been waiting for many years to access additional care and get coverage for our HRT, that was more than depressing. But at least we saw it coming.

What came like a bolt from the blue was the notice I got a week ago.

It was a Friday afternoon. I'd just given a colloquium talk in my department. The week was winding down, and so was I, sitting in my office going through the day's pile of email--the usual questions from students about assignments and discussions about programming with instructors in the LGBT+ studies program I direct. Then I came across an email from my university human resource specialist, opening with a cheerful "Hello!" It informed me that ETF had changed their policy on gender transitioning in their system (which covers not only health insurance but all benefits, like disability, retirement plans, etc.). It stated that in order to "maintain a gender change," I had to provide additional documentation for myself and for my wife.

We were being detransitioned by the state, though I'd legally transitioned nearly a decade ago, and my wife started her transition in the 1990s. And we did not have the additional documentation demanded.

Reading this email caused an immediate feeling of shock at the attack on our identities. But let me note that reverting our gender markers to what they were years ago does more than emotional or psychological damage. And it impacts more than how others view our genders. For example, I have developed a neurological problem with my arm leading to partial loss of the use of one hand. I'll be seeing a neurologist in a few days--and a mismatch in my identification can mean denial of insurance coverage. That could be very costly to my family--but delaying needed medical care is costly in other ways.

Between a Rock and a Hard Place

Before I get to discussing the additional demands ETF is making, let me point out a very broad problem, and that is the idea that agents of the state can change one's legal status retroactively at any time. Imagine, for example, if the state decided that it wished to make it harder for people to get married, and so it imposed a new requirement--that in order to have a marriage recognized, residents would have to provide DNA evidence proving they and their spouse are not related (an expensive prospect). Then imagine that all married state employees were informed that their status had been reverted to single in employment databases and systems, because they had not complied with the DNA test requirement when documenting their marriages. That's not the way regulatory changes, mundane or shocking, operate--they are applied going forward, but not retroactively.

Now, as for the new procedures for gender transitioning, there are three requirements listed by ETF. The first is that the employee must notify ETF directly, providing their old and new names, old and new gender markers, ETF ID number, and a declaration that they are gender transitioning. Previously, employees notified HR at their place of employment, and employer HR staff changed the gender marker directly in the benefits system. But now ETF will centralize control over implementing transitions, and maintain a database of gender transitioners. In essence, we are being required to register with the state. As a Jewish person who lost extended family in the Holocaust, I find this extremely creepy.

The second thing trans people are required to do is provide "proof of identity," such as a driver's license or military ID showing the new name and gender marker. That's what we had to do in the past, and my wife and I can easily produce our Wisconsin driver's licenses showing our names and most correct binary gender markers. But now ETF is demanding more.

We are now being required to produce a third item, "proof of gender." This is very strange, because a driver's license already provides state-recognized proof of one's gender. Requiring more serves no purpose other than to make it harder for people to get their identified genders recognized. And the new "proof of gender" items are difficult and intrusive items to get.

Let's look at the options. One is a court order of gender change. To get one of these is difficult, expensive, and in many states, like Wisconsin, requires a doctor to testify that one has had surgical sex reassignment. Now, some people cannot have such surgery for medical reasons. Others do not want it--they desire social recognition of their identified genders, not a program of body modifications. And nonbinary gender transitioners often find they are denied access to surgeries. But let me underline that in any case, the very surgeries that ETF is making necessary in order to have one's transition recognized it has also categorically excluded from insurance coverage. My wife and I have been waiting for years to access some surgical interventions that would make our lives easier on many levels, one of which is being able to access things like a court order of gender change. But we can't afford them without insurance coverage. It's a Catch-22, and seems deliberately cruel.

Well. Instead of presenting a court order of name change, another "proof of gender" is a US birth certificate showing the identified gender. Now, in bluer states than mine, amending one's birth certificate sex requires just a letter from a doctor or therapist attesting that a person under their care is gender transitioning. A few states with reactionary policies, like Ohio and Idaho, do not allow birth certificate sex to be changed for gender transitioners at all. But most states, like Wisconsin, will do it for people who have had sex reassignment surgery which is documented in some particular way--in Wisconsin, it's by a court order of gender change. So we're back to square one, for my family and for so many gender transitioners.

What else will ETF accept as proof of gender? Another option is a US passport showing the identified gender. My wife and I have been trying for months to get the documentation we need to get passports issued in our lived genders, but have run into difficulties trying to get certified copies of legal documents. Hopefully these problems will be resolved in time and the rules for gender transition and passports won't shift under us before then. But even if we had them, this option as provided by ETF is highly problematic. Their policy requires that for a passport to "count" as proof of gender, the original passport must be mailed to an ETF P.O. box to be examined. It's crazy to demand that someone hand over their passport, via ordinary mail, with no specified procedure for ensuring its safety, no description of how long it will be held, no contact information given for an employee to inquire about the location of their passport should they not receive it back in a timely fashion, and most of all no explanation as to why the original document has been demanded, rather than just shown to the employee's HR office. So, even if we did have passports, we wouldn't want to mail them off to ETF as required.

Finally, there's the alternative of mailing a letter from a care provider as "proof of gender." At first, this seems the go-to option. Letters from medical practitioners and therapists are employed in many transition contexts. But there are two problems with ETF's letter option. First, ETF will only accept a letter from someone with a doctoral-level credential. The clinic where my wife and I get our medical care is staffed solely by (very competent!) nurse practitioners, with masters-degree-level credentials. So our care provider isn't allowed to write a letter for us.

But there's something more insidious, and that is the content required in the letter. Transition letters are commonplace, and they follow a standard format intended to protect the private medical information of the gender transitioner. The care provider writing the letter makes only a general statement that "appropriate clinical treatment" has been provided. But ETF demands that the letter writer explain what that treatment was. This is none of their business! Moreover, ETF is staffed by bureaucrats and accountants, not medical personnel qualified to review such information.

There's no justification given for the letter to disclose such highly personal information. But given what we've just experienced in terms of retroactive de-recognition of our gender transitions, there's reason to fear. It may be that if certain medical procedures are not listed in the letter, even if the letter is accepted now, at some time in the future employees might find their gender transitions reversed in state records yet again.


So, I've been trying to mobilize my university HR to push back against the detransitioning of me and my wife in the benefits system, and against the imposition of onerous and atypical requirements future gender transitioners. A conference call is planned between ETF and HR administrators. We'll see what the outcome is, but one piece of information I have been given so far by the head HR administrator at my university is that apparently my wife and I are the only people to whom ETF directed a notice be sent that our gender transitions would be reversed unless we produced additional documentation, at least as far as he could determine.

There are two interpretations I can give this disconcerting bit of information. Both turn on the fact that I am quite open about being trans, run an LGBT+ studies program, and as an academic who researches intersex and trans issues, have been interviewed by the media numerous times to provide commentary on related news stories. The first interpretation is that some ETF staffmember has been tasked with identifying trans state employees to receive detransitioning notices, and as I'm simply particularly visible as a trans employee of the state, I and my wife were the first identified. And the other is that because I am a critic of transphobic policy initiatives, my family has been personally targeted in retaliation--which is a pretty unsettling possibility. I suppose there's a third scenario--that every other trans person who is a state employee or receives benefits as family member of a state employee presented their HR office with a court order of gender change or amended birth certificate when they gender transitioned. But given that there are almost 300,000 state employees, how hard it is to get those documents, and the fact that they were not considered necessary until now, this seems extremely unlikely. It's an anxiety-inducing situation to find oneself in under any interpretation.

In any case, the short story is this: around the US and the world, as trans rights have advanced, insurance coverage for transition care has become commonplace, while changing gender markers has shifted to being based upon gender identity, not any particular physical sex characteristic or its modification. States like Wisconsin were lagging behind the curve, but progress was being made. Yes, there were backlashes, like the flurry of so-called "bathroom bills," but under the Obama administration, these were federally identified as discriminatory.

But like so many things, a lot has changed fast. And trans people are among those finding themselves besieged.

And that's how I find myself facing detransition by an agency of the state.

Thursday, February 2, 2017

Doors Slamming Shut on Trans Care

A Preamble

So much has happened so quickly since the Trump inauguration, so much of it damaging to marginalized people, that it's difficult for folks to keep up with what is going on. That is clearly the intent of Trump puppeteer Steve Bannon, with his desire to produce shock and awe, stir up society like an anthill, and remake it in his nasty image.

With so much going on, it's important that we make and listen to reports from the many fields of struggle, which is why I'm writing this post. But I do want to preface my report with a call for unity. We've been set up, by this initiation of battles on many fronts via tweets and executive orders. Our opponents in Washington hope to divide us. They hope that we'll splinter into "interest groups," each demanding primacy and seeing calls for help and attention from other embattled groups as acts of betrayal. Remember, the concept of "divide and conquer" is as old as the hills. 

None of us can fight every battle--but we can support one another's efforts. We have to focus our individual efforts on what we can do best to resist in our local communities, with the skillsets we each have. But we also need to have one another's backs.

So: I make this small field report, not to distract people from protesting the ban on refugees and travelers from seven Muslim-majority nations, or from pushing their representatives in Washington to oppose the nominations of unqualified ideologues to head federal agencies, or whatever other actions people are engaging in. I make it because we must keep one another informed of all the negative changes that are taking place. That's what we need in order to keep taking positive steps to resist.

A Trans Report from the Midwest

I am an employee of the state of Wisconsin, teaching at a state university. About a decade ago, the University of Wisconsin system added to its nondiscrimination clause protections based on gender identity or expression. Yet the insurance plans offered to people working and learning at University of Wisconsin schools all banned coverage of "procedures, services, and supplies related to surgery and sex hormones associated with gender reassignment." I've been fighting that ban ever since.

Until the summer of 2016, I got nowhere. It was a strange battle, because at every turn, I encountered expressions of surprise and sympathy from colleagues and benefits staff and administrators in the University of Wisconsin system. Colleagues presumed transition care must be covered by our insurance, since our antidiscrimination policy bans discrimination based on gender identity, and that must mean what it says. Human resources staff presumed the denial of coverage in our insurance plans must have originated with the insurance companies, and be their national exclusion policy. Upper university administrators saw that the discriminatory medical exclusion came from on high--proclaimed for all state employees by an entity called the Employee Trust Fund. But they regretfully stated that the university system couldn't tell the state what to do. They promised to bring the exclusion up as an issue to be addressed at the state level should an opportunity arise.

And so, year after year, I'd repeat this process of approaching people at various levels, reporting on the ongoing discrimination and asking for their help. I'd speak to them personally, and tell them how my family was impacted. With two gender transitioners and two disabled people in the little family of three I support, we couldn't afford any uninsured surgical care, and the lack of coverage for our trans endocrinological care was costing us between $1000 and $2000 a year out of pocket. Between our other medical expenses and the big hit my take-home pay received when the state withdrew much of its benefits support, my family's savings disappeared, and we have been sinking further and further into debt. And not being able to access surgical transition care is not "just" some issue of psychological discomfort for my wife and myself. It means relying on antiandrogens for year after year, with side effects that can be cumulative. It means relying on the extended wearing of chest binders for year after year, with their restrictions on breathing, exercise, and risk of rib injuryIt means if we fly, we regularly get stopped by airport security and detained due to our "anomalies."

And year after year, the people I contacted would express sympathy, but do nothing.

Then, in the summer of 2016, the U.S. Department of Health and Human Services posted the "Final Rule to Improve Health Equity under the Affordable Care Act." And one of the things this document said was that health insurance could not discriminate on the basis of gender identity or expression. Blanket exclusions of transition-related care were stated to be unacceptable discrimination.

And lo! Based on this federal guidance, the Employee Trust Fund, the entity declaring policy for state benefits programs, instructed all the health insurers providing insurance to state of Wisconsin employees to remove the ban on trans care.

In the fall of 2016, my family received a letter from our insurer stating that the ban on coverage for transition-related medical expenses would be lifted on December 1, 2017. We put the letter up on the fridge and celebrated.

And then Trump won the election.

I wrote a social media post a few days after the election saying to watch out, because I bet that trans medical care coverage would disappear for people in red states soon after his inauguration in January. A batch of people replied in comments saying that of course things were uncertain, but that I shouldn't be so alarmist. Once rights are granted, they are very hard to take back, they said. Insurers wouldn't want to look bad. If insurers did try to put back blanket bans, they'd face years of lawsuits. And anyway, Trump said he was ok with Caitlyn Jenner using the women's bathroom in Trump Tower.

Who was right? Well, it seems under the Trump administration there is no such thing as an alarmist progressive worry.

What followed Trump's election in Wisconsin was an immediate flurry of activity in the state health insurance regulatory world. Insurers, who a couple of months ago had sent out sunny letters about how they did not discriminate and offered wonderful health care coverage to all, regardless of gender identity, had private conversations with the ETF. Soon, Governor Scott Walker and our anti-LGBT activist state Attorney General, Brad Schimel, were voicing their opinions that the federal bullies who had forced the state to offer trans medical care had no more influence, and the state should reassert its noble, sovereign right to discriminate. The ETF asked the Group Insurance Board for a ruling on whether a "rescission of coverage" would amount to a "breach of duty" to the employees of the state of Wisconsin. The GIB basically ruled, "No, go for it, once Trump is inaugurated."

The very first executive order Trump signed after his inauguration was one stating that Trump intended that Obamacare be repealed, and that meanwhile, all possible actions should be taken "to minimize the unwarrented economic and regulatory burdens" of Obamacare, and give the states "more flexibility and control."

And so, in the name of freedom, states rights, and economic security, the ETF acted. On February 1st, they issued a statement saying that "the exclusion of services related to gender reassignment is reinstated as of today."

One month. That's how long trans medical care needs were acknowledged to be valid in the state of Wisconsin. I didn't even get to have a single refill of my testosterone covered, because of a backorder at my pharmacy.

Hold the Doors

This is a moment where doors are swinging shut all over America. Due to racial and religious bigotry, they are being slammed shut at the national level in the faces of refugees who are fleeing the horrors of war. We must fight for the refugees and immigrants whose lives and livelihoods are endangered by anti-immigrant sentiments and actions. 

But we should also notice and help resist the other doors slamming shut on the smaller levels of state and local action. And the Wisconsin re-adoption of trans discrimination in health care for state employees is one of those actions.

So, can you do anything to help? Well, if you are actually a University of Wisconsin employee, especially an administrator, now is the time to stand up against transphobic discrimination and speak out. Perhaps you didn't know there was a ban on trans medical care coverage before. Perhaps you knew it existed, but thought that was true across the U.S.. Perhaps you knew it was an ETF policy, but thought of it as a sort of ancient fossil, some passive, unconsidered barrier. But now you know. The ETF has pulled the rug out from under your co-workers who are transgender, or have spouses or children who are trans. Coverage is clearly possible, since for one brief month it was offered. It is being denied in a blatant case of discrimination.

I realize that nobody at the University made this decision to reinstate the discriminatory policy. I know that it comes from the state, and that if you are an employee in the benefits office, you don't want to hand out discriminatory plans. University staff supervising and hiring individuals who are trans or have trans dependents don't want them to face unfair financial burdens and negative health and safety outcomes. You are just part of a large system.

But when you hear yourself saying, "I am a cog in a huge machine. I am just following orders," I hope that this makes you shiver, then shake yourself, and do something to resist. This is a habit that we need to develop or redevelop in these times, when talk of creeping fascism is not hyperbole.

Most readers, of course, aren't Wisconsin state employees. But you can help as well. You can contact state legislators via phone or fax. You can make a donation to a trans advocacy organization or the Wisconsin ACLU or other group. Most of all, what you can do is be aware of what is happening here as an example of what is happening in many states and localities now. Find out what is happening with regard to trans health care discrimination in the localities and states you live in or have connections to. Help raise awareness of the issue. There is so much to fight, now: xenophobia, racism, religious discrimination, misogyny. . . I'm not asking people to put transmisogyny and transphobia at the top of some list of deserving causes. I'm asking people to focus on the work they are best at, but when it comes to the list of issues they are not concentrating their personal work on, to make that an inclusive list. We need to have one another's backs, and help one another out where we can, though none of us can effectively take everything on. This is what I am trying me best to do.

And now you know one way to have my back.