Embedded Files
and McHugh’s special report in the New Atlantis states that gender dysphoria “is sometimes treated in adults by hormones or surgery, but there is little scientific evidence that these therapeutic interventions have psychological benefits” [37]. Mayer and McHugh do acknowledge what is not in dispute: that transgender people experience significant discrimination and disadvantages in the United States, with resulting impairment in physical and mental health measures [37]. Among transgender people, rates of suicidal ideation and suicide attempts (40 percent), homelessness (30 percent), HIV (1.4 percent), poverty (29 percent), and unemployment (15 percent) are many times the rates seen in the general US population [27, 38-40]. Many states have legislation that requires genital (sterilizing) surgery before transgender people can change their birth certificate, driver’s license, and other identification documents [41]. And voter identification laws can potentially disenfranchise an estimated 34,000 transgender people in local, state, and national elections [42]. Of note, transgender Americans are twice as likely as members of the general US population to serve in the US military. There are currently 134,300 transgender veterans and an estimated 15,000 transgender Americans in active military service [43], so appropriate transgender care is especially critical for these populations [35, 36, 42-44]. Denial of Gender-Affirming Care to Armed Services Veterans The VHA Health Benefits package [14, 46] and VHA Directive 2013-003 [15], first issued in February 2013 under the title “Providing Health Care for Transgender and Intersex Veterans,” specify that mental health services and the prescription of hormone therapy are to be provided for transgender veterans. The specific language in Section 4.b(1) of the directive states: Transgender patients and intersex individuals are provided all care included in VA’s [Veteran Affairs] medical benefits package including but not limited to: hormonal therapy, mental health care, preoperative evaluation, and medically necessary post-operative and long-term care following sex reassignment surgery to the extent that the appropriate AMA Journal of Ethics, April 2018 405 health care professional determines that the care is needed to promote, preserve or restore the health of the individual and is in accord with generally-accepted standards of medical practice [15]. However, Section 4.1(C) of the directive states: “Sex reassignment surgery as defined in subparagraph 2c(4), will not be provided or funded” (emphasis added) [15], thereby continuing the exclusion of gender-affirming surgery from the Health Benefits package that has been in place since 1992 [47]. In response to a petition filed by veterans Dee Fulcher and Giuliano Silva and by the Transgender American Veterans Association in May 2016, the VHA undertook a review of this policy that resulted in a proposal to lift the prohibition on gender-affirming surgery. The proposed rule change was an agenda item published in the Federal Register in spring 2016 [33], although it appears that a formal revision of the directive was never publically circulated. News media reports at the time indicated that the new policy lifting the ban on gender-affirming surgery would become effective in 2017 [48]. In preparation, the VA National Surgery Office (NSO) conducted a survey of all VA medical centers to gauge existing expertise for gender-affirming surgery within the VA system; the results of that survey, in which the first author (WK) participated, were not made public. In November 2016, news media sources reported that a revised directive would not include the provision of gender-affirming surgery [49] and, in fact, the revised directive released in February 2017 maintains the prohibition on surgical procedures for the purposes of gender affirmation. The Health Benefits package therefore remains unchanged; gender-affirming surgery is not a covered VHA benefit. Budgetary concerns were cited as the principal reason for continuing the ban. The VA issued the following statement regarding the revised directive: “VA has been and will continue to explore a regulatory change that would allow VA to perform gender alteration surgery and a change in the medical benefits package, when appropriated funding is available” [49]. (It is notable that the statement used inappropriate language: surgery does not “alter gender”; surgery affirms gender by altering anatomy.) On face value, this statement is confusing because gender-affirming surgery would not require infrastructural changes or capital investment; it requires only equipment and facilities already available in VA hospitals [21, 50]. However, beginning with a scandal at the Phoenix VA Health Care System in 2014, the VHA has come under considerable criticism and pressure related to delayed access to care. Access to Care Considerations in the VHA In response to the Phoenix VA Health Care System scandal, in August 2014 Congress passed the Veteran’s Access, Choice, and Accountability Act (VACAA), commonly referred to as “Choice” [51]. The legislation has been amended several times, but strict time requirements to complete new consults and to provide surgical services remain a centerpiece of the legislation. If a VA facility cannot provide care for a veteran within the 406 www.amajournalofethics.org times
Google Sites
Report abuse