Natalie was born a biological male and assigned the sex of a male. From an early age, however, she identified as female rather than male. Puberty was tough. “I was horrified by the growth of hair on my body and the deepening of my voice. Everything felt wrong, seeing myself in the mirror as a man.” In her twenties, Natalie disclosed to her family that she identified as female, not male. Some family members could not understand. Others reacted with disgust or hostility. Natalie became distant from her family, and moved away from her hometown. She began to experiment with her dress, body language, and voice.
Natalie has suffered from depression throughout her life. Natalie began psychiatric treatment and was later diagnosed with “gender identity disorder.” The DSM-5 (American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders) lists Gender Identity disorder as mental disorder describes persons who experience significant gender dysphoria: discontent with their biological sex assigned at birth.
Natalie initially sought psychiatric care precisely for this diagnosis. Her physician would not prescribe hormone replacement therapy without it. “I was eager to change the appearance of my body. I was desperate and willing to do anything.” Natalie was reluctant to visit another doctor, having had many negative experiences in the health system. She considered buying the hormones on the black market and self-administering to avoid further mistreatment. “I don’t mind the psychiatrist too much. She has a set story about the transgender experience, only one seems acceptable. I try to live up to it, so she will sign off on my other medical care.”
Natalie’s transition continues to be difficult. She suffers from verbal abuse and harassment, and fears violent attacks. Her registered sex as “male” on identity documents is a painful reminder of a lifetime of being mislabeled, and a daily source of humiliation and mistreatment. Every time she uses her health insurance card, driving license or education certificate, Natalie endures this experience. “I try to avoid these situations. I won’t travel internationally because I hate to show my passport. I discriminate against myself.”
Natalie has decided to seek legal recognition of her gender identity by changing her registered sex to female. She visits the government bureau to file an application. The clerk informs Natalie there are eligibility requirements she must satisfy. An individual must follow a process of gender reassignment under medical supervision, undergo genital reassignment surgery and be rendered surgically irreversibly infertile. “You must bring this evidence before an expert panel. There needs to be a clear-cut point,” the Clerk explains “You can’t simply choose.”
Natalie is frustrated. She desires genital reassignment surgery but cannot afford it without health insurance funding. Natalie calls to inquire. A representative informs Natalie the insurance plan will not cover the costs of surgery. Natalie has already paid substantial costs out-of-pocket for her hormone treatment. The representative explains that, “We only cover medically necessary treatment. These treatments do not qualify under this general condition. There is no medical evidence either treatment relieves the condition of gender identity disorder. You are lucky to have the diagnosis. With that, we can cover more extensive psychiatric care.”
Why is it important to Natalie that she be able to express her transgender identity?
Think about the ethical terms learned thus far in the course. What ethical terms would most apply to her situation? Justify your answers.
Which medical treatments should insurance plans and/or states provide to transgender individuals, and why?
Natalie’s story is a poignant illustration of the challenges faced by transgender individuals in their pursuit of personal identity, access to necessary medical care, and the fundamental human right to express their true gender identity. Her journey underscores the importance of recognizing and respecting the experiences of transgender people and calls attention to the ethical considerations surrounding gender identity and healthcare access.
Natalie’s ability to express her transgender identity is of paramount significance for several reasons. First and foremost, it is crucial for her mental and emotional well-being. Gender dysphoria, the profound distress resulting from a misalignment between one’s gender identity and assigned sex at birth, is a painful and debilitating experience. For Natalie, the distress caused by her body not aligning with her gender identity led to depression and severe psychological suffering.
Being able to express her transgender identity allows Natalie to live authentically, alleviate her gender dysphoria, and improve her mental health. This expression encompasses her dress, body language, and voice, which, when aligned with her gender identity, provide a sense of self-affirmation and emotional well-being.
Autonomy: Natalie’s right to express her true gender identity is an exercise of her autonomy. Autonomy is a fundamental ethical principle that emphasizes an individual’s right to make decisions about their own life and body, particularly regarding issues of identity, personal expression, and medical care.
Dignity: Respecting and acknowledging Natalie’s transgender identity is a matter of upholding her dignity as a human being. Denying her the right to express her true gender identity and access essential medical care devalues her as an individual, undermining her inherent dignity.
Justice: Justice plays a central role in Natalie’s situation, as it pertains to fairness, equality, and the right to be free from discrimination. Natalie’s struggles highlight the injustice of her experience, characterized by discrimination, harassment, and a lack of access to necessary healthcare.
The question of which medical treatments should be provided to transgender individuals by insurance plans and states is an ethical and healthcare issue. The World Professional Association for Transgender Health (WPATH) guidelines and the American Medical Association have recognized that gender-affirming healthcare, which includes hormone therapy and gender-affirming surgeries, is medically necessary and effective in alleviating gender dysphoria. Therefore, insurance plans and states should provide these treatments for several reasons:
Mental and Emotional Well-being: Gender-affirming medical treatments, including hormone therapy and surgery, have been proven to reduce gender dysphoria, alleviate depression, and improve the overall mental and emotional well-being of transgender individuals.
Reducing Discrimination: Access to gender-affirming care is essential to reduce the discrimination and mistreatment that individuals like Natalie often face. Providing these treatments can help transgender individuals integrate into society without the daily struggle of feeling mislabeled and humiliated.
Ethical Imperative: From an ethical standpoint, it is incumbent upon healthcare providers and insurers to offer medically necessary treatments that enhance the quality of life for transgender individuals, just as they do for any other medical condition. Denying access to these treatments constitutes a form of discrimination and a violation of individual autonomy and dignity.
In conclusion, Natalie’s journey serves as a compelling reminder of the importance of recognizing and respecting transgender individuals’ rights to express their true gender identity and access essential medical care. Ethical principles such as autonomy, dignity, and justice underline the need for healthcare providers and insurers to offer gender-affirming treatments as medically necessary, promoting the overall well-being and quality of life of transgender individuals. Natalie’s story underscores the urgency of addressing these ethical considerations and striving for a more inclusive and equitable healthcare system for all.
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