Tuesday, April 11, 2006 - Page updated at 12:00 AM

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Tax dollars and a sex change: a story of one patient

Seattle Times Olympia bureau

Gender-identity disorder

People with gender-identity disorder have strong and persistent feelings that they were meant to be the opposite gender.

The cause is unknown, but researchers theorize hormonal influences in the womb, genetics and environmental factors, such as parenting, are involved.

The condition is rare. According to some estimates, fewer than one in 12,000 men and one in 30,000 women have the disorder.

The cost of surgery varies. Male-to-female surgery averages between $10,000 and $30,000. Female-to-male surgery can cost $80,000 or more.

For more information, contact the Harry Benjamin International Gender Dysphoria Association at

For more than two decades, Andy had collected monthly disability checks and food stamps. Taxpayers picked up his medical bills, too, including the cost of more than half a dozen stays in mental hospitals.

But Andy has a job now and says his life is finally under control. He says he received his last disability check this month.

What's changed?

Andy used to be Ava. A woman. Tormented since childhood with what doctors later diagnosed as gender-identity disorder, Andy six years ago won a legal settlement that required the state to pay for him to undergo a sex change.

In all, Medicaid paid about $84,000 over three years for nearly 20 surgeries to complete Ava's conversion to Andy.

"I'm finally being allowed to live my life and contribute to society," said Andy, who is approaching 50, "instead of having to hole up in a corner someplace and eat drugs and be taken care of all my life."

Andy did not want his full name published, fearing it might embarrass his bosses and fellow employees at the building-supply store where he works.

His story provides a real-life look into what has become a highly charged debate over whether taxpayers should pay for sex-change operations, also known as sex-reassignment surgery.

When news surfaced earlier this year that Medicaid, the federal-state insurer for the poor and disabled, had paid for such procedures, some state lawmakers tried to impose a ban. A U.S. senator even weighed in, writing letters to top state officials and calling for a federal investigation.

Even before the political uproar, however, Medicaid officials were working on new rules that essentially classify sex-reassignment surgery as experimental and not eligible for coverage. The state would pay only for less costly treatments, such as hormone therapy and counseling.

But those rules might not stand.

The state has six pending requests from people seeking Medicaid coverage for sex-change operations. In the past few weeks, state hearing officers have reversed Medicaid decisions denying coverage for two of those people.

The state is appealing the rulings, and both cases could wind up in court. Other states, including some that have moved to bar using Medicaid money for sex changes, will be watching closely.

While a few companies, including Microsoft, offer coverage for sex-change surgeries, the vast majority of public and private employee health-insurance plans do not.

State Medicaid officials acknowledge gender-identity disorder is a real and serious medical condition. But they argue that sex-change surgery is risky and unproven.

"In gender surgery, you cannot predict who will benefit and who will not benefit — or perhaps even be harmed," said Dr. Jeff Thompson, medical director of the state Medical Assistance Administration.

Many experts in the field disagree. For some transgender patients, they say, surgery is the only way to relieve the mental anguish that prevents the patients from leading productive lives.

"Isn't this empirical proof?" said Andy, who figures he collected more than $100,000 in disability checks alone over the years. He's certain his mental-health care was far more costly.

"I'm off services, I'm off funding, I'm paying taxes," he said. "Isn't this what the goal was?"

Forced to wear a dress

Gender-identity disorder, also known as gender dysphoria, has been recognized in some form for more than two decades by the American Psychiatric Association's diagnostic manual. In general, people suffering this condition feel trapped inside a body of the opposite sex.

Andy recalls having such feelings since he was a little girl. To make matters worse, he says, he had an abusive father who seemed bent on beating him into being a regular girl.

Forced to wear dresses to school, Andy recalls ducking into an alley to change into his younger brother's clothes.

"I'd get clobbered at school, sent home and then clobbered again for not being dressed appropriately," he said.

He doesn't think the abuse contributed to his gender disorder. Instead, he is convinced it was a birth defect, something that happened to his brain while he was in the womb.

Wanting so much to be the woman his parents and others expected him to be, he got married and had a daughter. The marriage lasted only a few years, and he soon wound up in another relationship with a man who had three kids.

But his life never felt right.

Andy went on disability in the early 1980s. He says he was originally diagnosed with bipolar disorder and other ailments because Social Security did not recognize gender dysphoria. He suffered debilitating migraines and couldn't hold a job for more than a few months.

He says he came "damn close" to committing suicide on a few occasions.

"The more depressed you get, the more physical aches and pains you get, the more pain pills you take," he said. "It goes downhill from there. Sometimes I'd go into migraine phases because I couldn't handle being an 'it' anymore and end up in hospitals for 50, 60 days on Demerol and morphine."

Andy went to great lengths to look like a man. For 10 years, he lashed a back brace to his chest to flatten his breasts and wore two shirts to conceal the brace.

In the early 1990s, doctors confirmed he suffered from gender dysphoria, and he began testosterone treatments, paid for by Medicaid. Within a year, his beard came in and his hairline receded.

But the hormones weren't enough. Andy wanted a full sex change.

Though at the time the state said it covered "medically necessary" sex-change operations, Medicaid officials denied Andy's request. They said he had not proved surgery was necessary or that he was a suitable candidate.

Andy sought help from Lisa Brodoff, an attorney at the Seattle University Law Clinic who represents indigent people over Medicaid coverage.

In 2000, after a state attorney cautioned Medicaid officials that they would likely lose if the case went to trial, the state negotiated a settlement acknowledging that surgery was necessary. The state agreed to cover a long list of procedures, including a double mastectomy, removal of ovaries, and a surgically constructed penis.

The state also agreed to pay Andy's travel costs to Florida, where most of the surgeries were performed.

He is legally a man now — it even says so on his revised birth certificate. He owns his own home and is in his second straight year of holding a job. He says he's off the mental-health drugs and out of counseling.

"I had to be a man," Andy said.

Backlash erupts

Few things make better political hay than a taxpayer-funded sex-change operation.

A 2004 report by the state Auditor's Office faulted Medicaid for spending more than $180,000 of federal and state money on what it called questionable sex-related or cosmetic surgeries in 2003.

Among the items auditors singled out were about $9,500 worth of Andy's sex-change operations. (The report didn't mention the other $75,000 the state spent on his sex change.)

When the audit findings made headlines earlier this year, state House Republicans tried to bar Medicaid from putting any money toward "gender reassignment surgery or treatment." But majority Democrats, who thought the total treatment ban went too far, blocked it.

The auditor's report also caught the attention of Republican Charles Grassley of Iowa, chairman of the U.S. Senate Finance Committee. In a letter last month, he told Democratic Gov. Christine Gregoire that he was requesting that the federal Office of Inspector General look into the matter.

In a response letter, Gregoire suggested the auditor's report was misleading.

For one, she pointed out, the report didn't mention that the sex-change procedures were the result of a legal settlement. And she noted that the state no longer authorizes surgery for gender dysphoria.

The state's Medicaid agency pays for more than 500,000 surgical procedures of all types a year. But Medicaid officials say the state has covered sex-change operations for just five people in the past 15 years.

The last two cases, both approved in 2000, were Andy's and a male-to-female sex-change operation that cost the state nearly $29,000.

Report questions surgery

The state used to follow guidelines established by the Harry Benjamin International Gender Dysphoria Association, an organization of experts who specialize in gender disorders.

The Harry Benjamin care standards require people with gender dysphoria to undergo hormone treatment and live as the opposite sex for a year or more before having surgery.

But in 2004, Medicaid shifted to an "evidence-based medicine" process for determining whether a certain procedure should be covered. As part of that effort, the state commissioned a report evaluating studies on sex-change outcomes.

That review — done by Hayes Inc., a firm that assesses health-care technologies — concluded that sex-change surgery remains experimental. It said that while some people benefit from surgery, there is not enough solid data to prove it is safe or more effective than hormone therapy and counseling alone.

Many medical experts disagree.

In a letter last spring, the Harry Benjamin association said the Hayes report is flawed because it relies too heavily on outdated studies done when sex-change surgery was still new and complications were frequent.

Walter Meyer, a professor of psychiatry at the University of Texas' medical school and past president of the Harry Benjamin association, said more recent studies show significant improvement in people's mental health after surgery.

Dr. Marci Bowers, who performs more than 120 sex-change surgeries per year through her clinic in Colorado, said surgery is not always the right solution. But for some, she said, it works wonders.

"What people describe over and over again is a sense of relief," said Bowers, a former Seattle doctor who underwent surgery in 1998 to become a woman. "Finally, their bodies align with what their souls have told them from a very early age."

But Thompson, the state medical director, stands by the Hayes report and questions the objectivity of its critics. "I guess the question is, are they practicing evidence-based medicine or are they being advocates?" he said. "I think in this case they're being advocates."

Armed with the Hayes report, Medicaid since last year has denied three requests to cover sex-change surgeries. All were appealed to the state's Office of Administrative Hearings.

Rulings were issued last month in two of those cases. An administrative-law judge concluded surgery was medically necessary and should be covered.

The Medicaid agency is taking both rulings to the Department of Social and Health Services board of appeals. If Medicaid loses there, it cannot appeal. If the board sides with Medicaid, the cases likely will wind up in court.

In the meantime, the state has received three more requests for sex-change surgeries.

Ralph Thomas: 360-943-9882 or

Copyright © 2006 The Seattle Times Company


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