VA reviewing policy
against transsexual surgery
Star, AZ, USA
By Carol Ann Alaimo
Arizona Daily Star
Tucson, Arizona | Published: 02.23.2009
Enjoying the sun in her Mustang convertible, transsexual veteran Diane
Steen leaves the VA hospital, where she volunteers.
[Photo by Greg Bryan / Arizona Daily Star]
"You people don't exist."
Air Force veteran Diane Steen, who was born male and had surgery to
become a woman, still gets steamed when she recalls the comment from a
staffer at Tucson's veterans hospital, where Steen is a patient and a
The remark came, she said, when she asked the staffer, who had a
military background, how much training he had received about people
Officially, transgender patients barely do exist in the Veterans
Affairs health care system.
They often are denied treatments that experts say could help them most.
National Department of Veterans Affairs policy — now under review —
specifically forbids veterans hospitals to perform or pay for
"transsexual surgery." It also does not provide for the related health
care that experts recommend, such as psychotherapy, hormone treatment
and other measures.
Officials at VA headquarters, given 10 business days to answer, said
they couldn't determine how many transgender patients are in the VA
Officials at the Southern Arizona VA Health Care System — Tucson's
veterans hospital — said 48 VA patients in Southern Arizona are
transsexual or have been diagnosed at some point with "gender-identity
disorder," the medical term that covers such cases.
A national advocacy group estimates that about 300,000 active or
retired military personnel are transgender, though experts say an
accurate count is impossible because many live under the radar to
escape social stigma.
In June, the American Medical Association approved a new policy on the
care of transgender patients, effectively putting VA policy at odds
with the recommendations of the nation's largest doctors group.
The association said gender-identity disorder is a "serious medical
condition . . . which causes intense emotional pain and suffering" and
can lead to stress-related illness, chronic depression and suicide if
not properly treated.
The group urged all public and private medical insurers to cover the
cost of mental health care, hormone therapy and sex-reassignment
surgery whenever doctors deem them medically necessary.
Experts worldwide "have rejected the myth that such treatments are
'cosmetic' or 'experimental, ' " the AMA said.
VA examining policy
A spokesman for national VA headquarters, in a recent e-mail to the
Arizona Daily Star, said the VA is taking a second look at its policy
banning transsexual surgery at veterans hospitals.
"VA is in the process of rewriting its directive excluding
gender-reassignment surgery and will be conducting a review of the
evidence base on this issue," VA spokesman Terry Jemison said. "The
current policy may continue or may change, but our decision will be
based on the available evidence, not on the AMA's resolution."
The American Medical Association said many surgeries that help
transgender patients — such as removal of breasts, testicles or
ovaries — are routinely covered for other patients for various medical
Denying such coverage to transgender people "represents discrimination
based solely on a patient's gender identity," the doctors group said.
Jemison said that while the VA doesn't routinely provide such care,
officials "don't rule out the possibility of exceptions."
The VA policy that bans surgery also says the VA won't carry out "any
process or procedure involving genital identity revision."
Interpretations of that phrase vary widely from one VA hospital to the
next — and even from one VA employee to the next — resulting in vast
disparities in how such patients are treated, advocates say.
At some VA hospitals nationwide, staffers have been known to shut the
door on transgender veterans, turning them away for even routine
medical care unrelated to their gender disorder, a survey last year by
the Transgender American Veterans Association found.
Of the 240 veterans surveyed who were part of the VA system, 10
percent said they had been turned away for service because they were
transgender. Nearly one-quarter said they had been mocked or insulted
by VA staff members.
Jemison, the national VA spokesman, said the VA "does not condone
withholding delivery of routine medical care for transgender patients
anywhere in our system."
It depends on the doctor
Some VA hospitals — those in Tucson and Boston, for example — are seen
as more liberal in their interpretations of VA rules.
The Southern Arizona VA Health Care System says it routinely provides
hormone therapy to veterans transitioning from one sex to another —
testosterone for biological women becoming male, to help them grow
beards and reduce feminine curves, and estrogen for biological men, to
help them grow breasts.
Andoso climbs scaffolding while inspecting a construction job site.
From outward appearances, you'd never guess he served in the Air Force as a woman. He gets hormone treatments from the VA. [Photo by Greg Bryan / Arizona Daily
Mick Andoso, an Air Force retiree
who served as a female and now is
male, receives hormone treatments at the Tucson veterans medical
center, and he says he's satisfied with his care.
Steen, on the other hand, said she was denied hormone therapy at the
local VA as she prepared for her privately obtained sex-change
surgery. That forced her to find an outside doctor and cover the cost
"It all depends what doctor you get," Steen said of VA care.
Ex-Army Capt. Erin Russ says some VA staffers believe transgender people
"are crazy, and they refuse to deal with us on any other basis." [Photo by Greg Bryan /
Arizona Daily Star]
Erin Russ of Tucson, a former
Army officer who is transgender and a VA
Tucson VA staffers "are mostly accepting. But there are a few who
basically hold the line that we are crazy, and they refuse to deal
with us on any other basis," said Russ, who teaches transgender
awareness workshops at Wingspan, the local gay, lesbian, bisexual and
transgender resource center.
Dr. Jennifer Vanderleest, an assistant medical professor at the
University of Arizona, got a similar impression of the Tucson VA staff
when she conducted a training session on transgender health care two
"Overall, it was well-received, but there was a little push-back from
some of the providers, and one doctor in particular, who felt that
some of this is controversial, " she said. A VA patient later told
Vanderleest that the resistant doctor she encountered was
disrespectful toward transgender patients, she said.
Pepe Mendoza, a spokesman for the VA in Tucson, said he couldn't
comment directly on the incident Vanderleest described without more
details, but he did say that "all veteran patients are treated with
respect and courtesy."
Vanderleest said ignorance and prejudice are common in the medical
community because most practitioners — inside and outside the VA —
haven't received any training on transgenderism.
"They don't really know how to handle this," she said. "There is a lot
of misunderstanding about who a transgender person is and what this
It appears that only one VA hospital in America has a written policy
spelling out how transgender patients should be cared for.
Jillian Shipherd, a clinical psychologist at VA Boston and a pioneer
in improving health care for such veterans, said Boston's written
policy also protects her hospital's staffers from being disciplined
for providing certain types of help.
Some VA staffers nationwide — Shipherd did not want to say where —
"have gotten in trouble with their local administrations" because VA
rules "are interpreted very differently from place to place."
Exclusions are widespread
The VA isn't alone in not covering surgery for transgender patients.
The Human Rights Campaign, a national advocacy group, recently
surveyed about 1,300 colleges, law firms and major corporations,
finding 52 that provide full coverage for transgender care.
When the city and county of San Francisco made the change to cover
transgender medical care in 2001, critics feared it would be pricey.
Cost estimates ranged as high as $1.7 million a year.
But not all transgender patients seek surgery. The total tab over five
years was $386,000 — so little that the municipality dropped a $1- to
$2-a-month surcharge initially charged to its 80,000 insured to pay
for the extra coverage.
Advocates for transgender veterans are keeping their fingers crossed
that the VA's policy review will lead to changes.
"I think we can all agree that these are veterans, they served our
country and they deserve our respect," said Shipherd, the Boston VA
"And they deserve quality health care. No exceptions."
(pdf) Boston memo about transgender veterans
http://regulus2. azstarnet. com/pdf/pdfs/
Studies of brains, DNA find transgender physical differences
Is being transgender a choice?
Some experts believe the question itself is rooted in prejudice, yet
it often arises when the topic is discussed.
The study of how sexual identity develops is relatively new, spurred
in part by recent developments in genetic research.
So far, medical science hasn't been able to pinpoint why some people
born as one sex instead identify with the other.
Some recent studies point to possible biological underpinnings,
although experts caution that it's too early to draw firm conclusions.
The American Psychological Association says there may not be just one
cause but, perhaps, varied combinations of factors — genetic, hormonal
"The diversity of transgender expression argues against any simple or
unitary explanation, " the group says on its Web site.
In 1995, researchers at the Netherlands Institute for Brain Research
autopsied and compared the brains of heterosexual men and women,
homosexual men, and transsexuals who were born male and had surgery to
In one of the brain structures that may govern gender identity,
transsexuals' brains were more similar to female brains than to those
of males, the researchers found.
In 2003, scientists at UCLA studied the genes of embryonic mice and
found that the maleness or femaleness of their brains was apparent
before they ever developed sex organs.
"Our findings may explain why we feel male or female, regardless of
our actual anatomy," Dr. Eric Vilain, an expert in sexual development
and an associate professor at the UCLA medical school, said in a news
release put out by the university at the time.
And a 2008, study by Australian researchers compared the DNA of more
than 100 transsexuals who were born male and became female with the
DNA of more than 200 biological men.
The transsexuals were more likely to have a genetic variant believed
to reduce the signaling action of testosterone, the male sex hormone,
in the brain during fetal development, the study found.
Dr. Jennifer Vanderleest, a Tucson physician who has worked with more
than 100 transgender patients, does not believe "that transsexualism,
or being transgender, is a choice."
"In my opinion, it seems that this issue of choice is often used to
perpetuate discriminatory practices" against such people, she said.
Clinical psychologist Jillian Shipherd, who works with transgender
veterans in the VA Boston Health Care System, agreed.
Many health conditions, such as heart disease and diabetes, are fueled
by poor lifestyle choices, yet no one questions the need for proper
medical care in those cases, she said.
"For anyone who thinks (being transgender) is a choice, I wish they
could be a fly on the wall in my office," Shipherd said. "Why would
anyone choose this when it's such a difficult road?"
Sunday: Tucson's invisible veterans — former troops who change sexes
face stigma, scorn.
http://www.azstarne t.com/allheadlin es/281260
Today: Transgender veterans find VA medical care inconsistent.
To learn more
• Go to www.ama-assn. org/ ama1/pub/upload/ mm/16/a08_
hod_resolutions. pdf to read the American Medical Association policy on
Go to www.wpath.org to read about the World Professional Association
for Transgender Health.
• Go to www.tavausa. org/ Survey_Results. html to see the results of a
survey by the Transgender American Veterans Association.
Contact reporter Carol Ann Alaimo at 573-4138 or at
calaimo@azstarnet. com. Contact
reporter Carol Ann Alaimo at 573-4138
Copyright (c) 2009