One of the nation’s largest health insurers is agreeing to pay for breast augmentation for some trans women.
Allison Escolastico, a 30-year-old transgender woman, has wanted breast augmentation surgery for a decade. By 2019, she finally thought her insurance company, Aetna, would pay for it, only to find that it considered the procedure cosmetic, not medically necessary, and refused to cover it.
“I knew from my case, it wasn’t cosmetic,” said Ms. Escolastico, who contacted a lawyer after she lost her appeal last year. “I knew I had to fight for this,” she said.
Ms. Escolastico’s surgery is now scheduled for February. Working with the Transgender Legal Defense and Education Fund, a nonprofit that advocates transgender rights, and Cohen Milstein Sellers and Toll, a large law firm that represents plaintiffs, she and a small group of trans women persuaded Aetna to cover the procedure if they could show it to be medically necessary.
To qualify, the women would need to demonstrate that they had persistent gender dysphoria, undergo a year of feminizing hormone therapy and have a referral from a mental health professional.
The shift by Aetna represents an important evolution in how health insurers view the medical needs of transgender individuals. While some insurers offer a broad range of surgeries for trans women if they are deemed medically necessary, others exclude breast augmentation and other treatments as merely cosmetic.
“This has the potential to be a transformative moment,” said Kalpana Kotagal, a partner at Cohen Milstein.
Insurers have typically covered genital reassignment surgery as medically necessary. But transgender women and others say breast augmentation is also a necessary treatment for individuals who receive a diagnosis of gender dysphoria. “There is no question from a medical perspective,” said Noah E. Lewis, the director of the Trans Health Project at the fund.
In addition, he said, it is illegal for a health insurer to deny coverage of medical care because of someone’s gender identity. “It’s a really simple matter of discrimination,” he said.
Aetna, which is owned by CVS Health, had been actively reviewing the need for breast augmentation surgery for trans women, said Dr. Jordan Pritzker, senior director of clinical solutions for the insurer. He said he had talked to numerous doctors who provide the surgery.
“Our decision to update our clinical policy bulletin is consistent with many changes we have made over the years to better serve the needs of the L.G.B.T.Q. community,” Dr. Pritzker said in a statement.
Aetna said it would also reimburse some trans women who were denied coverage but had the surgery. The company said it was actively reaching out to individuals who had sought authorization for their surgeries and were denied.
Cora Brna was denied coverage for breast augmentation surgery two years ago, when she tried to schedule it at the same time that she was undergoing genital reassignment, which was covered by Aetna. “I was devastated,” she said.
“I felt like a group of people were deciding whether I was or was not a woman,” said Mrs. Brna, 32, who works as a health care worker in Pittsburgh and was one of the women who petitioned Aetna. She went ahead with the genital surgery but had the procedure to augment her breasts only after it was covered by a different health plan.
Aetna’s new policy also comes at a time when the federal government is re-examining whether denying some types of care to transgender individuals is discriminatory. Under the Affordable Care Act, insurers cannot discriminate against individuals on the basis of gender identity, and most insurance companies provide coverage for people who require gender reassignment surgery. But the law never mandated a specific benefit or detailed exactly what services the insurers would cover, said Katie Keith, who teaches law at Georgetown University and closely follows this area of the law.
“It’s almost like a parity issue,” she said.
While the Trump administration sought to undo protections for transgender individuals with a rule last June, the issue is still being sorted out in the courts, said Ms. Keith, who also pointed to the recent Supreme Court decision that said gay and transgender workers are protected from workplace discrimination under civil rights law.
The new Biden administration has already issued an executive order saying it will enforce civil rights laws that protect people from discrimination on the basis of gender identity.
Major insurance companies are uneven in their coverage. Health Care Service Corp., which offers Blue Cross plans in five states, will pay for breast augmentation and other services for trans women if they are deemed medically necessary. The insurer said it developed these policies in accordance with guidelines established by the World Professional Association for Transgender Health, a nonprofit.
But other major insurers, including Anthem and UnitedHealthcare, continue to view the surgery as cosmetic, since they do not generally cover the procedures for women without the gender dysphoria diagnosis. They say they are not discriminating against trans women.
Anthem says its “medical policy is applied equitably across all members, regardless of gender or gender identity.”
And UnitedHealthcare said in a statement that its “coverage for gender dysphoria treatment is comprehensive and, depending on members’ benefit plans, current coverage may include physician office visits, mental health services, prescription drugs and surgery to address gender dysphoria.” It added that it uses “evidence-based medicine to make coverage policy decisions,” which are regularly updated.
But lawyers for the women involved in the Aetna agreement say they are looking closely at the policies of other insurers to see if they can make the same case that their refusal to offer coverage is discriminatory. “This is something that needs to be changed across the industry,” said Ms. Kotagal of Cohen Milstein.
Credit Anna Parini
The universal truth of puberty and adolescence is body change, and relatively rapid body change. Teenagers have to cope with all kinds of comparisons, with their peers, with the childhood bodies they leave behind, and with the altered images used in advertising and in the self-advertising on social media.
It may be that the rapid way the body changes during these years can help adolescents believe in other kinds of change, including the false promises that various products can significantly modify their size and shape. A study published last month in the journal Pediatrics looked at two kinds of risky behavior that are increasingly common over adolescence: the use of laxatives for weight loss and the use of muscle-building products.
It used data from an ongoing study of more than 13,000 American children, the Growing Up Today Study (GUTS). The participants’ mothers took part in the Nurses’ Health Study II, and the children were recruited in 1996, when they were 9 to 14 years old, and surveyed about a variety of topics as they grew up.
By age 23 to 25, 10.5 percent of the women in this large sample reported using laxatives in the past year to lose weight; the practice increased over adolescence in the girls, but was virtually absent among the boys. Conversely, by young adulthood, about 12 percent of the men reported use of a muscle-building product in the past year, and again, this increased during adolescence.
So a lot of young women are taking laxatives to try to become very thin, and a lot of young men are using products to help them bulk up and become more muscular. The researchers were interested in how these practices were associated with traditional ideas of masculinity and femininity. They found that, regardless of sexual orientation, kids who described themselves as more gender conforming were more likely to use laxatives (the girls) or muscle-building products (the boys).
“The link is the perception that they are going to alter your weight, shape, appearance,” said Rachel Rodgers, a counseling psychology researcher who studies body image and eating concerns and is an associate professor of applied psychology at Northeastern University.
“The representations of ideal appearance in society are very restrictive and very unrealistic both for men and for women,” she said. “They portray bodies that are unattainable by healthy means.”
Jerel Calzo, a developmental psychologist who is an assistant professor at Harvard Medical School, and the lead author on the study, said that one important aspect of this research was the way it highlighted the vulnerability of those who identify with traditional gender ideals.
“Usually in research we tend to focus on youth who are nonconforming, who we might focus on as more at risk for negative health outcomes, depression, who might be ostracized or victimized,” he said. But there are risks as well for those who are trying to measure up to what they see as the conventional standard.
The GUTS participants were asked to describe themselves as children in terms of the games they liked and the movie and TV characters they imitated, and this was used to score them as more or less “gender conforming.”
The early patterns of gender conformity were significant, Dr. Calzo said, because they were linked to behaviors that lasted through adolescence and into young adulthood. “Laxative use increases with age, muscle-building product use increases with age,” he said. “There is a need for early intervention.”
Chronic use of laxatives can affect the motility of the bowel so that it can be hard to do without them, and overdoses can alter the body’s balance of electrolytes, to a really dangerous extent.
“There’s a lot of shame and guilt for laxative abuse,” said Sara Forman, an adolescent medicine specialist who is the director of the outpatient eating disorders program at Boston Children’s Hospital. And many products marketed as cleanses or herbal teas are not labeled as laxatives, though they contain strong laxative ingredients.
The muscle-building products in the study included steroids, creatine and several others. The risks of steroids are well known, from hormonal imbalances and shrinking testicles to acne and aggression. With other commercial muscle-building products, the risks may have more to do with the lack of regulation, Dr. Calzo said. The products can contain banned substances or analogues of banned substances, like the amphetamine analogue found in popular diet and workout supplements last year.
And of course, the muscle-building products won’t reshape you into the photoshopped model any more than the laxatives will.
As Dr. Calzo says, we need to worry about the vulnerabilities of children who are growing up with issues of gender identity and sexuality. But don’t assume that more “mainstream” or “conforming” kids have it easy when it comes to body image. Parents can help by keeping the lines of communication open and starting these conversations when children are young. We should be talking about the images that our children see, about how real people look and how images are altered.
And that conversation should extend to social media as well; in a review by Dr. Rodgers, increased social media use was correlated with body image worries. “Teenagers are looking at their friends on social media and seeing photos that have been modified and viewing them as something real.”
The other message for parents is about helping to model healthy eating, family meals, realistic moderation around eating and exercising, and to refrain from any kind of negative comments or teasing about a child’s body. “Research has shown people who have more body satisfaction actually take care of themselves better, which suggests that the approach of making them feel bad is actually not helpful,” Dr. Rodgers said.
Every adolescent, across gender, gender identity, gender conformity, and sexuality, lives with a changing body and the need to navigate body image and identity. There are a lot of unrealistic images out there to measure yourself against, and a lot of false promises about how you might get there.
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In 1952, George Jorgensen, a Bronx-born G.I., underwent surgical and hormonal treatment in Denmark to become Christine Jorgensen, a nightclub entertainer and advocate for gender identity rights. Ever since, health professionals and lay people alike have debated the origins of gender identity, the wisdom of altering one’s biologically determined sex, and whether society should accept the transgender community as a fact of nature.
There is even disagreement over whether the Civil Rights Act of 1964, which bars discrimination because of sex, also protects gender identity, a person’s inner sense of being male or female. Many more transgender people, whose identity does not match their biological sex, have come forward in recent years. Some seek sex change treatment. The Olympic gold-medalist Bruce Jenner made a high-profile announcement last year of his transition to Caitlyn Jenner, including a cover story in Vanity Fair.
This year, the Public Theater in New York presented the musical “Southern Comfort,” adapted from an award-winning 2001 documentary film about transgender people living in rural Georgia who came together to support a dying friend who developed ovarian cancer years after transitioning from female to male.
Yet the controversy now raging over the rights of transgender students to use bathroom and locker room facilities that match their gender identity rather than their birth sex reflects the persistence of widespread prejudice and misinformation about the nature and behavior of people who identify as transgender.
Those who insist that people should use only the facilities that match the sex on their birth certificates may not realize that most states allow those who change their sexual assignment to change the sex on their birth certificates. Furthermore, a transgender individual using a facility matched to his or her gender identity is no more of a sexual threat to others than anyone else using that bathroom might be. Psychosocial distress or embarrassment can be avoided simply by providing closed-door toilet and changing areas in public bathrooms and locker rooms. After all, we should be used to mixed-gender bathrooms by now: We’ve had them in our homes for years.
I recently read a most illuminating article, “Care of Transsexual Persons,” that answered many of the questions and concerns that have been raised about transsexualism, which is now more commonly referred to as being transgender. Written by Dr. Louis J. Gooren, an endocrinologist at VU University Medical Center in Amsterdam and a leading expert in the field, it was published in 2011 in The New England Journal of Medicine.
Perhaps the most important point Dr. Gooren and others make is that a mismatch between gender identity and biological sex is not something people choose. The most common description given by transgendered individuals is a persistent, painfully distressing belief that they are females trapped in a male body, or vice versa.
Although being transgender is classified in the psychiatric literature as “gender identity disorder,” Dr. Gooren pointed out that “a substantial proportion of the transgender population does not have a clinically significant coexisting psychiatric condition” other than chronic suffering from feeling they are not what their bodies tell them they are.
No chromosomal or hormonal causes of being transgender have been identified. Also lacking is convincing evidence that it is caused by some aberration of family dynamics — how a child is treated or dressed by mom, dad or anyone else.
Being transgender simply happens, possibly during brain development in the womb. All brains start out female; if the fetus is male, testosterone normally programs both the genitalia and the brain to develop as male. But autopsies of a small number of male-to-female transgender people found that two important areas of the brain had a typical female pattern, suggesting an alteration in the brain’s sexual differentiation.
In individuals who transition from female to male, it is possible that excessive production of androgens during pregnancy could have programmed the brain to be male.
Among adults, male-to-female transitions are nearly three times more common than female-to-male ones. It has not been unusual for people born male to first acknowledge and express their female gender identity in midlife, often after having married and fathered children.
In young children, girls who are tomboys and boys who act more like girls are quite common and should not be assumed to be transgender. Such behavior often changes by adolescence.
However, when bodily changes at puberty differ from a child’s gender identity, they are typically a source of extreme distress. Still, experts warn that at any age, and especially in adolescence, great caution must be taken before irreversible treatments are provided to induce changes that conform to a person’s discordant gender identity.
“Persons with gender identity disorder may have unrealistic expectations about what being a member of the opposite sex entails,” Dr. Gooren wrote. Therefore, he and others say that before starting hormone treatments, the person should live for at least a year as the desired sex. Only then should hormone treatments be used to induce the secondary sex characteristics of the new sex and suppress those of the birth sex.
Surgical sex reassignment may then follow to remove and reconstruct the genitalia, breasts and internal sex organs to more closely resemble the desired sex. Some people, especially transgender males, also undergo facial reconstruction. Even after surgery, hormone treatments must continue indefinitely to maintain the desired gender characteristics.
It is especially important for transgender individuals seeking treatment to know the risks involved. Long-term studies of people who underwent sex reassignment surgery have been conducted in Sweden and Denmark, where excellent population-wide medical records are kept.
A Swedish team from the Karolinska Institute and the University of Gothenberg followed 324 people who underwent sex reassignment surgery and compared them with matched controls in the general population. After an average follow-up of 11.4 years, men and women who had sex reassignments had death rates three times higher from all causes. Suicide rates were especially high, suggesting “the need for continued psychiatric follow-up” among those undergoing sex change, the authors wrote. Cancer deaths were doubled in the surgical group, though the cancers appeared to be unrelated to hormone treatments.
The recent Danish study, by researchers in Copenhagen, investigated postoperative diseases and deaths among 104 men and women representing 98 percent of those who underwent sex reassignment surgery in Denmark from 1978 through 2010. One person in three had developed an ailment, most often cardiovascular disease, and one in 10 had died, with deaths occurring at an average age of 53.5.
The authors suggested that a host of societal factors, including social exclusion, harassment and negative experiences in school and at work, could largely contribute to the patients’ health problems. The findings underscore the importance of better postoperative support and closer attention to injurious lifestyle issues like smoking and alcohol abuse.
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Belgian and Polish adolescents are among the least happy in Europe, more than half the teenagers in Greenland smoke, and Eastern European boys are far more likely than girls to have had sex, according to a report from the World Health Organization. But over all, the report found, 15-year-old girls were perhaps the worst off of any group surveyed.
The report on adolescent health and happiness was based on surveys of more than 200,000 young people in 42 countries in Europe and North America. Conducted mainly between September 2013 and June 2014, it was released on Tuesday. (American teenagers did not participate.)
Partly titled “Growing Up Unequal,” the report found that 15-year-old Polish, British and French girls were among those expressing the least satisfaction with their lives. They were the most likely to report a decline in their well-being, and on average, one in five reported poor or fair health. They also displayed an increased dissatisfaction with their bodies, “particularly in western and central European countries, despite actual levels of overweight and obesity remaining stable,” the report said.
W.H.O.’s regional director for Europe, Zsuzsanna Jakab, wrote, “Despite the considerable advances made in the W.H.O. European Region over the decades in improving the health and well-being of young people and recent actions to reduce the health inequalities many of them face, some remain disadvantaged from birth by virtue of their gender.”
Boys reported higher life satisfaction over all. But the report highlighted some elevated risk factors for male adolescents. It found that boys were more likely to engage in physical fights and to experience injury. They smoked tobacco and drank alcohol more often, though in some countries, gender differences in those behaviors were narrowing “as girls adopt behaviors typically regarded as masculine.”
Early tobacco use has declined significantly since 2010, the last time the study was conducted. In many countries, fewer than 20 percent of 15-year-olds reported smoking at least once a week. But in Greenland, 53 percent of girls and 51 percent of boys said they smoked at least weekly.
Drinking was heavily skewed by gender in many countries, with 15-year-old boys in Croatia, Malta, Bulgaria and Italy reporting some of the highest incidences of alcohol use. On average, 16 percent of 15-year-old boys drink alcohol at least once a week; the number for girls is 9 percent.
Frequent marijuana use was also divided along gender lines —in some countries, boys used the drug more than girls — though that factor seemed to matter less where it was most popular. French and Canadian 15-year-olds were among the most enamored of marijuana, with boys and girls similarly reporting they had used it in the previous 30 days. Over all, 15 percent of those surveyed had used.
Boys were more likely than girls to have had sexual intercourse in about half the countries and regions surveyed, particularly in Eastern Europe. Forty percent of male 15-year-olds surveyed in Bulgaria said they had had sex, compared with 21 percent of female Bulgarians of the same age. The numbers were even more skewed in Albania, where 39 percent of boys there said that they had had sex, while 2 percent of girls the same age reported such behavior. Over all, 21 percent of the 15-year-olds surveyed reported having sex.
Apart from surveying the habits and health practices of young people, the latest report added new questions to track the health risks posed to the thousands of young migrants uprooted from their homes, and warned that new communications technology could prove a double-edged sword, particularly when it comes to young people bullying their peers over social media.
“Technology is unquestionably a positive presence in all our lives, but we must remain vigilant to the threats it poses to children and young people,” Jo Inchley and Dorothy Currie, two executives who helped coordinate the study, wrote in its preface.
The report concluded that policy makers must strive to recognize girls’ unhappiness and find structural solutions, and called for efforts to address the “clear gender-difference issue.”
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