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Shifting priorities

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I came out as genderqueer 11 months ago.

I started a new job 6 months ago. I haven't talked about it much, but I put in a lot of angst over how I'd present at interviews while I was between employment. The one thing you do not want to look like at an interview is a weirdo. I elected to grit my teeth and go for the suit with tie because I can do that, and a few other reasons I'm not entirely proud of. It worked though, I got a job with a nice raise over what I used to make, and it seems the kind of place where I might have actual advancement potential! I haven't had that in.. 11 years. Cool.

However, new job means a new chance to make first impressions and it was time to do it right. Also, this job has a written dress-code (professional, not just office-casual) which required a major wardrobe upgrade from me. I'd been living in t-shirt-casual land for 11 years, my office-casual wardrobe was w-a-y out of date and heavily pruned after two cross-country moves. I needed an update, so what would I get?

There was less angst this time

Nature is analog, not digital

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A bit off topic, but it's been on my mind lately.

XX and XY are not the sex-absolutes you may think it is. They're the two most common bins, but they're far from the only genetic bins that humans end up in. Many, many people have been surprised when examining genes to determine "true" sex, often unhappily, and often complicatedly as a genetic condition a test wasn't designed to handle is encountered (how do you type XXY?).

What else is there out there?

Possibly the most famous is Androgen Insensitivity Syndrome (which comes in 'complete' and 'partial' varieties) in which a mutation on the hormone receptor for Testosterone either doesn't work or only partly works. Babies with C-AIS will end up with an F on their birth-certificate because that's what they look like, and they'll go through a normal female puberty even though they're still producing Testosterone.

That's because the liver does this neat trick called armoatization in which excess Testosterone is converted into Estrogen. This is why some perfectly normal teenage boys end up with gynecomastia, as all that surging Testosterone (puberty does that) causes a bit of it to convert.

Anyway, AIS girls develop in the womb along female patterns. The testes are still there, they're just not well developed. They also won't develop a uterus, since it wasn't there to begin with. Because of this, they won't menstruate but in every other way will look like any other girl (if a bit taller).

P-AIS is less definite, and is where some Intersex conditions come in to play.

I remember a scandal in the 90's when genetic testing for maleness was introduced among female Olympians, and they found two who tested male because of this. This was an extremely unpleasant surprise for them, as they'd both been competing at the world level for a while.

Next up is Klinefelter syndrome, which is an individual with an extra X chromosome to make XXY. And sometimes even more chromosomes get tacked on depending on what happened. These babies will most likely get an M on their birth-certificate, but development is where the differences begin to show. Testosterone production is reduced compared to XY males, but is still elevated compared to XX females.

In the same vein we have XXYY males. Those extra chromosomes aren't good things to have, but it does show up often enough we know about it.

The thing that breaks peoples brains is mosaicism, in which one person can have two different genomes. People with this can have a heart with one set, and an ovary with another, or eyes with different colors. One type of Turner Syndrome involves a mosaic of -X and XY (where -X is a missing X, they're short one). Depending on what tissue you take for typing, that individual may come up as either Turner-Female, or Male.

A slightly different version of this is chimerism, in which the two genomes came from two different zygotes. This can lead to fun things like true hermaphrodism if the reproductive parts of both individuals end up in the same body, and may have already allowed human parthogenesis. As with mosaics, these individuals can sex-type differently based on which tissue you take for testing.

If you ever wanted to see what a highly complex, failure accepting system looks like... biology. It's amazing we get anything done with all those transcription errors.

With Manning announcing that she'll spend her 35 years of incarceration as a self-assigned woman, the US is getting a brief look at a particularly nasty state of affairs that been there for years. The US Army does not provide any treatment services other than mental health for people with Gender Identity Disorder. Which means Manning will spend her 35 years in a men's prison with no access or hormones, surgery, or even simple hair-removal.

If you dig out the big coverage document that came with your (US-based) health-care plan (assuming you even have one) there is a section you probably never bothered to look at titled EXCEPTIONS. This is the list of things that the plan will NOT cover. This is the list that tells you that, no, they won't cover things like:

  • Going to Aruba for your (otherwise covered) kidney transplant.
  • Costs related to medical studies of pre-market drugs and treatments.
  • Costs relating to anything the FDA labels as 'Experimental'.
  • Purely cosmetic procedures.

There is something else that almost always shows up on this list that really, really gets in the way of treating people like me and Chelsea Manning.

  • Costs related to treatment of Gender Identity Disorder.

Yep, even though the DSM recognizes GID as an actual treatable disorder, and there is even a widely accepted treatment protocol for it, it's explicitly not covered in most plans. It has been this way for decades. By the protocol, treatment of GID requires interaction with three different medical professionals:

  1. Mental health professionals who guide the person through the whole process.
  2. Endocrinologists for the administration of hormones.
  3. Surgeons for any surgeries that may be needed.

My current plan covers only the first step. They'll happily talk me out of it, but won't cover any actual medical interventions. This is the same coverage that Manning will get.

My plan at WWU didn't cover any of it. This is progress of a sort, but only a grudging one. Hormones and Endocrinologist visits are thousands of dollars a year. Surgeries such as double mastectomies will be completely out of pocket and can easily end up close to $10K. Hair removal takes years and multiple treatments (hair grows in cycles, you see).

Employers have to specifically negotiate coverage, which some do. San Francisco made news several years ago when they started covering the full costs. Several large tech companies advertise that they do so as well. It can be done, the effort just has to be taken.

Why is this protocol treated so very differently than anything else?

Dicks, but I'll get to that.

The only other thing that got even close to the exclusions of GID coverage is:

  • Ovariohysterectomies in women under 30

And even that has fallen off in recent years.

Way back in the 1960's when the male-to-female surgery first became generally available, people started doing it. It was very scandalous since men were cutting off their dicks. Unfortunately, some of those transitioners experienced buyers remorse and learned that the surgery is a one way street, and the results aren't as good as the imagination suggests. And some of those remorse sufferers suicided.

Cue the epic pearl-clutching.

Something had to be Done, and Something certainly Was Done. Regulation started to fall down on this elective surgery in a haphazard way. It was in light of this that the Harry Benjamin Standards of Care were created in the 1970's, as a way to provide a widely accepted protocol for treatment. It worked.

However, those suicides haunted the insurance actuaries. Wrongful death suits are really, really expensive. Treating GID can lead to death, therefore, we won't cover it. QED.

That was 40 years ago, though.

One of the big reasons those early transitioners suicided was regret over not being able to have kids. The BSC is big on making clear that sterility is one of the side effects of transition, and is a major component of the mental health requirement being satisfied before going on hormones.

However, we've gotten a lot better at reproductive technology in the last 40 years. Sperm donation is a lot easier than it used to be, and they're viable longer. Egg donation is a thing now. I've known transitioners who've done gamete donation before taking the sterilization steps because of plans for maybe-kids later on.


Numbers are illustrative, not scientific. Do not cite.

40 years ago society was a lot more divided along gender lines and the concept of genderqueer wasn't really a thing. You were either male or you were not (things were also a weensy bit more sexist too), there was no between. It was a much more gender essentialist time. Men transitioning to women were told to always wear skirts, grow their hair out, and learn how to be demure (failure to comply could mean not getting access to hormones). Never mind that gender performance varies considerably even among those who never question their gender, that's a pointless detail; these people need to over-perform in order to pass at all.

Another reason those transitioners suicided was because they were crammed into a role they didn't want to fit into. Perhaps they didn't want to change their job from the one they spent 20 years in to one more in line with Women's Work like teaching, but that's what the therapists demanded... and ended up hating it. And wanting the old life back, just different. But that's impossible so...

Speaking from direct personal experience, having between be an option really takes the stress out of many people who are in the middle of the gender spectrum. Not having to be shoved into a -8 or +8 on the spectum in order to have the gatekeeper open the door for you takes a lot of the stress out of the process.

The assumptions of 40 years ago no longer hold true, and it's time for that needless exclusion to be dropped.

We're getting more people suiciding from untreated GID than we ever did for treated. The continued presence of this health-care exclusion is unexcusable discrimination.

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