Transgender health care a maze of difficulty, technicalities

Dallas (AP) — After nearly 50 years living as a man, Leslie McMurray was reborn — but then lost nearly everything: her home, her marriage of 33 years and her job as a radio program director in Dallas.

McMurray also began her long and complicated battle with health insurance. She and many other transgender people face difficulties with health insurance providers who will not cover certain medical procedures or medications.

An estimated 700,000 transgender people live in the U.S. As public awareness of this population grows, spurred by such high-profile stories as that of Bruce Jenner's transition to Caitlyn, it's become clear that health insurance coverage for transgender-related procedures and wellness is a complicated maze of terminology and technicalities, experts say.

Some insurance providers cover surgical procedures like gender reassignment surgery but do not cover procedures like feminization of the face for trans women (someone who was born male, but identifies as female) or mastectomies for trans men (an individual born female who identifies as male). Other providers do not cover surgeries related to gender reassignment but will cover certain hormonal treatments and mental health therapy.

"When health care really stresses biology, it leaves a large portion of us out," Nell Gaither, president of the Trans Pride Initiative, a local advocacy group, told The Dallas Morning News (http://bit.ly/1NtIL1m). "Our lives depend on medical intervention. One way or another, we'll figure out how to get the treatment we need. (But) when insurance doesn't work, a lot of people turn to the Internet to get what they need, and that's extremely dangerous."

Insurance company representatives say their plans abide by industry standards, including meeting Affordable Care Act regulations, which include a clause that insurance providers cannot discriminate on the basis of gender identity or stereotypes.

And some insurance providers, like Aetna and Cigna, have broadened their policies to include more access for transgender-related coverage.

But many transgender patients who don't have an ACA plan say they have had components of their coverage denied or have been denied insurance altogether because the provider considers gender dysphoria a pre-existing condition, which they do not cover.

Jody Herman, scholar of public policy at the Williams Institute at UCLA, said insurance policies vary by state. For example, California law requires that insurers cover gender reassignment and hormone therapy, but Texas doesn't. Some Texas legislators have tried unsuccessfully to end insurance discrimination.

After McMurray lost a six-figure salary, her financial situation shifted dramatically, making it difficult for her to afford insurance. The complicated life she suddenly found herself living brought her to the brink of suicide.

A 2014 study found that 46 percent of trans men and 42 percent of trans women attempt suicide in their lifetimes, according to the National Transgender Discrimination Survey, a report published by the Williams Institute and the American Foundation for Suicide Prevention.

"For me, it was life or death," she said. She couldn't go on living in a body she felt she didn't belong in and she didn't see any other way out.

ACA plans include deductibles of up to thousands of dollars and high monthly payments — and gender reassignment surgery may not even be covered. So McMurray saw no sense in trying to get insurance.

In 2014, nearly 35 percent of transgender people living below the poverty level were uninsured, according to the Center for American Progress.

She began tapping into her retirement fund to pay for her procedures, which turned out to be more expensive than the cost of her surgeries because she had to pay taxes and penalties. She's continued to take from her retirement in order to make ends meet.

"The way health care is set up, I'm one of those people who slips through the cracks," McMurray said.

Federal employees can now undergo gender reassignment surgery through Aetna insurance plans, because of a policy change that began in January. Aetna will be adding gender reassignment surgery to many other commercial plans over the next few years.

But breast augmentation, hair removal and forms of facial reconstruction are considered cosmetic and therefore will not be covered. The World Professional Association for Transgender Health considers both necessary for the transgender patient.

These surgical interventions are often of greater practical significance in the patient's daily life than reconstruction of the genitals, said Jamison Green, president of the association.

One day in January, Katie Sprinkle, a local attorney and a trans woman, got a call from one of her clients, a trans man.

He was legally recognized as male, which required a gender marker change, a legal process similar to having a name changed. He had recently undergone a procedure to remove his breasts, but now he was terrified because he had just been diagnosed with a form of breast cancer that only women can get.

Sprinkle considered going to a judge to reverse her client's gender marker back to female so that insurance would cover the cost of his treatment. In the end, her client chose not to.

She warns her clients who are trans men that, if they develop any transition-related illnesses, they could have a problem with insurance companies. She tells them to talk to every woman in their family to find out what kind of diseases they may have inherited.

Sprinkle has experienced this herself. After a routine blood test, she got a bill for $600 from the lab. Her insurance provider, which at the time was Blue Cross and Blue Shield of Texas, wasn't going to cover the charge because it found out she was a trans woman and her tests were considered trans-related care.

Like many transgender people, Sprinkle undergoes these tests every six months to make sure her hormone treatments haven't led to complications.

A Blue Cross Blue Shield statement said the company is unable to discuss an individual's health care coverage because of privacy laws.

Sprinkle had to switch to a doctor who could run basic blood tests so that she would be charged only about $100.

In August 2013, Sprinkle received a letter from GoldenRule, a United Healthcare company, saying they were unable to provide her with health coverage because she was diagnosed with "gender identity disorder for which surgery was required." At that point, she hadn't had reassignment surgery — she has had surgery since then.

A United Healthcare representative said that although individual policies cannot be discussed, any transgender applicant who indicated that surgery was desired would not have been eligible for coverage prior to Jan. 1, 2014. Today, although surgeries are still not covered, a trans person will not be denied insurance coverage, which Sprinkle says is better than nothing.

A large percentage of transgender people report being mistreated by a medical care provider.

The National Transgender Discrimination Survey reports that 60 percent of the transgender population who have attempted suicide have had a doctor or other provider refuse to treat them.

Part of McMurray's mission is to educate those in the medical profession. So on a recent day, she took questions from a class of 30 to 40 medical students at UT Southwestern.

The doctor moderating her visit to the classroom asked her to clarify the difference between gender dysphoria — identifying with a gender contrary to the one assigned at birth — and homosexuality.

"The best way I can put it is gender identity is who I go to bed as," she said. "Sexuality is who I go to bed with."

McMurray shared some of the issues she's had with insurance companies and medical care providers, including a doctor who wrote a prescription for her, but checked "male" on her receipt.

"I cried all the way home," McMurray said. "I didn't even go pick up that prescription." She kept the receipt and passed it around the classroom.

When McMurray found herself without a home in June of 2013, Sprinkle gladly welcomed her into her two-bedroom apartment.

The two had met in person only a few times but had been in touch through phone calls and emails. A few months later, Sprinkle realized the two were in a relationship.

Although McMurray has encountered dark times, she knows the future is much brighter. She has the love and support of her daughters, one of whom has taught her children to call her "Grandma Leslie."

McMurray's only regret is that her mother, who passed away 23 years ago, never got to meet Leslie.

"I know she would have loved Leslie," said McMurray, who believes her mother must have always known deep down she was transgender. "She would have been so supportive and happy to see me the way I was meant to be."

Information from: The Dallas Morning News, Dallas, TX.

By Jasmine Aguilera, The Dallas Morning News. Copyright 2015 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

The Gayly – July 5, 2015 @ 7:30am.