The Portland, Ore., city council voted on Wednesday to cover the cost of sex-reassignment surgery for municipal workers in its health-care plan. Portland is only the second major city, after San Francisco, to offer surgical benefits to its transgender employees. But the move comes at a time when surgery has become less relevant to many, if not most, of those who define themselves as transgender.
Portland Mayor Sam Adams filed the new ordinance, which the city council passed unanimously. (Adams, 47, may be best known for surviving an Anthony Weiner-like scandal in 2009, when he admitted lying about a sexual relationship with a teenager.) The new law will cover “services to alter … physical characteristics to that of the opposite sex” up to $50,000.
Most physicians who diagnose Gender Identity Disorder (GID) in patients agree that surgery can be a medical necessity for many of them. The American Medical Association has said since at least 2008 that it supports insurance coverage for treatment of GID “as recommended by the patient’s physician.”
But many clinicians and transgender activists have long disputed the validity of the GID diagnosis. One reason is that the Diagnostic and Statistical Manual of Mental Disorders, the compendium of psychiatric illnesses, defines a person with GID as one who has “persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.” For many trans activists (here’s an example), the main problem isn’t discomfort with sex organs but discomfort with the fact that those organs are used to define gender in legal terms. One’s sense of gender, they note, is informed not only by sex organs but by powerful psychological impulses as well as cultural and social stimuli. Female-to-male activist Chaz Bono summarized this idea recently when he noted — in a turn of phrase familiar to many trans activists — that gender lies “between the ears,” not between the legs.
The transgender community is responding with restraint to the Portland law. Neither the National Center for Transgender Equality nor the Human Rights Campaign even mentions the new ordinance on its news pages. Riki Wilchins, the executive director of True Child, an organization dedicated to eradicating gender stereotypes among children, says the law will have only a small impact. “In reality, there are so few people that will take advantage of this, it amounts to a rounding error on the insurance policy,” she says.
(More on TIME.com: Gender-Free Baby: Is it O.K. for Parents to Keep Their Child’s Sex a Secret?)
Activists say truly equal health-care access for the transgender community would involve insurance funding for hormone treatment and other health services short of surgery. Says Wilchins: “All phases of gender reassignment should be covered.”
Many other transgender people no longer seek any kind of reassignment. At least 2,000 Americans undergo sex-reassignment surgery each year, but many other transgenders (especially the young) express gender their own way, perhaps just with clothing, hair style or cosmetic procedures. As trans legal expert Shannon Minter has said, “What’s important is hate crimes and job discrimination. Why does everyone want to talk about my genitals?”
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