Young People Push Back Against Gender Categories

[cbayer]

This story dates back to mid-July, but it is a fascinating look at a trend among youth about gender pronouns. Audio at link.

http://www.npr.org/templates/story/story.php?storyId=202729367

by MARGOT ADLER
July 16, 2013 4:53 PM

As society has become more accepting of gays, lesbians and even transgender people, a new generation of young people is challenging those categories in favor of a more fluid understanding of gender. They refuse to be limited by notions like male and female.

MARGOT ADLER, BYLINE: It began with a speaking event at Oberlin College in Ohio. I was at dinner with the college chaplain and 16 students on his interfaith council. I was startled when everyone introduced themselves saying their name, what year they were, what they were studying and then described their preferred gender pronouns. I wasn't taping but it sounded similar to these high school students introducing themselves to me recently in New York.

RUSSELL LASDON: I'm Russell Lasdon and I use he/him/his pronouns.

KETZEL FEASLEY: I'm Ketzel Feasley and my PGP's are she/her/hers.

ADLER: For those of you who have never heard this done, as I hadn't, this is happening on many campuses. It's a way of being supportive or an ally to those who are transgender or gender non-conforming. Those who are not cisgender - that is, their emotional gender identity does not match their biology.

more at link

[Wilms]

1. I've witnessed that in surprising places.

[skippy66]

2. When they come into my clinic......

Do I treat based upon their perceived gender? Am I transphobic because I was taught to treat the anatomy and not the perceived gender? Do I put the perceived female in stirrups to do a prostate exam?

[gollygee]

4. You deal with their physical needs as needed

and call them by what they want to be called by. It really isn't that tricky.

[justiceischeap]

5. If you have to ask this question, you may want to educate yourself

because if I knew my health care provider were asking this kind of question, I'd ask for a new one. I'm not saying you're transphobic but you do sound uneducated on the matter.

At one point I made sure to tell me health care provider I was a lesbian because it was thought, at the time, that lesbians had a higher risk of reproductive cancers because we didn't have children (this was a long time ago and these notions have since been proven false). Anyway, if I got a blank look, I asked for another provider.

[Ms. Toad]

6. You need to treat her as a woman

but provide medical care appropriate to her anatomy. More sensitively than you asked the question - which is quite offensive and the reality that far too many medical care providers have that attitude is one of the reasons many trans* individuals go for years without proper medical care.

It isn't a "perceived female", it is a female. But if you would not put someone with a prostate in stirrups to examine their prostate, you should not put her in stirrups to examine her prostate.

You also need to advocate with the insurance companies with whom you have relationships for appropriate billing and care.

My friend just (after years of going without) went for a general physical out of the fear of encountering physicians who might treat her with the same lack of respect you exhibited here.

My friend has male body parts, and had both a breast exam and a prostate exam. The biggest challenge (as the first trans* patient for this doctor) came when the insurance company rejected some of the bloodwork based on gender, so the doctor decided to do what was practical rather than advocating with the insurance company for proper care of the anatomy this woman has, and changed my friend's gender to "M." NOT appropriate. Even putting trans* individuals aside, there are medical conditions which mean that medical record genders do not match the body parts, so insurance companies have to have a way of dealing with the exceptions, and when you have a trans* patient, it is our obligation to advocate for proper medical care without falsifying the records.

[pnwmom]

9. Doctors have mountains of paperwork as it is. I don't think they should have to spend

additional time fighting the insurance companies over the gender designation. If the "perceived female" has a biologically male body, it is not falsifying records to list the body as male for the purpose of insurance reimbursement. Why can't the doctor address the person with her preferred gender designation in his office, but check off the box for "male" on the insurance form?

[Ms. Toad]

16. The short answer is that the insured patient is female.

in gender expression, legally, and on the insurance company forms. The insurance company would have very good reason to deny any claim for its female insured if the claim is submitted for a male patient, and to start an investigation for fraud. Doing so would be legally risky both for the doctor and the patient. In formal matters, the doctor must work with the gender of the patient as the insurance company has it recorded and must advocate on behalf of her patient for procedures that are medically necessary but receive a denial which is intended as an initial flag to prevent fraud (as this one was - by ensuring that female patients aren't permitting male friends/relatives to borrow their insurance.) (If the insurance company listed my friend as "M" - it would have been equally risky for the doctor to submit forms for her as a female.)

The longer answer is that doctors have contracts with the insurance company from which both benefit. Part of the bargain for doctors is that when an insurance company denies what they believe to be medically necessary care, they have an ethical obligation to advocate on behalf of their patient's right to receive that care. I have fired two doctors who rolled over and played dead when the insurance company refused to provide medically appropriate treatment. I cannot argue with the insurance company over medical necessity - that has to be done by doctors - and we have enough oddities in our family that require exceptions to the insurance company rules that I will not patronize a doctor who believes the insurance company is entitled to reject medically necessary treatment without a challenge. I have had two who refused to even try. I have also had at least a half dozen who have successfully advocated for medically appropriate treatment which was initially denied, in two instances in situations which were portrayed on the TV show ER as examples of insurance company idiocy (not my case, but others in identical situations). My health, and the health of my family, is too important to tolerate doctors who can't be bothered to do what is right.

[pnwmom]

18. Here's a doctor's point of view on this.

http://www.democraticunderground.com/?com=view_post&forum=1002&pid=3532135

I'm wondering . . . if the person who identifies as female is still biologically male in all her body systems, how would it harm her medical care to have her body labeled as biologically male for insurance purposes? What difference does it make what the computer at the insurance company classifies her as, as long as it is consistent and doesn't interfere with her getting proper medical care?

[Ms. Toad]

24. Any doctor who refers to a trans* individual

as having a "perceived" gender, or who snarks about using medically inappropriate techniques based on gender (rather than anatomy) is not one whose opinion I give much weight as to care for trans* individuals.

[cbayer]

7. I think that's an entirely different question.

If it is your job to treat anatomy, then do so. But how you refer to the person you are treating should have no bearing on that.

There is a really good documentary called Southern Comfort about this very topic. It is primarily about a female to male transgendered person who develops ovarian cancer. He has a great deal of trouble finding a team who is comfortable treating him.

[nadinbrzezinski]

17. As a medic I treated Trans ladies

we talked about this as if they were women, I treated their injuries as if they were women. I only touched on legal name for a run record. They were grateful and quite frankly surprised, that they were treated with full respect and no demands were made on them to act male when they are not.

Try this... use a she, and her pronouns as you would with a female patient.

I think you really need to get that sensitivity training by the way.

[LeftyMom]

19. You're in health care and you don't know? Shameful.

[Ms. Toad]

3. Interesting how perspectives differ -

I've been living with the concepts of gender fluidity and preferred gender pronouns since at least 2009, although it has become more prominent recently.

[cbayer]

8. I think there is a wide variety of experiences in this area.

For some, these are new concepts, but they indicate movement forward, imo.

[skippy66]

10. Wow. I'm sorry I'm so insensitive.

I have 10 min to see a patient. There are 7-8 patients scheduled per hour. I'm two patients behind within the first hour of clinic. Most of the patients do not have health insurance or they pay on a sliding scale. Our clinic is begging for donations from the community so that these patients aren't dumped into the ER. I do not have time to be PC. I treat what I see. In a social setting I will happily call the patient whatever they want to be called. I do not have time to call insurance companies and advocate for the client's perceived gender. I do not have time to clarify with staff that the medical record is correct despite what the client perceives their gender to be. A patient bristled at the suggestion they needed a PSA test. "can't you see I'm a female?". I told her your prostate doesn't know that? Insensitive probably but it would medically negligent not to treat the anatomy and I would have my license yanked for treating the perceived gender.

[cbayer]

11. Who said you were insensitive.

It's a tricky area, but not that hard to handle. Anatomy is anatomy and you treat what you have.

But you also have an opportunity to support your patient and possibly educate your staff.

Sounds like you handled the PSA issue perfectly.

Who is suggesting that you not examine and treat a patient's anatomy? All that is being suggested here is that you use whatever pronouns the person prefers.

Maybe awkward at first for people who haven't been around transgendered individuals, but really not that difficult.

[pnwmom]

14. Someone else said that it was inappropriate

to designate the person as a male for insurance purposes, even though the tests needed are only for a biologically male body. (And the insurance company would reject them for a female.)

The poster said that the doctor should instead have advocated with the insurance company on behalf of this person's right to be designated a female.

[cbayer]

15. Ah, I see. I guess paperwork is different than how you interact with someone.

I think a word with the patient would do the trick. The insurance company is a machine that just needs to be placated. It's not amenable to education, imo. I think most patients would opt for whatever gets them taken care of with the least hassle.

And, to be honest, the insurance company, if there is one, is probably quite aware of the situation.

[Ms. Toad]

29. That someone would be me -

And a word with the patient is a step in the right direction (and was skipped in my friends' case - the records were just changed to "M&quot .

It is inappropriate to submit claim forms for a person using a gender which doesn't match the insurance company's records - that will trigger a fraud investigation. Any temporary gain by taking the "whatever gets them take care of" way out will be completely outweighed by the ensuring complications of the fraud investigation.

And submitting a PSA claim for a female patient will be rejected) that's the machine part. That is where it is the doctor's obligation to advocate on behalf of their patient for appropriate care for the body parts that patient has, either by appeal or by obtaining pre-approval. The doctor is (generally) the only one who can do that - insurance companies insulate the people who handle appeals for medical necessity from the public, which is presumed not to be able to speak authoritatively about medical necessity. So when the doctor refuses to advocate for his or her patient, the patient either doesn't get care - or has to pay for it out of pocket even if it should have been a covered expense.

As to whether the insurance company is aware of it - the mechanical part of the insurance operation is not aware of the situation (and the non-mechanical part may well not be aware of it at all - as to my friend the hormone therapy (all the insurance company is aware of) is also standard therapy for a different condition she also has, so although it is covered it does not necessarily inform them that she is a trans* individual ). They have a gender in their data bank, and routinely reject gender specific tests when ordered for a differently gendered patient - as a way of preventing fraud. The rejection will happen automatically,and has to be appealed on a medical necessity basis, which is something the doctor has to do.

[cbayer]

31. I see your point and can see how it would become complicated.

I would hope that an insurance company would have some advance knowledge about those they cover. I would also hope that the patient would have the opportunity to explain prior to getting the insurance.

I've dealt with insurance companies who are covering transgendered individuals from early stages of transition all the way through the surgeries. Finding an adjuster or claim representative who knows exactly what is going on was key.

Again, it can be tricky, as the insurance company probably has no way of indicating in their data bank that someone may be female but have some male anatomy. So I can see how it might trigger the machine. Perhaps if their data systems were retooled to allow for this as an option, it would eliminate the problem entirely.

[Ms. Toad]

34. It is complex -

and I have spent hours on the phone with insurance companies - straightening out things they are willing to talk to me directly about.

But the impression I have from doctors who are good at their job is that in most instances obtaining an exception is pretty routine. The times when I have to get involved directly, with any quasi-competent doctor/insurance company are pretty rare. But even when I am forced to get involved, I have not yet lost a fight I chose to pursue. (I have decided two were not worth the effort and dropped them - one because I was also fighting a doctor we subsequently fired.)

There's really nothing wrong with flags (this test generally shouldn't be ordered for a female, for example), as long as there are clear and easy paths to get exceptions when they are medically appropriate.

[cbayer]

36. Agree with you on all of this.

And thank you for not backing down. It's important that those who can exercise their voice do so for those who can't.

[pnwmom]

13. Welcome to DU, skippy66. And thanks for the informed perspective. n/t

[nadinbrzezinski]

20. It is not that hard, treat them with the correct pronouns they want

and deal with the legal when you need to. As in legal given name and paperwork.

[LeftyMom]

21. If you don't have the time to be kind and decent to your patients,

it's never too late to train as an auto mechanic. Engines don't care what you say to them.

[Morning Dew]

22. Cool story, Bro. n/m

[Ms. Toad]

23. You DO have an obligation not to falisfy records.

and to treat your patient as is medically appropriate.

When the insured is a female with a prostate, and a PSA test is denied by her insurance company you have an obligation to advocate with the insurance company on her behalf for medically necessary care. She cannot do that herself, because insurance companies will not allow individual customers to discuss such matters with the people who are able to make exceptions to the rules. Just because someone is poor does not mean they are not entitled to competent medical care - and allowing the insurance company to deny coverage for your female client who also has a prostate is incompetent care.

Would you the same attitude for a female patient with Guevedoces or true gonadal intersex condition, whose insurance records identified her as female - but who was denied a PSA exam, or treatment for testicular cancer? You cannot legally change the records with the insurance company, and you cannot ethically refuse to advocate for coverage of medically necessary care for your patients.

I understand you are doing work that many others aren't doing, and that time and funding are short. Your suggestion that your trans* female patient needed a PSA test was appropriate. But if you order that test and the insurance company denies it based on gender, you have a similar ethical obligation to advocate for that test as medically necessary - and your license should be yanked if you fail to do so.

The specific insensitivity buttons you pushed were with your description of gender as "perceived," and the suggestion that you would put someone needing a prostate exam in stirrups. If that is not the medically appropriate position for that physical exam (and since I have never had one I can't categorically say it isn't - but I suspect not), it was rude to suggest that you use that position merely because the patient's gender was female.

[pnwmom]

25. If there hasn't been a legal sex change, is it really falsifying medical records

to indicate that the body is biologically male?

[Ms. Toad]

26. The insurance claims need to reflect the gender of the person insured.

In my friend's case - on the day her claims were changed to "M," she was by gender expression, legally, and in insurance company records a female who has a penis, testicles, a prostate, and breasts. Changing her records to obtain payment for a PSA test would trigger a fraud investigation. Ultimately, it should be straightened out, but it would likely cost both the doctor and my friend significant time (and money, depending on whether it got to the stage of criminal charges). There are medical conditions (aside from being a trans* person) in which a female will have male body parts, or vice versa. No doctor I know (even the ones I fired) would change the gender on the records of those patients in order to get approval for the appropriate tests. When the tests were denied, the doctor would file an appeal (or more likely obtain pre-approval) for the medically necessary tests. It should be no different for trans* individuals.

Aside from that - trans* women, at least, depending on what medical procedures they have had, require preventative screening for both their male and female body parts. My friend requires both breast exams (and in 3 years will require annual mammograms) and a prostate exam. Each of these screening exams is medically necessary and covered as part of the annual preventative care package - if the insurance company denies it based on gender, the doctor needs to explain to the insurance company why it is medically necessary because the people with authority to grant exceptions will not speak to their insured customers (at least in my experience with three insurance companies in the past 5 years).

[pnwmom]

27. But what about a trans person who has had no hormones or other body-altering treatment

and doesn't have an inter-sex condition? Who has a biologically male body with no female attributes but identifies as female?

Why would the insurance claims need to reflect the person's identity as female if her body is consistently biologically male?

I understand that a person who has both male and female body parts would need to have that clear in the medical records; but maybe it would be more accurate to have a 3rd classification for gender, as needed, than to check off a box saying "female" when the person involved has mostly male body parts. What would you think of having a third classification? I would think that would be easy enough for the insurance companies to deal with.

[Ms. Toad]

32. If the person is female in the insurance company records,

the medical records and claims are for woman. Whatever the insurance company records say is how the forms need to be submmitted.

Insurance companies can be a royal pain. But they can actually be changed if you are persistent. My insurance company offers coverage for domestic partners - and has for years. It is a high deductible policy ($3000/person, $6000 per family). My family of three was registered as a family ($6000) and a single individual ($3000). That raised our deductible by 50%.

When I complained, they said - essentially - that I should just be grateful she was covered at all, and that they couldn't list us as a single family despite the fact that the policy had very carefully dealt with all the legal ramifications of doing just that (down to analyzing how the state DOMA and federal DOMA applied separately and together, and in connection with COBRA and HIPAA).

I took them on, providing arguments through our insurance agent, that the contract they signed with my employer entitled us to a single $6000 family deductible. It turns out the problem was just that they had no way to enter a same gender partner in their computer. They fixed our family temporarily by adding my spouse as a special dependent of some sort, and within 9 months rewrote their software for (at least) the entire state - and now we listed the same as every same gender domestic partner/married couple.

That said, I don't know that it is worth it in this case. The flag is a generally appropriate one as a first filter to prevent both dumb mistakes (checking the wrong test box by accident) and fraud (loaning your coverage to a friend). What was inappropriate was the doctor's response of just changing the gender on the records and tests ordered so that the claims didn't match the insured, rather than going through the appeal/exception process with the insurance company.

[pnwmom]

33. I'm glad that you were able to fix the problem for your family.

Hopefully, the insurance companies will be on a fairly quick learning curve as more and more states approve marriage equality.

[Ms. Toad]

35. I was actually surprised this company hadn't already dealt with it.

Their analysis was so careful about the legal implications of same gender coverage (it even made me aware of a couple of quirks I was not aware of), for them to fall down on this basic aspect of implication - which would double the cost of the premium and out of pocket expenses for couples who each had children - was a bit of a shock. And - for me to have been the first to raise it was also a shock - since I know this company had been offering domestic partner coverage for at least 5 years before our family came along. Surely some other same gender couple had children in that time...

[skippy66]

12. That is an extremely reasonable response.

[bhikkhu]

28. Nice. Worth saying - biological form is independent from brain structure and identity

...the two are independent genetically, so there is no real reason (other than a tradition of bigotry and ignorance on the issue) that we shouldn't move toward more flexibility in language, and allow more personal freedom.

[cbayer]

30. One of the things I found really interesting about this story is that

some of the people desire a particular set of pronouns in one situation and another in a different setting.

It speaks to some of the fluidity they are experiencing.

Like sexuality, gender identity has those who are clearly one on end or the other, but many may land somewhere in between.

Interesting stuff, anyway.

[madville]

37. Seeing gender lines disappear at work

We have semi-annual physical fitness tests at work and there have always been separate standards for men and women. Like men had to run a mile in 8 minutes and women had 10 minutes, men had to do 30 push-ups in a minute and women had to do 18, men 10 pull ups, women 2, etc.

Starting next year it will be the same standard for everyone and the standards will now only vary by age.

The men are excited about it since the word is basically their requirements will be lowered down to the womens'.

[cbayer]

38. Interesting, but there are well documented differences in certain kinds of physical strength,

aren't there?

Endurance I think is one thing, and maybe that is what these changes reflect. While running should be equivalent, bench pressing probably would not be.

[madville]

39. I think they are trying to prevent a future lawsuit

They present the physical standards as the minimum amount of physical strength and endurance necessary to perform this job.

It shouldn't vary by gender in my opinion because if a man can do 9 pull ups and fail but a woman can do 2 and pass as it presently is, how is that equal or fair? If it's the minimum standard it should be the minimum standard for all even if it will be much easier for the men now.

[cbayer]

40. I see. So the tests are based on what someone should be able to do for their job?

Then it would make sense that everyone have the same test.