October 28, 2016
October 6, 2016
September 25, 2016
By Dr. Kelly Winters, Ph.D., member of the International Advisory Panel for the World Professional Association for Transgender Health (WPATH) Standards of Care:
WPATH: clarify and correct the childhood “desistance” myth statement in the SOC7
WPATH: Issue a public policy statement discrediting the practice of gender-conversion psychotherapies that is consistent with the SOC7
APA: clarify and correct the childhood “desistance” myth statement in the DSM-5
APA: remove “Transvestic Disorder” category from the DSM-5
WHO: initiate substantive conversation on converging the Adult/Adolescent Gender Incongruence categories in the proposed ICD-11 with the childhood category to refute the historical stereotype of childhood gender “confusion” and practice of gender conversion psychotherapies
US Dept. of HHS: align transition related categories in ICD-10-CM to ICD-11 in 2018
US Dept. of HHS/CMS: issue a National Coverage Determination for surgical transition care that is recognized as medically necessary by US and international medical authorities
From here: https://gidreform.wordpress.com/2016/09/19/gender-madness-in-psycho-politics-transgender-children-under-fire/
September 21, 2016
The Department of Housing and Urban Development joined other Obama agencies Tuesday in ruling that ‘Gender Identity’ determines reproductive biology and overrides Title IX sex-based protections for women and girls in homeless shelters. The department defines Gender Identity as “the gender with which a person identifies, regardless of the sex assigned to that person at birth and regardless of the person’s perceived gender identity.” [p70]
The ruling allows any male to access female sleeping quarters, showers, and restrooms on the basis of self-declared ‘Gender Identity’. Questioning such a declaration on any basis is ruled as discriminatory and women’s rational need for privacy and safety from male violence is dismissed as “unsubstantiated fears” [p52].
The rule explicitly forbids requesting evidence of a “transition”, including duration, consistency, or sincerity of belief in declared ‘Gender Identity’. There is no provision to address men who may assert ‘Gender Identity’ for an improper purpose:
“HUD also revises paragraph (b) to add a provision that the policies and procedures must ensure that individuals are not subjected to intrusive questioning or asked to provide anatomical information or documentary, physical, or medical evidence of the individual’s gender identity.”[p13]
HUD disregards with a handwave the rationale for protection of female privacy and safety against male violence behind the Congress’s Title IX provision for sex-segregation in areas of public nudity:
“Contrary to the public comment that suggests what Congress’s intent was in creating single-sex facilities, HUD does not opine on Congress’s intent behind permitting single-sex facilities, but does make clear in this rule that, for purposes of determining placement in a single-sex facility, placement should be made consistent with an individual’s gender identity. This rule does not attempt to interpret or define sex.” [p30]
Yet the HUD ruling does re-define legal sex -as a characteristic on par with sex-stereotypes of “appearance, behavior, expression”- falling under the newly invented federal category of “Perceived Gender Identity”:
“Perceived gender identity means the gender with which a person is perceived to identify based on that person’s appearance, behavior, expression, other gender related characteristics, or sex assigned to the individual at birth or identified in documents.” [p70]
The ruling itself re-defines ‘sex’ as a component of ‘Perceived Gender Identity’ but the agency also defines ‘Gender Identity’ as a “component of sex’ in its response to public comment:
“In response to the comment with regard to this rule’s impact on a “legal sex category,” this rule does not provide a definition of “woman” or “sex.” In this rule, HUD notes that gender identity—and whether a person identifies with their sex assigned at birth or not—is a component of sex.” [p45]
HUD cites the Title IX re-interpretation of other Obama appointed agencies (which call for the elimination of sex as a protected category) as precedent for Tuesday’s ruling, making no mention of the current legal challenges to this very interpretation by 23 states and various private litigants:
“Consistent with the approach taken by other Federal agencies, HUD has determined that the most appropriate way for shelter staff to determine an individual’s gender identity for purposes of a placement decision is to rely on the individual’s self-identification of gender identity.” [p39]
HUD cites various internet surveys as evidence that males with ‘Gender Identities’ are at greater risk of harassment and violence than women and girls. Therefore HUD rules that women and girls must be forced by the state to sacrifice their own safety and absorb the risk from males who prefer sleeping and bathing among women. HUD addresses the safety concerns of individuals with ‘Gender Identities’ extensively, including those who ‘identify as’ having no reproductive biology at all:
“In circumstances where an individual does not identify as male or female and such information is relevant to placement and accommodation, the individual should be asked the gender with which the individual most closely identifies. In these circumstances, the individual is in the best position to specify the more appropriate gender-based placement as well as the placement that is most likely to be the safest for the individual—either placement with males or placement with females.” [p48]
Yet HUD completely disregards voluminous FBI, CDC, and other forensic documentation of epidemic sex-based violence against women committed by males as “beyond the scope” of the ruling, wrapping up their dismissal with a version of the classic ‘but women rape too!’:
“HUD’s rule requires that individuals be accommodated in accordance with their gender identity. It is beyond the scope of this rule to detail methods for best serving victims of domestic violence, dating violence, sexual assault, or stalking. However, as discussed earlier, this final rule requires that providers must take nondiscriminatory steps that may be necessary and appropriate to address privacy concerns raised by all residents or occupants. HUD notes that both victims and perpetrators of domestic violence and other VAWA crimes include persons who are transgender or gender nonconforming individuals and persons who are not”. [p58]
HUD fully expects violence, (which it calls “physical harassment”) to occur between homeless women and the males placed in female sleeping and bathing areas as a result of this ruling:
“If some occupants initially present concerns about transgender or gender nonconforming occupants to project staff and managers, staff should treat those concerns as opportunities to educate and refocus the occupants. HUD recognizes that, even then, conflicts may persist and complaints may escalate to verbal or physical harassment. In these situations, providers should have policies and procedures in place to support residents and staff in addressing and resolving conflicts that escalate to harassment.”[p17]
Strangely, although statistics show that female stranger violence against males is an infinitesimal probability compared to the reverse, the Federal Department of Housing and Urban Development is, yet again, solely concerned with the former- the issue of women’s protection from male violence being “beyond the scope” of the Obama administration’s mandate to eliminate sex-based protections for women.
Read the full HUD decision here:
September 17, 2016
Meet Julia Cushion, your new Westminster UK ‘Outreach and Engagement Officer’ for Parliament’s Department of Information. She can’t tell you what she thinks about politics, except that she thinks Lesbians and Feminists are “awful people” for wanting representation in policy that effects us. Good Luck Westminster lesbians and feminists!
Your ‘Outreach and Engagement Officer’ thinks you – and every feminist ally with concerns about over-broad “Gender Identity” statutes, the legal codification of sex stereotypes, the elimination of lesbian rights to lesbian spaces, and the medicalization of gender non-compliance in children (among other issues) are “awful people”. She wants you to know it so I’m reblogging her post here. Do make a note of it.
Link to events she describes in her post : http://www.gaystarnews.com/article/trans-people-uk-government/#gs.hUn59Ik
*UPDATE- Gosh. Officer Cushion appears to have taken her post offline.
I find this interesting. In her post of September 2, Ms. Julia Cushion describes her new position as Outreach and Engagement Officer for Westminster. She explains that a condition of her Parliamentary service is that she must remain apolitical. See screencap here:
Yet on September 17, she writes a post describing the brilliant lesbian and Women’s Rights activists, authors, and educators who spoke at the Women’s Equality forum, including the renowned Lesbian Feminist author and professor Sheila Jeffreys, as “awful people” because Ms. Julia Cushion is against lesbian and women’s rights to representation.
Not only are lesbian and feminist politics “awful” to Ms. Cushion, but we are “awful people” entirely. See Julia Cushion’s relevant statements here:
Now, I’m not going to call Julia Cushion an “awful person” for sharing her homophobic and misogynist views. Clearly she is a completely uninformed about the issues as she admits herself. She knows nothing about transgender people, lesbians or feminism.
That someone so completely clueless might lunge clumsily and publicly in defense of a politics they’ve never deeply considered is not unique.
What I find interesting is that Ms. Cushion believes that lesbian and feminist concerns are so maligned that publicly bashing lesbians and feminists as “awful people” is a position safe to take- even for an individual whose government position is conditioned on impartiality. The hatred of lesbians and feminists expressed by Ms. Cushion- not just politically, but as people, is remarkable.
Medicare denies national coverage for gender reassignment surgery: No evidence of therapeutic outcome
August 31, 2016
On June 2, 2016 the Centers for Medicare & Medicaid Services (CMS) denied national coverage for gender reassignment surgery after the agency conducted a year long review which determined that there is no medical evidence of a therapeutic outcome for patients who have undergone these procedures.
Excerpts from their report:
On December 3, 2015, CMS accepted a formal complete request from a beneficiary to initiate a national coverage analysis (NCA) for gender reassignment surgery.
CMS opened this National Coverage Analysis (NCA) to thoroughly review the evidence to determine whether or not gender reassignment surgery may be covered nationally under the Medicare program.
In general, when making national coverage determinations, CMS evaluates relevant clinical evidence to determine whether or not the evidence is of sufficient quality to support a finding that an item or service is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. (§ 1862 (a)(1)(A)). The evidence may consist of external technology assessments, internal review of published and unpublished studies, recommendations from the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC), evidence-based guidelines, professional society position statements, expert opinion, and public comments.
The overall objective for the critical appraisal of the evidence is to determine to what degree we are confident that: 1) specific clinical question relevant to the coverage request can be answered conclusively; and 2) the extent to which we are confident that the intervention will improve health outcomes for patients.
CMS staff extensively searched for primary studies evaluating therapeutic interventions for gender dysphoria. There was particular emphasis on the various surgical interventions, but other treatments including hormone therapy, psychotherapy, psychiatric treatment, ancillary reproductive and gender modifying services, and post-operative surveillance services for natal sex organs were also included because of their serial and sometimes overlapping roles in patient management. The emphasis focused less on specific surgical techniques and more on functional outcomes unless specific techniques altered those types of outcomes.
The reviewed evidence included articles obtained by searching literature databases and technology review databases from PubMed (1965 to current date), EMBASE, the Agency for Healthcare Research and Quality (AHRQ), the Blue Cross/Blue Shield Technology Evaluation Center, the Cochrane Collection, the Institute of Medicine, and the National Institute for Health and Care Excellence (NICE) as well as the source material for commentary, guidelines, and formal evidence-based documents published by professional societies. Systematic reviews were used to help locate some of the more obscure publications and abstracts.
CMS reviewed and considered potential objective measures of function including mortality, psychiatric treatment, and attempted suicide. None of the longitudinal studies in which patients served as their own control, however, comprehensively tracked changes in these events as objective measures of function before and after surgery. Events such as suicide and institutionalization were mentioned incidentally when describing patients excluded from a follow-up study or during the study (Heylens et al., 2014; Ruppin, Pfafflin, 2015). Other times investigators tracked these functional outcomes (e.g., psychiatric out-patient treatment, psychiatric in-patient treatment, and substance abuse) for the most current prior year (Ruppin, Pfafflin, 2015).
The most comprehensive study with functional endpoints, the Swedish study that followed all patients who had undergone reassignment surgery (at mean age 35.1 years) over a 30 year interval and compared them to 6480 matched controls, identified increased mortality and increased psychiatric hospitalization (Dhejne et al., 2011). The mortality was primarily due to completed suicides (19.1-fold greater than in control Swedes), but death due to neoplasm and cardiovascular disease was increased 2 to 2.5 times as well. The divergence in mortality from the Swedish population did not become apparent until after 10 years. The risk for psychiatric hospitalization was 2.8 times greater than in controls even after adjustment for prior psychiatric disease (18%). The risk for attempted suicide was greater in male-to-female patients regardless of the gender of the control. Unfortunately, the study was not constructed to assess the impact of gender reassignment per se. The finding of this study, again, demonstrated that reassignment surgery does not return patients to a normal level of morbidity risk and that the morbidity risk is significant, because of its clinical importance, its persistence over the interval of data collection and the increase in risk over time for the individual.
The currently available evidence has limitations:
- There were design deficiencies. All but one of the studies were observational in nature. All but two were non-blinded. The accompanying loss to follow-up suggests that there is selection bias and that the population that seeks treatment for gender dysphoria is not the same population that undergoes reassignment surgery without hesitation or regret.
- The psychometric and psychosocial function endpoints are not well validated.
- There were limitations of the psychosocial endpoints and of the data collection of other hard functional outcomes. Evidence on mortality and especially suicide was stronger. The mortality and psychiatric hospitalization rates even after vetting in highly structured programs are of concern.
- There are insufficient data to select optimal candidates for surgery.
- The results were inconsistent, but negative in the best studies, i.e., those that reduced confounding by testing patients prior to and after surgery and which used psychometric tests with some established validation in other large populations. (Atkins et al., 2004; Balshem et al., 2011; Chan, Altman, 2005; Deeks et al., 2003; Guyatt et al., 2008a-c; 2011a-e; Kunz, Oxman,1998; Kunz et al., 2007 and 2011; Odgaard-Jensen et al., 2011).
Data on reassignment surgery performed on geriatric patients or follow-up data in geriatric patients who had reassignment surgery in the distant past is anecdotal (Orel, 2014).
Based on a thorough review of the clinical evidence available at this time, there is not enough evidence to determine whether gender reassignment surgery improves health outcomes for Medicare beneficiaries with gender dysphoria. There were conflicting (inconsistent) study results – of the best designed studies, some reported benefits while others reported harms.
The quality and strength of evidence were low due to the mostly observational study designs with no comparison groups, potential confounding and small sample sizes. Many studies that reported positive outcomes were exploratory type studies (case-series and case-control) with no confirmatory follow-up. Due in part to the generally younger and healthier study participants, the generalizability of the studies to the Medicare population is also unclear. Additional research is needed. This proposed conclusion is consistent with the West Midlands Health Technology Assessment Collaboration (2009) that reported “[f]urther research is needed but must use more sophisticated designs with comparison groups.” WPATH also noted the need for further research: “More studies are needed that focus on the outcomes of current assessment and treatment approaches for gender dysphoria.” Further, as mentioned earlier, patient preference is an important aspect of any treatment. With that in mind, CMS is interested in knowing from the patients with gender dysphoria what is important to them as a result of a successful gender reassignment surgery.
Knowledge on gender reassignment surgery for individuals with gender dysphoria is evolving. The specific role for various surgical procedures is less well understood than the role of hormonal intervention. Much of the available research has been conducted in highly vetted patients at select care programs integrating psychotherapy, endocrinology, and various surgical disciplines and operating under European medical management and regulatory structures. Standard psychometric tools need to be developed and tested in the patients with gender dysphoria to validly assess long term outcomes. As such, further evidence in this area would contribute to the question of whether gender reassignment surgery improves health outcomes in adults with gender dysphoria.
Because CMS is mindful of the unique and complex needs of this patient population and because CMS seeks sound data to guide proper care of the Medicare subset of this patient population, CMS strongly encourages robust clinical studies with adequate patient protections that will fill the evidence gaps delineated in this decision memorandum.
Currently, the local Medicare Administrative Contractors (MACs) determine coverage of gender reassignment surgery on an individual claim basis. The Centers for Medicare & Medicaid Services (CMS) proposes to continue this practice and not issue a National Coverage Determination (NCD) at this time on gender reassignment surgery for Medicare beneficiaries with gender dysphoria. Our review of the clinical evidence for gender reassignment surgery was inconclusive for the Medicare population at large.
Read the complete evidence review and text of Medicare’s denial of a national coverage determination for ‘Gender Reasignment Surgery” here: