It's any wonder that healthcare costs are spiraling out of control...

[qtpai]

Depression is not about one physical flaw that can be fixed. It is multifactorial.

The cause of gender dysphoria is also likely multifactorial. The etiology for gender dysphoria is as well established as it is for major depression. Which is to say, not well established at all. Even though we say that gender dysphoria is real, even if we can observe it, we do not know what it is or what it is caused by. We do not know why people have gender dysphoria, any more than we know why they get depressed. Arguably we know more about depression than we do about gender dysphoria. The comparison to depression highlights our ignorance about gender dysphoria. It does not make gender dysphoria look good by comparison.

Now it is said that gender dysphoria is a medical disorder like any other--and amenable to surgery like any other medical disorder that is amenable to surgery. Making this a cut-and-dried issue. But it's not like any other disorder. It's not like a congenital heart valve defect that needs replacement. It's not even like erectile dysfunction (although it's more like that than a congenital disorder). Gender dysphoria, again, is more like major depression.

Having such an obscure status as a medical disorder, we need data that surgical treatment of gender dysphoria is effective. Especially with the risks of a major surgery. The risks of failure. And especially the risk that gender dysphoria may be less amenable to surgery than some suggest.

Now as far are the boobie woman is concerned, the hypothetical mentioned previously:

Why is gender dysphoria an actual disorder, while breast dysphoria isn't? Is it because we know more about its causes--than someone who presented to us with the apparent symptoms of a "breast dysphoric" disorder? (Answer: No, since we don't know what causes gender dysmorphia.)

Do we really know that there aren't people out there with something like breast dysphoria--a disorder that would, presumably, be as unknown and perplexing in its causes as gender dysphoria? (Answer: There probably are.)

If we have no reason to think that there aren't people with this kind of breast dysphoria, why do we treat gender dysphoria in one way, and the woman with the small breasts who wants bigger ones to deal with her depression, in another? (Answer: The American Psychiatric Association said it's a disorder, which makes it more special than my new diagnosis breast dysmorphia.)

Again, the proof is in the evidence, not in the proclamations of a committee. The fuzziness surrounding gender dysphoria causes us to suspect that, like depression, it may be as amenable to non-surgical treatments (rather than removing bodyparts) as, say, depression is amenable to CBT or pharmacotherapy (rather than, say, removing parts of the brain).

Speaking of removing parts of the brain, this was actually done for depression... and, hey, wait a minute, it was heralded as a miracle cure. Nobel Prizes given. Careers eventually destroyed over the charlatantry. Ah the thousands of people given lobotomies in the 1940s. But hey, it's a miracle cure to a medical condition, right? ... Right?

So for this gender dysmorphia: given the lack of evidence otherwise, for a medical category so simultaneously political and thoroughly baffling, it makes more sense to proceed with caution--than to drink the Koolaid because the AMA, buttressing their recommendations with flimsy support, says so. I mean, it's no wonder the AMA continues to see its membership decline.

Back to the OP's original point. It really is no wonder that our medical system's costs are spiraling out of control when so many people, even the AMA and Medicare, make such cavalier recommendations. What other dubious positions have they taken--on scant evidence bases, that have costed billions of dollars? It's not so much that reimbursing gender dysmorphia is a problem for our spiraling medical costs. It's the general attitude. It's that swimming in the political currents so smoothly and daftly seems to be so much the norm these days, that even a procedure as potentially devastating as a sex change operation can be recommended for actual reimbursement by taxpayers so cavalierly--as if its perfectly okay for taxpayers to pay for some major medical procedure of dubious efficacy because a powerful group of people ask for taxpayers to fork out for it.

---

Members don't see this ad.

 

[DermViser]

http://www.ncbi.nlm.nih.gov/pubmed/24508222
http://www.ncbi.nlm.nih.gov/pubmed/18951077

If you treat someone who is entirely focused on one aspect of their appearance and correct it, it will improve their quality of life in a lot of instances. It may not be indicated right now, but the entire field of cosmetic plastic surgery is built around this premise. Go talk to any of those surgeons and you'll hear how so and so went from a sad depressed girl to an outgoing whatever. Constantly. And patients also see breast augmentation as the "final step in their treatment".

I am not saying that transgender patients could not benefit from surgery, only that results seem rather dubious on its efficacy given its risks. The studies showing improved psychosocial factors are also dubious, as you can see from the 2 articles. If you give someone who desperately wants a surgery and they believe the surgery will improve their quality of life, you'll get positive results on a postop survey. The proponents in this thread are rather cavalier about major surgery....which has inherent risks. I think there needs to be a ****ton more research before you just jump into it due to social bias. Just because there is a lot of social pressure to accept transgender patients (a separate matter entirely) doesnt mean the medical community shouldnt do its due diligence on efficacy of treatment.

Apparently actual efficacy of treatment is irrelevant in this whole discussion, esp. when it can be categorized as transgender discrimination.

 

[Barcu]

The cause of gender dysphoria is also likely multifactorial. The etiology for gender dysphoria is as well established as it is for major depression. Which is to say, not well established at all. Even though we say that gender dysphoria is real, even if we can observe it, we do not know what it is or what it is caused by. We do not know why people have gender dysphoria, any more than we know why they get depressed. Arguably we know more about depression than we do about gender dysphoria. The comparison to depression highlights our ignorance about gender dysphoria. It does not make gender dysphoria look good by comparison.

Now it is said that gender dysphoria is a medical disorder like any other--and amenable to surgery like any other medical disorder that is amenable to surgery. Making this a cut-and-dried issue. But it's not like any other disorder. It's not like a congenital heart valve defect that needs replacement. It's not even like erectile dysfunction (although it's more like that than a congenital disorder). Gender dysphoria, again, is more like major depression.

Having such an obscure status as a medical disorder, we need data that surgical treatment of gender dysphoria is effective. Especially with the risks of a major surgery. The risks of failure. And especially the risk that gender dysphoria may be less amenable to surgery than some suggest.

Now as far are the boobie woman is concerned, the hypothetical mentioned previously:

Why is gender dysphoria an actual disorder, while breast dysphoria isn't? Is it because we know more about its causes--than someone who presented to us with the apparent symptoms of a "breast dysphoric" disorder? (Answer: No, since we don't know what causes gender dysmorphia.)

Do we really know that there aren't people out there with something like breast dysphoria--a disorder that would, presumably, be as unknown and perplexing in its causes as gender dysphoria? (Answer: There probably are.)

If we have no reason to think that there aren't people with this kind of breast dysphoria, why do we treat gender dysphoria in one way, and the woman with the small breasts who wants bigger ones to deal with her depression, in another? (Answer: The American Psychiatric Association said it's a disorder, which makes it more special than my new diagnosis breast dysmorphia.)

Again, the proof is in the evidence, not in the proclamations of a committee. The fuzziness surrounding gender dysphoria causes us to suspect that, like depression, it may be as amenable to non-surgical treatments (rather than removing bodyparts) as, say, depression is amenable to CBT or pharmacotherapy (rather than, say, removing parts of the brain).

Speaking of removing parts of the brain, this was actually done for depression... and, hey, wait a minute, it was heralded as a miracle cure. Nobel Prizes given. Careers eventually destroyed over the charlatantry. Ah the thousands of people given lobotomies in the 1940s. But hey, it's a miracle cure to a medical condition, right? ... Right?

So for this gender dysmorphia: given the lack of evidence otherwise, for a medical category so simultaneously political and thoroughly baffling, it makes more sense to proceed with caution--than to drink the Koolaid because the AMA, buttressing their recommendations with flimsy support, says so. I mean, it's no wonder the AMA continues to see its membership decline.

Back to the OP's original point. It really is no wonder that our medical system's costs are spiraling out of control when so many people, even the AMA and Medicare, make such cavalier recommendations. What other dubious positions have they taken--on scant evidence bases, that have costed billions of dollars? It's not so much that reimbursing gender dysmorphia is a problem for our spiraling medical costs. It's the general attitude. It's that swimming in the political currents so smoothly and daftly seems to be so much the norm these days, that even a procedure as potentially devastating as a sex change operation can be recommended for actual reimbursement by taxpayers so cavalierly--as if its perfectly okay for taxpayers to pay for some major medical procedure of dubious efficacy because a powerful group of people ask for taxpayers to fork out for it.

I think you make good points here and much of what you say is true.

I still have two issues that make it hard to agree with you completely:

1. I concede that there may be a "breast dysphoria" that is similar to gender dysphoria. The problem is that having an upsetting character flaw is very common (certainly much more common than gender identity issues), and it is harder to tease out as a true disorder amenable to surgery than gender identity. To me, saying "I wish my boobs were bigger" is a lot different than saying "I am the wrong gender" even if they both cause emotional distress. That is my personal bias that stems from this fact that many people have complaints about their personal appearance, while significantly fewer people wish they were a different gender.

Side note: I think your point about the APA calling one a disorder and not the other is a good one. I am not a psychiatrist nor do I plan to be one. so I probably put too much weight into their recommendations.

2. I am also bothered by something mentioned by other posters as well- much of the objection rises from discomfort with transgendered persons themselves. (Less of that on this forum and more in the general population).

Oh well, this has been fun. I probably have said all that I need to at this point.

 

[Mad Jack]

I guess my main concern is about how the money is being used, and on the utility of it. Assuming a finite spending limit for healthcare, is the money for treating this disorder worth more than if it were spent on leukemia patients?

I know it's somewhat of a false dichotomy (increasing spending on one does not preclude increased spending on the other), but I guess it bothers me that this idea is totally ignored. At some level, we are making the decision of forgoing using that money on something else.

If it were better studied, and could show a clearer benefit, I would have less of a problem with it. Perhaps the money they're planning on throwing it would be better spent on generating a real clinical trial.

The trouble is, right now there is no rationing or cost control. So that money isn't coming out of research or harming anything else, it's just adding to the deficit. Until we actually implement some form of rationing or true cost control, your argument is merely hypothetical. Even still, we could cut funds to other areas of the government, such as military spending, to continue to provide the same levels of services without implementing any sort of rationing. I mean, the cost we spent on one of the F-22 Raptor jets we purchased that have never (and likely will never) fly in combat would fund 6,141 operations. At a rate of 800-1000 performed in the U.S. each year, we piss away enough money on a single fighter jet to pay for 6-7 years of SRS surgeries. But hey, dem turrorists ain't gonna blow demselves up, amirite?

 

[WhippleWhileWeWork]

This is a picture I just took of the bookshelf within arms reach of me right now.

I'll I can see is far left and your specialty.

 

[Doudline]

I'll I can see is far left and your specialty.

Agatha Christie is far left?!

 

[WhippleWhileWeWork]

Agatha Christie is far left?!

More evidence that photon reception is selective. N=2 so far.

 

[mimelim]

I'll I can see is far left and your specialty.

Haha! My wife is an ADA and is focusing on sex crimes and domestic abuse. She bought it for me after I made her read House of God XD.

 

[WhippleWhileWeWork]

.

 

[DermViser]

Haha! My wife is an ADA and is focusing on sex crimes and domestic abuse. She bought it for me after I made her read House of God XD.

I was going to say, I wouldn't have pegged you as someone who loves reading Agatha Christie novels.

 

[DermViser]

The trouble is, right now there is no rationing or cost control. So that money isn't coming out of research or harming anything else, it's just adding to the deficit. Until we actually implement some form of rationing or true cost control, your argument is merely hypothetical. Even still, we could cut funds to other areas of the government, such as military spending, to continue to provide the same levels of services without implementing any sort of rationing. I mean, the cost we spent on one of the F-22 Raptor jets we purchased that have never (and likely will never) fly in combat would fund 6,141 operations. At a rate of 800-1000 performed in the U.S. each year, we piss away enough money on a single fighter jet to pay for 6-7 years of SRS surgeries. But hey, dem turrorists ain't gonna blow demselves up, amirite?

It's instances like this, re: a treatment whose efficacy is unproven and bends to political pressures, where I can't say a thing against people who want to effectively ration care.

 

[Mad Jack]

It's instances like this, re: a treatment whose efficacy is unproven and bends to political pressures, where I can't say a thing against people who want to effectively ration care.

Actually it's the only thing that seems to have any real effectiveness in treating gender identity disorder. There aren't a whole lot of studies out there on it due to the small sample population and difficulties with following up on patients, but every analysis I can find shows that roughly 80% of patients show some relief of symptoms. That's pretty solid. And the only long-running study I can find was done in Sweden, which found that if you only look at people who underwent reassignment from 1989 onward (when recognition and treatment of GID was more accepted and formal), their rates of suicide and mortality were the same as healthy controls. Compared to the outcomes of those that do not undergo reassignment, in which suicide rates are roughly 20 times the general population per a VHA study, that is an astoundingly good outcome.

Yeah, we need more research. But when it is the only treatment we have that has any level of real effectiveness for a disorder that can have severe impacts both in regard to mental health and life expectancy, I think it should be covered.

This is a governmental health insurance issue anyway. If it were private insurance, it would be up to the provider. But this is a government plan, which means it is required to cover the needs of everyone that needs care in the country. If we've got an effective treatment to substantially reduce the suicide risk of some of the people covered by this plan then we should make that treatment available.

(I say this as a person who isn't a big fan of insurance. I don't think it should exist for anything that isn't catastrophic, and that people should pay basic and elective health care needs out of HSAs or the like. But so long as health insurance exists in its current form, SRS should rightly fall under its umbrella of coverage. Also if this is a bit scatterbrained and simplified I apologize- I'm at work at the moment and can't really do a bunch of editing and drop a bunch of references.)

 

[DermViser]

But this is a government plan, which means it is required to cover the needs of everyone that needs care in the country.

Uh, no. NOT when it it wholly subsidized by taxpayers. When it is paid for by taxpayer dollars, then real questions of what should be covered by the taxpayer and what shouldn't be covered by the taxpayer are valid questions.

 

[Mad Jack]

Uh, no. NOT when it it wholly subsidized by taxpayers. When it is paid for by taxpayer dollars, then real questions of what should be covered by the taxpayer and what shouldn't be covered by the taxpayer are valid questions.

A treatment that has a 95% reduction in suicide risk per the only long-term study I can find- I'd say that's a pretty solid one to provide to a taxpayer that paid into the Medicare system. Dare I say that not doing so would be unethical, as they are taxpayers that have paid for medical care that should sustain and improve their quality of life. SRS is effective enough that many private insurers have decided to cover it without the government forcing their hand. Even financially it sort of makes sense. If you've got 19 extra patients attempting suicide, nearly all will live (only 1 in 20 suicide attempts is successful). Those that live will land themselves in intensive care, most likely. The average cost of an ICU stay is 31,574 +/- 42,570 as of 2005, probably much more now, for an intubated patient, and 12,931 +/- 20,569 for a non-intubated patient. Total SRS surgery costs are between $13,020-22,390, with an extra $2,580-5500 if the procedure is done in two stages. I'm not an actuary and don't have reams of data on me, but if you really broke down the statistics on it and calculated the odds, I'm betting it's a break even or better than even proposition financially given the high suicide rates of those with GID. And this excludes all of the other psychiatric and substance abuse admissions that go along with the condition which also tend to improve mildly to moderately post-procedure.

Aside from all that, given that Medicare is only covering adults over the age of 65 and older, I doubt that a bunch of them are dying to go have this surgery done to begin with, and that many surgeons would be willing to perform the operation on someone of such advanced age due to the healing issues involved. It's probably practically a non-issue due to the tiny number of people that will even utilize it, the small number of surgeons that would accept Medicare rates, and the even smaller number of surgeons that would perform such substantial surgical alterations to a person in this age group.

 

[WhippleWhileWeWork]

Uh, no. NOT when it it wholly subsidized by taxpayers. When it is paid for by taxpayer dollars, then real questions of what should be covered by the taxpayer and what shouldn't be covered by the taxpayer are valid questions.

Agreed, what is meant by "need" becomes the real debate.

 

[qtpai]

I think you make good points here and much of what you say is true.

I still have two issues that make it hard to agree with you completely:

1. I concede that there may be a "breast dysphoria" that is similar to gender dysphoria. The problem is that having an upsetting character flaw is very common (certainly much more common than gender identity issues), and it is harder to tease out as a true disorder amenable to surgery than gender identity. To me, saying "I wish my boobs were bigger" is a lot different than saying "I am the wrong gender" even if they both cause emotional distress. That is my personal bias that stems from this fact that many people have complaints about their personal appearance, while significantly fewer people wish they were a different gender.

Side note: I think your point about the APA calling one a disorder and not the other is a good one. I am not a psychiatrist nor do I plan to be one. so I probably put too much weight into their recommendations.

2. I am also bothered by something mentioned by other posters as well- much of the objection rises from discomfort with transgendered persons themselves. (Less of that on this forum and more in the general population).

Oh well, this has been fun. I probably have said all that I need to at this point.

Thanks for the response.

1. I agree that there is arguably something more fundamental in terms of one's gender identity than one's breast size. The latter is not living up to one's concept of one's gender. The former is feeling that one is of the wrong gender altogether. I agree that gender dysphoria is for that reason a more fundamental problem than our breast dysphoria. At the very least, it is a very different problem.

But I do not think that this changes anything in the discussion. Why should our breast dysphoria being a different kind of problem necessarily make it subject to a negative value judgment, a kind of dismissal, by you calling it a “character flaw”, while gender dysphoria remains a legitimate "medical problem"?

Let us remember how gender dysphoria was regarded before it gained the political clout to be taken seriously. In but rare instances were gender dysphoric people taken seriously in wanting to have their sex changed. Such a request would typically be met by disgust and/or dismissal.

If the goal is respecting, and not discriminating against people, whether their problems are caused by their race, gender, or psychological disorders, then, by that same logic, even if these two problems are quite different, the woman with so-called breast dysphoria, if she experiences it as authentic, must be taken seriously and respected in her problem. If the gender dysphoric should have reimbursement, so too should the breast dysphoric person.

If you say that these two cases are different on a moral level, that one is amenable to surgery but the other shouldn’t be allowed, then I question your consistency; I am not convinced that you can make that distinction on a basis consistent with your other (I assume) principles. And that is why I think that the breast augmentation scenario remains an interesting challenge to the position in favor of reimbursement.

I respect your forthrightness in saying that the distinction you made is a personal bias. That brings us naturally to your next point, the all-pervasive problem of bias.

2. Absolutely, I agree with you.

I also understand your concern about posters being dismissive of trans-patients. I agree that this is wrong and not appropriate.

But both sides of this debate have biases. And biases or not, the science can answer the question of what is good for the patient. So let’s look at the actual data.

Actually it's the only thing that seems to have any real effectiveness in treating gender identity disorder. There aren't a whole lot of studies out there on it due to the small sample population and difficulties with following up on patients, but every analysis I can find shows that roughly 80% of patients show some relief of symptoms. That's pretty solid. And the only long-running study I can find was done in Sweden, which found that if you only look at people who underwent reassignment from 1989 onward (when recognition and treatment of GID was more accepted and formal), their rates of suicide and mortality were the same as healthy controls. Compared to the outcomes of those that do not undergo reassignment, in which suicide rates are roughly 20 times the general population per a VHA study, that is an astoundingly good outcome.

Yeah, we need more research. But when it is the only treatment we have that has any level of real effectiveness for a disorder that can have severe impacts both in regard to mental health and life expectancy, I think it should be covered.

This is a governmental health insurance issue anyway. If it were private insurance, it would be up to the provider. But this is a government plan, which means it is required to cover the needs of everyone that needs care in the country. If we've got an effective treatment to substantially reduce the suicide risk of some of the people covered by this plan then we should make that treatment available.

(I say this as a person who isn't a big fan of insurance. I don't think it should exist for anything that isn't catastrophic, and that people should pay basic and elective health care needs out of HSAs or the like. But so long as health insurance exists in its current form, SRS should rightly fall under its umbrella of coverage. Also if this is a bit scatterbrained and simplified I apologize- I'm at work at the moment and can't really do a bunch of editing and drop a bunch of references.)

I looked up your study. Or at least I think I did...

http://www.plosone.org/article/infooi/10.1371/journal.pone.0016885

And now the results section.

Results

The overall mortality for sex-reassigned persons was higher during follow-up (aHR 2.8; 95% CI 1.8–4.3) than for controls of the same birth sex, particularly death from suicide (aHR 19.1; 95% CI 5.8–62.9). Sex-reassigned persons also had an increased risk for suicide attempts (aHR 4.9; 95% CI 2.9–8.5) and psychiatric inpatient care (aHR 2.8; 95% CI 2.0–3.9). Comparisons with controls matched on reassigned sex yielded similar results. Female-to-males, but not male-to-females, had a higher risk for criminal convictions than their respective birth sex controls.

Sex-reassigned persons have a literally 19 times greater chance of dying of suicide as controls. That is astronomical. It's also *gasp* right around the same figure for suicide deaths as the figure you posted, for those who do not have their gender reassigned. In other words, this study would suggest that gender reassignment has no effect on the astronomically pronounced suicide rate of gender dysphoric patients. An paper better suited for an SDN rebuttal... has never existed.

Here are a few charts and graphs if you want more detail.

The data is explained as follows, in the discussion section. It may explain why the study you posted, and mine, are so different.

This contrasts with previous reports (with one exception[8]) that did not find an increased mortality rate after sex reassignment, or only noted an increased risk in certain subgroups.[7], [9], [10], [11] Previous clinical studies might have been biased since people who regard their sex reassignment as a failure are more likely to be lost to follow-up. Likewise, it is cumbersome to track deceased persons in clinical follow-up studies. Hence, population-based register studies like the present are needed to improve representativity.[19], [34]

The poorer outcome in the present study might also be explained by longer follow-up period (median >10 years) compared to previous studies. In support of this notion, the survival curve (Figure 1) suggests increased mortality from ten years after sex reassignment and onwards. In accordance, the overall mortality rate was only significantly increased for the group operated before 1989. However, the latter might also be explained by improved health care for transsexual persons during 1990s, along with altered societal attitudes towards persons with different gender expressions.[35]

In light of this information, I want to reiterate how crazy it is to claim that the data are actually in any way supportive of sex-reassignment for gender dysphoric individuals. The data remain ambiguous, even downright troubling. We don’t merely not know if sex-reassignment works. We don’t even know that it doesn’t cause harm. Contrary to trans-advocates trying to gain healthcare access for trans-persons, benefitting them, etc. these advocates don't even know whether or not they are causing long-term harm or not...

That you base the other part of your discussion on patient satisfaction scores disturbs me greatly. Are you going to base the decision to reimburse major surgery through Medicare on the fact that patients like it?

This brings us again back to the original point. Should an unproven treatment with (as yet) disturbingly bad outcomes be reimbursed by Medicare because patient satisfaction is good, i.e. because people simply want it? To me, the answer to that question is abundantly clear.

 

[Mad Jack]

Thanks for the response.

1. I agree that there is arguably something more fundamental in terms of one's gender identity than one's breast size. The latter is not living up to one's concept of one's gender. The former is feeling that one is of the wrong gender altogether. I agree that gender dysphoria is for that reason a more fundamental problem than our breast dysphoria. At the very least, it is a very different problem.

But I do not think that this changes anything in the discussion. Why should our breast dysphoria being a different kind of problem necessarily make it subject to a negative value judgment, a kind of dismissal, by you calling it a “character flaw”, while gender dysphoria remains a legitimate "medical problem"?

Let us remember how gender dysphoria was regarded before it gained the political clout to be taken seriously. In but rare instances were gender dysphoric people taken seriously in wanting to have their sex changed. Such a request would typically be met by disgust and/or dismissal.

If the goal is respecting, and not discriminating against people, whether their problems are caused by their race, gender, or psychological disorders, then, by that same logic, even if these two problems are quite different, the woman with so-called breast dysphoria, if she experiences it as authentic, must be taken seriously and respected in her problem. If the gender dysphoric should have reimbursement, so too should the breast dysphoric person.

If you say that these two cases are different on a moral level, that one is amenable to surgery but the other shouldn’t be allowed, then I question your consistency; I am not convinced that you can make that distinction on a basis consistent with your other (I assume) principles. And that is why I think that the breast augmentation scenario remains an interesting challenge to the position in favor of reimbursement.

I respect your forthrightness in saying that the distinction you made is a personal bias. That brings us naturally to your next point, the all-pervasive problem of bias.

2. Absolutely, I agree with you.

I also understand your concern about posters being dismissive of trans-patients. I agree that this is wrong and not appropriate.

But both sides of this debate have biases. And biases or not, the science can answer the question of what is good for the patient. So let’s look at the actual data.



I looked up your study. Or at least I think I did...

http://www.plosone.org/article/infooi/10.1371/journal.pone.0016885

And now the results section.



Sex-reassigned persons have a literally 19 times greater chance of dying of suicide as controls. That is astronomical. It's also *gasp* right around the same figure for suicide deaths as the figure you posted, for those who do not have their gender reassigned. In other words, this study would suggest that gender reassignment has no effect on the astronomically pronounced suicide rate of gender dysphoric patients. An paper better suited for an SDN rebuttal... has never existed.

Here are a few charts and graphs if you want more detail.

The data is explained as follows, in the discussion section. It may explain why the study you posted, and mine, are so different.



In light of this information, I want to reiterate how crazy it is to claim that the data are actually in any way supportive of sex-reassignment for gender dysphoric individuals. The data remain ambiguous, even downright troubling. We don’t merely not know if sex-reassignment works. We don’t even know that it doesn’t cause harm. Contrary to trans-advocates trying to gain healthcare access for trans-persons, benefitting them, etc. these advocates don't even know whether or not they are causing long-term harm or not...

That you base the other part of your discussion on patient satisfaction scores disturbs me greatly. Are you going to base the decision to reimburse major surgery through Medicare on the fact that patients like it?

This brings us again back to the original point. Should an unproven treatment with (as yet) disturbingly bad outcomes be reimbursed by Medicare because patient satisfaction is good, i.e. because people simply want it? To me, the answer to that question is abundantly clear.

I'll worry about the rat of your post later, I'm still all groggy from taking a couple benadryl and can't math even worse than usual. As to patient satisfaction, should we also stop converting beat reconstruction post-mastectomy because it is unproven to provide any real benefits aside from the obvious cosmetic ones? How about viagra, which certainly produces erections but is not proven to improve quality of life or interpersonal relationships? These certainly both could be done away with a well, and would save the public a lot more money than the handful of SRS procedures that would be done.

 

[Psai]

I'll worry about the rat of your post later, I'm still all groggy from taking a couple benadryl and can't math even worse than usual. As to patient satisfaction, should we also stop converting beat reconstruction post-mastectomy because it is unproven to provide any real benefits aside from the obvious cosmetic ones? How about viagra, which certainly produces erections but is not proven to improve quality of life or interpersonal relationships? These certainly both could be done away with a well, and would save the public a lot more money than the handful of SRS procedures that would be done.

Diphenhydramine makes you groggy by blocking histamine H1 receptors, it's a first generation drug.

 

[Mad Jack]

Diphenhydramine makes you groggy by blocking histamine H1 receptors, it's a first generation drug.

I took it with some booze specifically to get to sleep. Two benadryl gel caps and a shot of Captain Morgan (I call it a captain Ben) knocks me right out if I'm still not sleeping and the sun's coming up. Dat half life tho...

 

[qtpai]

I'll worry about the rat of your post later, I'm still all groggy from taking a couple benadryl and can't math even worse than usual. As to patient satisfaction, should we also stop converting beat reconstruction post-mastectomy because it is unproven to provide any real benefits aside from the obvious cosmetic ones? How about viagra, which certainly produces erections but is not proven to improve quality of life or interpersonal relationships? These certainly both could be done away with a well, and would save the public a lot more money than the handful of SRS procedures that would be done.

The rat of my post?

You make interesting points about Viagra and mastectomy. Let's examine them in more detail.

It is important to note that Viagra is not, in fact, covered by Medicare. Coverage of erectile dysfunction drugs are not considered medically necessary. This situation is similar worldwide; governments generally do not pay for drugs that treat erectile dysfunction, because it is usually not thought that patients "need" the drugs from a medical point of view.

An exception to this exclusion is when ED can be demonstrably shown to be caused by a medical problem. When this is the case, Viagra (and other ED drugs) can be reimbursed through Medicare.

And likewise for post-mastectomy breast reconstruction. Post-mastectomy breast reconstruction is reimbursed by Medicare because the "need" for breast reconstruction comes from a medical cause (breast cancer and consequent removal of the breast).

The basic logic behind this is understandable. A patient becomes ill, and as a result of the medical complications, often caused by the physician him- or herself, loses a bodypart or function important to their sense of identity. In order to provide concessions to the patient, it is thought that the patient deserves a replacement for this loss of function to restore this sense of him- or herself, if a replacement can be offered by the medical profession--even when this replacement is not shown to have medically quantifiable benefits.

Here begins the problems. For starters, the complication rate for post-mastectomy breast reconstruction is extremely high. I quote a 2011 FDA news release. Bolded are the especially relevant points:

Based on the report, women should know:

• Breast implants are not lifetime devices. The longer a woman has silicone gel-filled breast implants, the more likely she is to experience complications. One in 5 patients who received implants for breast augmentation will need them removed within 10 years of implantation. For patients who received implants for breast reconstruction, as many as 1 in 2 will require removal 10 years after implantation.
• The most frequently observed complications and outcomes are capsular contracture (hardening of the area around the implant), reoperation (additional surgeries) and implant removal. Other common complications include implant rupture, wrinkling, asymmetry, scarring, pain, and infection.
• The complications that existed for women receiving breast implants at the time of approval are similar to the complications observed today.
• Preliminary data do not indicate that silicone gel-filled breast implants cause breast cancer, reproductive problems or connective tissue disease, such as rheumatoid arthritis. However, in order to rule out these and other rare complications, studies would need to enroll more women and be longer than those conducted thus far.

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm260235.htm

Half of the time, the Medicare-reimbursed post-mastectomy breast reconstruction introduces additional medical complications of such a degree as to require removing the implant. Among these complications include life-threatening infections and hospitalizations.

Although a slew of papers claim “enhanced patient psychosocial outcomes”, “improved quality of life”, etc., a recent review (2009) states:

Several studies have suggested that body image and feelings of attractiveness are improved following breast reconstruction,15–17 although mood state, uncertainty, distress, and overall QOL do not differ significantly.18–20

No difference in quality of life! Imagine that.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691644/

Then again, this may be a non sequitur. Another recent paper (2007) from the Memorial Sloan-Kettering Cancer Center states that most if not all studies have not measured self-reported patient outcomes, especially quality of life, to acceptable scientific standards.

I quote three sentences from the abstract:

...
Quality of life has become a crucial research topic augmenting traditional concerns focused on complications and survival. Given this, reliable and valid patient questionnaires are essential for aesthetic and reconstructive breast surgeons.
...
Valid, reliable, and responsive instruments to measure patient-outcomes in cosmetic and reconstructive breast surgery are lacking.

http://www.constancechenmd.org/upload/Pusic et al, Measuring quality of life in cosmetic and reconstructive breast surgery.pdf

Given such scientific uncertainty, along with such risk of complications, one might begin to… see a pattern.

Is it that mastectomy and… gender reassignment surgery are scientifically speaking, one and the same? That their reimbursement seems more driven by cultural and political factors than an evidence base? That, for all we know, in both cases, physicians could be mauling patients in the name of "holistic" or “progressive” medicine—in the total absence of evidence to support their practices?

Couldn’t be! Why, why, why, if this were the case, we might be spending gobs of money on scientifically unsupported medical practices! The healthcare sector, each dollar of which has a negative productivity (i.e. each dollar spent shrinks GDP), might, might, be gobbling up the American economy if that happened. Tuition for higher education might be skyrocketing as states scramble to salvage enough money to fund their bloated healthcare budgets. All of public finances might be threatened! We, we, we, might have a budgetary crisis!

Our "progressive” physicians and health “activists” might, might, might be unwitting agents of corporate medicine and the vampiric juggernaut that we call American healthcare!

Oh wai- LOL.

I was being facetious. Get it! LOL!!!

What is more delightful (or shocking depending on your attitude), coming from an AMA that claims to speak for physicians, are the completely Orwellian pronouncements on gender reassignment surgery. They appeared at first extremely ******ed to me, until I decided to take a closer look.

Let us take a moment to break them down.

http://www.tgender.net/taw/ama_resolutions.pdf

Gender Identity Disorder (GID) is a serious medical condition recognized as such in both the Diagnostic and Statistical Manual of Mental Disorders (4th 5 Ed., Text Revision) (DSM-IV-TR)

Means about as much to me as citations of passages from The Hobbit.

Except I like The Hobbit.

GID, if left untreated, can result in clinically significant psychological distress, 12 dysfunction, debilitating depression and, for some people without access to appropriate medical care and treatment, suicidality and death;

I think we’ve established that when it is treated with gender reassignment surgery, it also leads to suicidality (20x) and death (3x).

An established body of medical research demonstrates the effectiveness and 25 medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment for many people diagnosed with GID

"Forms of therapeutic treatment"? Yes, they are forms of therapeutic treatment… so is hydrotherapy and electroshock on schizophrenics. Doesn’t mean any of it works. Hey wait, the AMA didn’t claim that the “forms of therapeutic treatment” worked, did it…

Hmmm…

Health experts in GID, including WPATH, have rejected the myth that such 29 treatments are “cosmetic” or “experimental” and have recognized that these treatments can provide safe and effective treatment for a serious health condition

The health experts associated with the AMA said so. Must be true, like the time when the health experts associated with the AMA told us that cigarettes safely and effectively cleared an ailing throat. And that, as doctors, they preferred... Camel.

Note that there is no sign here of making any strong claims about the scientific literature itself. Just what experts say. Smooth, AMA… like menthol.

The AMA opposes limitations placed on patient care by third-party payers when such care is based upon sound scientific evidence and sound medical opinion

It’s strange that they append “sound medical opinion” after “sound scientific evidence”. As if “sound medical opinion" was at all appropriate to cite, if “sound scientific evidence” stood on its own. It’s almost as if they couldn’t bear but acknowledge that they needed “sound medical opinion” to buttress the sparseness of the evidence.

Additionally, note that it doesn’t say strong or conclusive evidence. Only sound evidence. Sound scientific evidence could simply mean "some tangential piece of evidence, which isn’t complete ****, that marginally supports my point of view". If you think about it, “sound scientific evidence” is a good sounding but empty phrase. Which is exactly what it is supposed to be.

Whereas, Many health insurance plans categorically exclude coverage of mental health, 2 medical, and surgical treatments for GID, even though many of these same treatments, 3 such as psychotherapy, hormone therapy, breast augmentation and removal, 4 hysterectomy, oophorectomy, orchiectomy, and salpingectomy, are often covered for 5 other medical conditions; and 6 7

Whereas, The denial of these otherwise covered benefits for patients suffering from GID 8 represents discrimination based solely on a patient’s gender identity

Ouch! Now I'm a bigot.

Let's recap everything to this point. “Blah blah blah insubstantial claims blah blah. Now, if you don’t spend your money on the blah blah, then you’re an evil bigot.”

Come to think of it, this thread is a homage to evil. To bigotry. The forces of darkness. To… the *shudder* responsible management of scarce medical and national resources. To the practice of *shudder* evidence… based... medicine.

So then.

Takeaway on gender reassignment surgery and the AMA?

Here's my best.

Let us hope that, someday, there are genuine leaders among the major organizations of American medicine. And not this trash.

 

[Mad Jack]

The rat of my post?

You make interesting points about Viagra and mastectomy. Let's examine them in more detail.

It is important to note that Viagra is not, in fact, covered by Medicare. Coverage of erectile dysfunction drugs are not considered medically necessary. This situation is similar worldwide; governments generally do not pay for drugs that treat erectile dysfunction, because it is usually not thought that patients "need" the drugs from a medical point of view.

An exception to this exclusion is when ED can be demonstrably shown to be caused by a medical problem. When this is the case, Viagra (and other ED drugs) can be reimbursed through Medicare.

And likewise for post-mastectomy breast reconstruction. Post-mastectomy breast reconstruction is reimbursed by Medicare because the "need" for breast reconstruction comes from a medical cause (breast cancer and consequent removal of the breast).

The basic logic behind this is understandable. A patient becomes ill, and as a result of the medical complications, often caused by the physician him- or herself, loses a bodypart or function important to their sense of identity. In order to provide concessions to the patient, it is thought that the patient deserves a replacement for this loss of function to restore this sense of him- or herself, if a replacement can be offered by the medical profession--even when this replacement is not shown to have medically quantifiable benefits.

Here begins the problems. For starters, the complication rate for post-mastectomy breast reconstruction is extremely high. I quote a 2011 FDA news release. Bolded are the especially relevant points:



http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm260235.htm

Half of the time, the Medicare-reimbursed post-mastectomy breast reconstruction introduces additional medical complications of such a degree as to require removing the implant. Among these complications include life-threatening infections and hospitalizations.

Although a slew of papers claim “enhanced patient psychosocial outcomes”, “improved quality of life”, etc., a recent review (2009) states:



No difference in quality of life! Imagine that.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691644/

Then again, this may be a non sequitur. Another recent paper (2007) from the Memorial Sloan-Kettering Cancer Center states that most if not all studies have not measured self-reported patient outcomes, especially quality of life, to acceptable scientific standards.

I quote three sentences from the abstract:



http://www.constancechenmd.org/upload/Pusic et al, Measuring quality of life in cosmetic and reconstructive breast surgery.pdf

Given such scientific uncertainty, along with such risk of complications, one might begin to… see a pattern.

Is it that mastectomy and… gender reassignment surgery are scientifically speaking, one and the same? That their reimbursement seems more driven by cultural and political factors than an evidence base? That, for all we know, in both cases, physicians could be mauling patients in the name of "holistic" or “progressive” medicine—in the total absence of evidence to support their practices?

Couldn’t be! Why, why, why, if this were the case, we might be spending gobs of money on scientifically unsupported medical practices! The healthcare sector, each dollar of which has a negative productivity (i.e. each dollar spent shrinks GDP), might, might, be gobbling up the American economy if that happened. Tuition for higher education might be skyrocketing as states scramble to salvage enough money to fund their bloated healthcare budgets. All of public finances might be threatened! We, we, we, might have a budgetary crisis!

Our "progressive” physicians and health “activists” might, might, might be unwitting agents of corporate medicine and the vampiric juggernaut that we call American healthcare!

Oh wai- LOL.

I was being facetious. Get it! LOL!!!

What is more delightful (or shocking depending on your attitude), coming from an AMA that claims to speak for physicians, are the completely Orwellian pronouncements on gender reassignment surgery. They appeared at first extremely ******ed to me, until I decided to take a closer look.

Let us take a moment to break them down.

http://www.tgender.net/taw/ama_resolutions.pdf



Means about as much to me as citations of passages from The Hobbit.

Except I like The Hobbit.



I think we’ve established that when it is treated with gender reassignment surgery, it also leads to suicidality (20x) and death (3x).



"Forms of therapeutic treatment"? Yes, they are forms of therapeutic treatment… so is hydrotherapy and electroshock on schizophrenics. Doesn’t mean any of it works. Hey wait, the AMA didn’t claim that the “forms of therapeutic treatment” worked, did it…

Hmmm…



The health experts associated with the AMA said so. Must be true, like the time when the health experts associated with the AMA told us that cigarettes safely and effectively cleared an ailing throat. And that, as doctors, they preferred... Camel.

Note that there is no sign here of making any strong claims about the scientific literature itself. Just what experts say. Smooth, AMA… like menthol.



It’s strange that they append “sound medical opinion” after “sound scientific evidence”. As if “sound medical opinion" was at all appropriate to cite, if “sound scientific evidence” stood on its own. It’s almost as if they couldn’t bear but acknowledge that they needed “sound medical opinion” to buttress the sparseness of the evidence.

Additionally, note that it doesn’t say strong or conclusive evidence. Only sound evidence. Sound scientific evidence could simply mean "some tangential piece of evidence, which isn’t complete ****, that marginally supports my point of view". If you think about it, “sound scientific evidence” is a good sounding but empty phrase. Which is exactly what it is supposed to be.



Ouch! Now I'm a bigot.

Let's recap everything to this point. “Blah blah blah insubstantial claims blah blah. Now, if you don’t spend your money on the blah blah, then you’re an evil bigot.”

Come to think of it, this thread is a homage to evil. To bigotry. The forces of darkness. To… the *shudder* responsible management of scarce medical and national resources. To the practice of *shudder* evidence… based... medicine.

So then.

Takeaway on gender reassignment surgery and the AMA?

Here's my best.

Let us hope that, someday, there are genuine leaders among the major organizations of American medicine. And not this trash.

Was supposed to read "rest of your post" but autocorrect sucks.

Sorry, I was wrong. Medicare paid for penis pumps, not Viagra. Over $350 a pump for damn near half a million of them.

Anyway, my point was that if we're providing scientifically unproven but expert recommended care in one area but not another. I don't think Medicare should cover a lot of things, but within its current model of what is acceptably reimbursed, SRS fits. Keep in mind, I am not saying that I agree with Medicare's current structure in determining what should be reimbursed, but if you throw out SRS for particular reasons, you'd also have to throw out some far more common procedures that are deemed not to be all that effective as well. I'd also be wary of the evidence based medicine bandwagon, as statistics and studies are far more easily manipulated than they should be and many effective treatments can be extremely difficult to find a study model for.

 

[qtpai]

The situation with sex reassignment surgery points to broader issues, which your points about breast reconstruction and penis pumps show. I tried to touch on some of this but probably wrote too much.

The issue I have with SRS is not necessarily that there is an absence of evidence base--but that physician groups misrepresent the evidence base for political reasons. The evidence base is demonstrably weak for SRS. Yet it is misrepresented as strong.

You say that "many effective treatments can be extremely difficult to find a study model for." But how can you know that these are effective treatments, if a high quality study model cannot be found to show that they work?

How can a physician be certain of the efficacy of a treatment, if he or she cannot reproduce or imitate the process by which this judgment was made, in the form of a scientific study? Does not such a inability to replicate this judgment in the form of a scientific study, cast a shade of doubt on the process by which the physician made his or her judgment?

Scientific studies are, after all, merely a form of controlled experience--to eliminate bias and error. To say that an effective treatment cannot be proven in a controlled way, and can only be trusted to work in an uncontrolled environment--this is tantamount to saying that biases and errors are acceptable to include when exercising scientific judgment. On the contrary, I think that biases and errors are not acceptable in science.

Of course, they may be inevitable in a clinical setting. The very fabric of medical judgment may harbor them inextricably and forever. And it may be the physician's undeniable responsibility to manage and to some degree, maybe even a large degree, accept their constant companionship.

But they shouldn't be denied. If clinical practice doesn't square with scientific literature, this limitation should be acknowledged. And reasons should be given--that are either consistent or at odds with the literature (and then explained)--when using a medical intervention that is at odds with the science.

Papering over such difficulties makes a joke out of a profession that claims science as its source of legitimacy. It also makes medicine susceptible to political and cultural trends. In my opinion, this is not only a source of shame for medicine, but also a source of danger for the population--which trusts physicians to be primarily concerned with their health, and not to act as political or cultural agents.

So you say that many effective treatments cannot be proven. But let us come to a corollary of your statement, shall we? "There are some treatments that are thought to be effective, which, because they have thought not necessary to prove scientifically, are actually not effective."

To conclude, I will repeat something I said before. I don't think that treatments need to be shown to be effective to be used. But we need to be honest about their evidence base if using them or recommending their use.

 

[Mad Jack]

The situation with sex reassignment surgery points to broader issues, which your points about breast reconstruction and penis pumps show. I tried to touch on some of this but probably wrote too much.

The issue I have with SRS is not necessarily that there is an absence of evidence base--but that physician groups misrepresent the evidence base for political reasons. The evidence base is demonstrably weak for SRS. Yet it is misrepresented as strong.

You say that "many effective treatments can be extremely difficult to find a study model for." But how can you know that these are effective treatments, if a high quality study model cannot be found to show that they work?

How can a physician be certain of the efficacy of a treatment, if he or she cannot reproduce or imitate the process by which this judgment was made, in the form of a scientific study? Does not such a inability to replicate this judgment in the form of a scientific study, cast a shade of doubt on the process by which the physician made his or her judgment?

Scientific studies are, after all, merely a form of controlled experience--to eliminate bias and error. To say that an effective treatment cannot be proven in a controlled way, and can only be trusted to work in an uncontrolled environment--this is tantamount to saying that biases and errors are acceptable to include when exercising scientific judgment. On the contrary, I think that biases and errors are not acceptable in science.

Of course, they may be inevitable in a clinical setting. The very fabric of medical judgment may harbor them inextricably and forever. And it may be the physician's undeniable responsibility to manage and to some degree, maybe even a large degree, accept their constant companionship.

But they shouldn't be denied. If clinical practice doesn't square with scientific literature, this limitation should be acknowledged. And reasons should be given--that are either consistent or at odds with the literature (and then explained)--when using a medical intervention that is at odds with the science.

Papering over such difficulties makes a joke out of a profession that claims science as its source of legitimacy. It also makes medicine susceptible to political and cultural trends. In my opinion, this is not only a source of shame for medicine, but also a source of danger for the population--which trusts physicians to be primarily concerned with their health, and not to act as political or cultural agents.

So you say that many effective treatments cannot be proven. But let us come to a corollary of your statement, shall we? "There are some treatments that are thought to be effective, which, because they have thought not necessary to prove scientifically, are actually not effective."

To conclude, I will repeat something I said before. I don't think that treatments need to be shown to be effective to be used. But we need to be honest about their evidence base if using them or recommending their use.

I agree with you.

 

[deleted500612]

People also do not know when they will discover their true identity and if they only enroll in those plans that do cover transgender procedures when they need it, it would defeat the purpose of insurance. Plus the prevalence is low enough that it wouldn't put too much dent on the general population. Just my two cents.

What if I am Asian and discover that my true identity is white? Or what if I'm a woman with A cups who decides my true identity is a stripper with double Ds? Should the government healthcare plan pay for my plastic surgery? I feel like today's society is so overly politically correct that people throw logic out the window in favour of ensuring they don't somehow appear intolerant of transgenders or other groups. Fact of the matter is that we are born male or female, just as we are born of a certain ethnicity. You don't get to pick your sex or your ethnicity, the shape of your nose or your eyes, you get what you are given and you deal with it. If you want to change any of those things, that is absolutely fine and it is your choice, but pay for it yourself. Treatment to pay to change who you are when there is absolutely nothing medically wrong with you (except the psychological desire to be something you're not) is the very epitome of "elective" and should not be done at tax payer expense.

 

[BobbyB]

What if I am Asian and discover that my true identity is white? Or what if I'm a woman with A cups who decides my true identity is a stripper with double Ds? Should the government healthcare plan pay for my plastic surgery? I feel like today's society is so overly politically correct that people throw logic out the window in favour of ensuring they don't somehow appear intolerant of transgenders or other groups. Fact of the matter is that we are born male or female, just as we are born of a certain ethnicity. You don't get to pick your sex or your ethnicity, the shape of your nose or your eyes, you get what you are given and you deal with it. If you want to change any of those things, that is absolutely fine and it is your choice, but pay for it yourself. Treatment to pay to change who you are when there is absolutely nothing medically wrong with you (except the psychological desire to be something you're not) is the very epitome of "elective" and should not be done at tax payer expense.

countless ugly, obese women identify as hot princesses and suffer from severe depression because of it. we need to get these women the plastic surgery they need so they don't have to suffer anymore. how can you put the needs of transgenders over the needs of females. that is misogyny!!!

 

[Siggy]

No, then buy a specific plan that covers gender reassignment surgery. Don't foist the costs on everyone else, esp. on a GOVERNMENT funded plan. I can't believe you are equating treatment of gender dysphoria thru gender reassignment surgery to the treatment of depression as if they are on the same plane.

What other psychiatric disorders should the government not pay for?

Also, how much money are we really talking about? Why do I get the feeling that we're paying much more for the CHFers who refuse to follow their fluid restrictions or the diabetics who don't want to control their sugar? Hell, I've seen back to back ICU admissions for DKA by a jail patient who refuses to take his insulin. I'd definitely rather pay for the gender reassignment than another ICU stay for a person who obviously doesn't care one bit about his health (ok... mental issues might just be at play in the prison patient, but still, the overall point stands).

 

[Siggy]

Cure it? No. Does it treat it in the sense of slowing damage, improving the patient's ability to live their life, and extending longevity to up the odds of getting a transplant? Yup.

I'm pretty sure that suicide tends to limit a person's ability to live and decreases longevity. Suicide rates tends to be pretty high in the trans community.

 

[Wordead]

I'm pretty sure that suicide tends to limit a person's ability to live and decreases longevity. Suicide rates tends to be pretty high in the trans community.

Did you even read this thread? Suicide rates were found to be unchanged or increased after the surgery in several studies. Your CHF / diabetes compliance comparisons are pointless.

 

[Siggy]

I guess my main concern is about how the money is being used, and on the utility of it. Assuming a finite spending limit for healthcare, is the money for treating this disorder worth more than if it were spent on leukemia patients?

Is one disease ipso facto worth more than another disease? Is leukemia more or less important than kidney failure? Is depression worth more or less than another condition? Is the letter A any more or less important to English than the letter B?

If I have leukemia, then nothing is worth more than treating leukemia.

If I had gender dysphoria, then nothing is worth more than treating gender dysphoria.

If I wanted to spell Zzyzx (road and location in California), then nothing is worth more than the letters X, Y, and Z, despite having relatively low use compared to other letters.

 

[Siggy]

Did you even read this thread? Suicide rates were found to be unchanged or increased after the surgery in several studies. Your CHF / diabetes compliance comparisons are pointless.

The study ("Long-Term Follow-Up of Transsexual Persons Undergoing SEx Reassignment Surgery: Cohort Study in Sweden") didn't answer the question being presented.

Question: Does a person with dysphoria post SRS have a change in risk for suicide compared to a patient with dysphoria without SRS?

Study: Does a person with dysphoria post SRS have a change in risk for suicide compared to the general population.

Apples to oranges.

Edit: I'd also like to point out that the 95% confidence interval is atrociously large. Granted, it's a relatively small study, but a hazard ratio for suicide between 5.8 and 62.9?

Edit 2: Did YOU read the study? I mean the actual study, not the abstract?
"
Given the nature of sex reassignment, a double blind
randomized controlled study of the result after sex reassignment
is not feasible. We therefore have to rely on other study designs.
For the purpose of evaluating whether sex reassignment is an
effective treatment for gender dysphoria, it is reasonable to
compare reported gender dysphoria pre and post treatment. Such
studies have been conducted either prospectively[7,12] or
retrospectively,[5,6,9,22,25,26,29,38] and suggest that sex reas-
signment of transsexual persons improves quality of life and
gender dysphoria. The limitation is of course that the treatment
has not been assigned randomly and has not been carried out
blindly"

 

[deleted500612]

What other psychiatric disorders should the government not pay for?

I'd say anyone else with a body dysmorphic disorder who wants to change arbitrary characteristics about themselves for no legitimate medical reason. Oh wait, we already don't pay for any of them. Well we do, but we treat the underlying psychological problems, not pay to fulfill their fantasies of having smaller noses, bigger breasts, bigger eyes, or bigger dicks. Well unless you are a woman who wants a dick, then we'll give you a nice big one at tax payer expense.

 

[michaelrack]

What is this distinction between public and private insurance that some posters are making??? By 2017, after the Obamacare transition period is over, there will be no meaningful difference. Private insurance may be run by a private company, but that insurance company is just selecting a network, collecting funds (much in the form of government subsidies), and administering government-mandated levels of coverage.

 

[dadaddadaBATMAN]

Is one disease ipso facto worth more than another disease? Is leukemia more or less important than kidney failure? Is depression worth more or less than another condition? Is the letter A any more or less important to English than the letter B?

If I have leukemia, then nothing is worth more than treating leukemia.

If I had gender dysphoria, then nothing is worth more than treating gender dysphoria.

If I wanted to spell Zzyzx (road and location in California), then nothing is worth more than the letters X, Y, and Z, despite having relatively low use compared to other letters.

My argument was uninformed in a lot of ways, and I think there are serious flaws with it. For example, I had no idea we provided treatment funding for ED. Assuming reasonably equitable costs and outcomes, if we are going to treat one set of sexual issues and not another (because it is experienced by a minority who we disapprove of), that seems like discriminatory policy to me.

And as I pointed out in my original comment, spending more on leukemia only precludes spending money on GD assuming finite spending which must be divided between the two. That is obviously not the case.

In regards to your argument: I would hypothesize that a is more vital to speaking english than b. It's one of five options which essentially appear in every word.

I can objectively say that a or b appear in a given number of words, or form a vital sound in a number of words. For example: 22 of my 66 words in the first block of my reply have a in them. 4 of 66 contain b. We could also count how many words a is essential to the pronunciation of, or the reading of, or the power/importance of each word beginning with a or b/containing them, etc.

Obviously I had to make subjective judgements in order to make a final decision, but if I have to sacrifice one I will sacrifice b.

Fortunately, we do not have to decide whether kidney failure or leukemia is more important. If we did have to make this decision, I would rather have someone analyze trends in incidence/prevalence, numbers of years lost, NNT for benefit, than say "well **** we can't decide."

A new cure for breast cancer might not matter to me much if I have a kidney stone tomorrow, but that doesn't make it less important than my kidney stone. The fact that some individuals will regard healthcare spending as less important to them personally is irrelevant to what decisions society should make in order to serve the most individuals.

This isn't a question of what is worth more to an individual patient. It's a question of what's worth most to all patients together.

Your argument would have great significance to the treatment of an individual: I cannot say whether a depressed man would rather have me manage his diabetes or treat his depression (although even here, I may be more informed as to the consequences of not treating either condition, and so be better disposed to make a decision).

Finally, I'm curious how you think you can speak for all patients who have gender dysmorphia. Perhaps I missed a national announcement making you supreme ruler of the gd population. If so, I accord you all the appropriate honors and graces due to your esteemed position.

If not, I'm curious how you came to your position of "if I have gender dysmorphia nothing is more important to me than treating that condition."

 

[Siggy]

Finally, I'm curious how you think you can speak for all patients who have gender dysmorphia. Perhaps I missed a national announcement making you supreme ruler of the gd population. If so, I accord you all the appropriate honors and graces due to your esteemed position.

If not, I'm curious how you came to your position of "if I have gender dysmorphia nothing is more important to me than treating that condition."

I neither advocated for nor disparaged any specific treatment in that post. You can ask the same question regarding lymphomia? Am I the supreme ruler of lymphoma who can make the argument that the treatment of lymphoma is of the utmost importance to people who have lymphoma? I simply don't think it is a stretch to say that people who have disease or disorder X (assuming it's something major, and not, say, the common cold) believe that treating X is of the utmost importance. If this wasn't true, then why do lobbyists love trotting out X-disease survivors when advocating for X?

While I agree that we need to look at NNT, total cost, and a whole lot of other statistics if we need to decide which diseases we aren't going to treat with publicly funded dollars. However none of that was done in your suggestion that lymphoma is worth more than GD.

 

[dadaddadaBATMAN]

I neither advocated for nor disparaged any specific treatment in that post. You can ask the same question regarding lymphomia? Am I the supreme ruler of lymphoma who can make the argument that the treatment of lymphoma is of the utmost importance to people who have lymphoma? I simply don't think it is a stretch to say that people who have disease or disorder X (assuming it's something major, and not, say, the common cold) believe that treating X is of the utmost importance. If this wasn't true, then why do lobbyists love trotting out X-disease survivors when advocating for X?

While I agree that we need to look at NNT, total cost, and a whole lot of other statistics if we need to decide which diseases we aren't going to treat with publicly funded dollars. However none of that was done in your suggestion that lymphoma is worth more than GD.

I dislike broad statements implying absolutes, which is what "___ is the most important to all people who have ___ " seemed to be.

I also disagree with my interpretation of your earlier comment, which is that we cannot make objective decisions as to which diseases need treatment more.

I agree that my post was foolish. I disagree with your reasoning as to why it was foolish, and as phrased your reasoning makes little sense to me.

My suggestion was simply that we should evaluate whether or not we should treat disease based on the expected benefits. If it wasn't clear to you from my statement that this should be done using an objective measurement, then I agree that I should have been clearer.

 

[Mad Jack]

I'd say anyone else with a body dysmorphic disorder who wants to change arbitrary characteristics about themselves for no legitimate medical reason. Oh wait, we already don't pay for any of them. Well we do, but we treat the underlying psychological problems, not pay to fulfill their fantasies of having smaller noses, bigger breasts, bigger eyes, or bigger dicks. Well unless you are a woman who wants a dick, then we'll give you a nice big one at tax payer expense.

There's plenty of effective treatments for other types of body dysmorphic disorder, but zero proven effective treatments for those suffering from GID, so it isn't exactly an apples-to-oranges comparison.

 

[DermViser]

There's plenty of effective treatments for other types of body dysmorphic disorder, but zero proven effective treatments for those suffering from GID, so it isn't exactly an apples-to-oranges comparison.

So then if there are zero proven effective treatments for Gender Identity Disorder, as you say, then why must the rest of us pay for it (thru higher premiums)?

 

[Mad Jack]

So then if there are zero proven effective treatments for Gender Identity Disorder, as you say, then why must the rest of us pay for it (thru higher premiums)?

I already posted my argument for this. Because we cover a lot of other bull**** that is unproven but "recommended by experts" and denying treatments that fall into this category for one group but not another is basically just arbitrary descrimination. There's going to only be a handful of these operations performed, which will probably cost the system a fraction of what all the breast reconstructions and penis pumps medicare pays for. You want to really save money? Stop providing futile, proven to be ineffective end of life care. BAM. You just cut your Medicare budget in half. Stop focusing on the nickels and dimes and focus on the real problems with the system, then we'll get somewhere.

80% of medicare cash is spent in the final month of care. Not on elective surgeries, not on day-to-day pharmaceuticals, not on any of the crap we so frequently focus on. And a good chunk, dare I say most of it, is on people that we know without a doubt will die anyway.

 

[DermViser]

I already posted my argument for this. Because we cover a lot of other bull**** that is unproven but "recommended by experts" and denying treatments that fall into this category for one group but not another is basically just arbitrary descrimination. There's going to only be a handful of these operations performed, which will probably cost the system a fraction of what all the breast reconstructions and penis pumps medicare pays for. You want to really save money? Stop providing futile, proven to be ineffective end of life care. BAM. You just cut your Medicare budget in half. Stop focusing on the nickels and dimes and focus on the real problems with the system, then we'll get somewhere.

80% of medicare cash is spent in the final month of care. Not on elective surgeries, not on day-to-day pharmaceuticals, not on any of the crap we so frequently focus on. And a good chunk, dare I say most of it, is on people that we know without a doubt will die anyway.

Wrong. It's not 80%. It's 28% - http://www.medicarenewsgroup.com/co...-third-rail-of-u.s.-health-care-policy-debate

 

[Mad Jack]

Wrong. It's not 80%. It's 28% - http://www.medicarenewsgroup.com/co...-third-rail-of-u.s.-health-care-policy-debate

Ah, sorry. Turns out the number I gave is a frequently misattributed figure that comes from a report in which it is stated that 80% of money spent on those that die in a given year is spent in the last month of life, which is a pretty meaningless number really. End of life care did cost us $170 billion last year though. That's roughly 386,300% more than people spend on every single sex change operation combined in a given year (most of those people pay out of pocket and the vaaaaaaaaaaaaaaast majority aren't old enough to use Medicare, so it's not costing the taxpayer a dime, aside from the odd prisoner here and there).
http://articles.latimes.com/2010/jan/22/health/la-he-end-of-life-costs25-2010jan25

 

[DermViser]

Ah, sorry. Turns out the number I gave is a frequently misattributed figure that comes from a report in which it is stated that 80% of money spent on those that die in a given year is spent in the last month of life, which is a pretty meaningless number really. End of life care did cost us $170 billion last year though. That's roughly 386,300% more than people spend on every single sex change operation combined in a given year (most of those people pay out of pocket and the vaaaaaaaaaaaaaaast majority aren't old enough to use Medicare, so it's not costing the taxpayer a dime, aside from the odd prisoner here and there).
http://articles.latimes.com/2010/jan/22/health/la-he-end-of-life-costs25-2010jan25

Your point? Unnecessary care is unnecessary care.

 

[JTR+HL]

Let me try my best to summarize this debate so far. So it seems to me that the focus of contention is whether SRS is medically necessary and hence should it be covered by gvt funded insurance such as Medicare. And I also see people countering by pointing out other unproven procedures or medications covered by the same said plans. Hypothetically, if there is a procedure or medication that can potentially increase chance of survival but is unproven, because the condition is rare, do you think it is okay for gvt funded plans to cover it? Let's take out the fact that it is SRS we are talking about, would we be looking at it differently? If someone with breast dysphoria is truly tormented as someone with gender dysphoria is, I believe plastic surgery should be granted. Of course, that judgement call is never easy and would be prone to abuse. I don't know if such data exist, but I imagine if we compare the percentage of suicide among people suffering from gender dysphoria to those of breast dysphoria, the former would be a lot higher, and thus justify having SRS as a last resort. Then again, as others repeatedly pointing out, this is Medicare we are talking about. How many 65+ yo or their providers would actually contemplate such things? Some believe that what is wrong, is wrong, no matter how minor the issue is. I would quote from the movie Lincoln: If in pursuit of your destination, you plunge ahead, heedless of obstacles, and achieve nothing more than to sink in a swamp... What's the use of knowing True North?.

 

[BobbyB]

i believe this article is relevant to this thread

http://www.dailymail.co.uk/news/art...taxpayer-funded-taxi-rides.html#ixzz35SPdnssn

She provoked outrage when she had her breasts enlarged on the NHS because her flat chest upset her.

Now aspiring glamour model Josie Cunningham is risking the wrath of taxpayers yet again for taking council-funded taxi trips worth nearly £6,000 a year – because she says she is too scared to take the bus.

The 24-year-old claims she is so hated following publicity about her breast operation that she cannot use public transport to take her two young children to and from school.

She told her GP that the stress was giving her anxiety attacks and that her children, aged six and three, were missing school and nursery as a result.

Leeds City Council has reportedly now accepted an application for free school taxi trips on health grounds.

It means Miss Cunningham, a single mother who is five months pregnant, is receiving around £150 of free fares a week – the equivalent of £5,700 per school year.

Comparing herself to former glamour model Katie Price, she said: ‘You wouldn’t see Katie Price get a bus — and I’m much more hated than her.

‘Why should I foot the bill when it’s the public who cause me so much discomfort? They can pay for it. I couldn’t get a bus again. I’m too well recognised and the amount of hate I receive makes it impossible to get public transport.’

And, in a brazen interview with the Sun, she added: ‘Taxpayers should be grateful it’s only taxi fares and not private hire cars.’ Yesterday she refused to comment further and referred all questions to her agent.

Miss Cunningham shot to notoriety last year when she had a £4,800 operation to increase her bust from size 32A to 36DD, claiming she had been bullied since she was 14 for having a flat chest. Her operation was carried out by the same NHS trust that had refused to fund surgery that would have enabled a two-year-old girl with a form of cerebral palsy to walk.

Miss Cunningham later claimed her breasts were ‘so big’ she found them embarrassing and said the NHS should pay for a reduction.

Then she tried to placate public opinion by promising to pay back the cash.

But when she became pregnant after working as a £1,000-a-night escort, she admitted she cannot uphold her pledge – and now continues to be a drain on public funds.

Indeed two months ago she boasted she would be having £2,500 of free dental work now she is expecting.

Since last month, Miss Cunningham and her children have been driven two-and-a-half miles to and from the local school, twice a day. The journey would cost around £30 a week by bus.

 

[InGen]

i believe this article is relevant to this thread

http://www.dailymail.co.uk/news/art...taxpayer-funded-taxi-rides.html#ixzz35SPdnssn

She provoked outrage when she had her breasts enlarged on the NHS because her flat chest upset her.

Now aspiring glamour model Josie Cunningham is risking the wrath of taxpayers yet again for taking council-funded taxi trips worth nearly £6,000 a year – because she says she is too scared to take the bus.

The 24-year-old claims she is so hated following publicity about her breast operation that she cannot use public transport to take her two young children to and from school.

She told her GP that the stress was giving her anxiety attacks and that her children, aged six and three, were missing school and nursery as a result.

Leeds City Council has reportedly now accepted an application for free school taxi trips on health grounds.

It means Miss Cunningham, a single mother who is five months pregnant, is receiving around £150 of free fares a week – the equivalent of £5,700 per school year.

Comparing herself to former glamour model Katie Price, she said: ‘You wouldn’t see Katie Price get a bus — and I’m much more hated than her.

‘Why should I foot the bill when it’s the public who cause me so much discomfort? They can pay for it. I couldn’t get a bus again. I’m too well recognised and the amount of hate I receive makes it impossible to get public transport.’

And, in a brazen interview with the Sun, she added: ‘Taxpayers should be grateful it’s only taxi fares and not private hire cars.’ Yesterday she refused to comment further and referred all questions to her agent.

Miss Cunningham shot to notoriety last year when she had a £4,800 operation to increase her bust from size 32A to 36DD, claiming she had been bullied since she was 14 for having a flat chest. Her operation was carried out by the same NHS trust that had refused to fund surgery that would have enabled a two-year-old girl with a form of cerebral palsy to walk.

Miss Cunningham later claimed her breasts were ‘so big’ she found them embarrassing and said the NHS should pay for a reduction.

Then she tried to placate public opinion by promising to pay back the cash.

But when she became pregnant after working as a £1,000-a-night escort, she admitted she cannot uphold her pledge – and now continues to be a drain on public funds.

Indeed two months ago she boasted she would be having £2,500 of free dental work now she is expecting.

Since last month, Miss Cunningham and her children have been driven two-and-a-half miles to and from the local school, twice a day. The journey would cost around £30 a week by bus.

Well, at least the people have "free" healthcare, right?

 

[PikminOC]

There are many reasons for skyrocketing costs including third party payor and lack of transparent pricing.

 

[PikminOC]

It's instances like this, re: a treatment whose efficacy is unproven and bends to political pressures, where I can't say a thing against people who want to effectively ration care.

Get used to it. Everything bends to political pressure.

 

[DermViser]

Get used to it. Everything bends to political pressure.

The point I was making is that none of us can complain when an outside force rations care, when insurance companies are forced to cover things like this, whose efficacy isn't even proven to help.

 

[yappy]

I love the hypocrisy of societies that confiscate wealth via threat of violence & imprisonment to provide health care ; it is doubly satisfying to see hilarious anecdotes such as that.

i believe this article is relevant to this thread

http://www.dailymail.co.uk/news/art...taxpayer-funded-taxi-rides.html#ixzz35SPdnssn

She provoked outrage when she had her breasts enlarged on the NHS because her flat chest upset her.

Now aspiring glamour model Josie Cunningham is risking the wrath of taxpayers yet again for taking council-funded taxi trips worth nearly £6,000 a year – because she says she is too scared to take the bus.

The 24-year-old claims she is so hated following publicity about her breast operation that she cannot use public transport to take her two young children to and from school.

She told her GP that the stress was giving her anxiety attacks and that her children, aged six and three, were missing school and nursery as a result.

Leeds City Council has reportedly now accepted an application for free school taxi trips on health grounds.

It means Miss Cunningham, a single mother who is five months pregnant, is receiving around £150 of free fares a week – the equivalent of £5,700 per school year.

Comparing herself to former glamour model Katie Price, she said: ‘You wouldn’t see Katie Price get a bus — and I’m much more hated than her.

‘Why should I foot the bill when it’s the public who cause me so much discomfort? They can pay for it. I couldn’t get a bus again. I’m too well recognised and the amount of hate I receive makes it impossible to get public transport.’

And, in a brazen interview with the Sun, she added: ‘Taxpayers should be grateful it’s only taxi fares and not private hire cars.’ Yesterday she refused to comment further and referred all questions to her agent.

Miss Cunningham shot to notoriety last year when she had a £4,800 operation to increase her bust from size 32A to 36DD, claiming she had been bullied since she was 14 for having a flat chest. Her operation was carried out by the same NHS trust that had refused to fund surgery that would have enabled a two-year-old girl with a form of cerebral palsy to walk.

Miss Cunningham later claimed her breasts were ‘so big’ she found them embarrassing and said the NHS should pay for a reduction.

Then she tried to placate public opinion by promising to pay back the cash.

But when she became pregnant after working as a £1,000-a-night escort, she admitted she cannot uphold her pledge – and now continues to be a drain on public funds.

Indeed two months ago she boasted she would be having £2,500 of free dental work now she is expecting.

Since last month, Miss Cunningham and her children have been driven two-and-a-half miles to and from the local school, twice a day. The journey would cost around £30 a week by bus.

 

[el_duderino]

I love the hypocrisy of societies that confiscate wealth via threat of violence & imprisonment to provide health care ; it is doubly satisfying to see hilarious anecdotes such as that.

The other side of the coin is that it's sad and ridiculous that it's apparently impossible to provide everyone with some basic level of health care. We're all human beings.

 

[PikminOC]

The point I was making is that none of us can complain when an outside force rations care, when insurance companies are forced to cover things like this, whose efficacy isn't even proven to help.

Just like the argument for other providers....