The Cost of Right: A Bargain

June 7, 2008

There is a letter to the editor of the Niagara Falls Review in Niagara Falls, Ontario, published June 6, 2008, captioned “Money for sex changes, but not for diabetics.” It can be found at:

http://www.niagarafallsreview.ca/ArticleDisplay.aspx?e=1061878

The letter writer, a Type 1 diabetic, wasn’t diagnosed until age 25. Not being diagnosed until after age 18 means the writer was not eligible for a publicly funded insulin pump, which are available only for those diagnosed before age 18.

Early diagnosis “would prevent kidney deterioration and vision problems while promoting a longer life. This would result in fewer trips to the doctor or emergency room.”

I agree.

Early diagnosis of all chronic illness will save enormous amounts of money over the long term and “is not only better for the person with the disease but also less of a burden on the health system.”

I agree.

For transgendered people and especially transsexual people—the specific sub-group of transgendered people who seek surgery—surgery, after hormone therapy and gender transition, alleviates chronic problems including clinical depression, addictions, other self-destructive behaviours up to and including suicide and also the violence, resulting from prejudice and fear, that so often follows transgendered people.

All of these cost far more to society than a very, very small public investment in surgery—as I will detail later.

There is also the cost to society of the lost productivity of all those whose time, just like the writer’s, is taken up with managing, as best they can, their disability.

The letter writer then concludes, quite reasonably, “why wouldn’t they put the money toward an insulin pump program for people over 18?”

I only disagree with the article “the”—referring to the $200,000 a year Ontario Minister of Health, George Smitherman, has said will go to fund “sex-change” surgery.

At the end of the letter the writer proposes a list of what is worthy for public funding: “other lifesaving medical devices that would improve quality of life for anyone with diabetes, cancer, multiple sclerosis or other life-altering disease” or “the use of these funds could be to increase staff in the emergency room, rather than having one overworked doctor.”

“Sex-change surgery,” in the writer’s mind, is “not vital to the quality of a person’s health.” In the understandable challenge of his own life, the writer has dismissed the evils that beset the lives of transgendered people and that are certainly detrimental to the quality of their health—and cost society as a whole.

“Lifesaving medical devices” and “increase[ing] staff in the emergency room” are important and should be on the agenda of any health care ministry—and should have been on the agenda for the decade transex surgery has been unavailable in Ontario.

But for $200,000 a year none of the things this writer has legitimately asked for could ever be funded. This fact is not trivial, though the amount of money we’re speaking of, in the overall Ontario health care budget, is.

There is another point in the letter that strikes me.

The writer uses as justification for ‘lifesaving medical devices” that they “would improve quality of life” for people with “diabetes, cancer, multiple sclerosis or other life-altering disease.” But, for people with gender identity disorder, surgery is “not vital to the quality of a person’s health.”

Why the different test? Why must surgery for gender identity disorder be “vital to the quality of a person’s health” and not “improve quality of life”? For that matter, why isn’t it?

Why are transsexual people subject to a special test, a different test?

When we advocate for human rights we advocate for something not “special,” but simply to be treated with dignity and respect as all should—but transgendered people aren’t because of ignorance and the prejudice and fear that follow—especially when it comes to the allocation of public resources.

The writer accepts implicitly the judgment of medical and other “expert” persons when it comes to who has a “life-altering disease” but quite clearly will refuse to accept the judgment of the same personnel when it comes to gender identity disorder—the diagnosis for those who need transsex surgery.

Smitherman’s press secretary, Laurel Ostfield, was quoted in a Canadian Press story in the Toronto Globe and Mail on May 20, 2008:

“This sexual reassignment surgery is regarded amongst the mental health community as a necessary treatment for a very small number of individuals,” she said.

“It is listed in other provinces, such as Alberta. So, if Mr. Poilievre wants to play politics with people’s health, it’s really rather unfortunate.”

http://www.theglobeandmail.com/servlet/story/RTGAM.20080520.wsexchange20/BNStory/National/home

She is referring to the MP for Nepean-Carleton, Pierre Poilievre, who seems to have been the first to comment negatively on Smitherman’s proposal.

My heart goes out to the writer, but I disagree with the premise of the letter’s argument, that if these public funds are denied to transsex surgery they will be enough to support the needs identified.

Now, while we’re talking money, there are two other classes of people who also deserve public compensation and are not yet part of the discussion: those who have been approved for surgery in the decade it has been unavailable in Ontario but have not had the resources to cover it themselves; and those, in this same decade, who have, say, taken out a mortgage, settled a human rights complaint, had a well-paying enough job to save and/or medical insurance to cover it and funded it themselves.

After all, if it is right to cover surgery for those who will be approved starting, well we don’t know exactly when, but let’s say January 1, 2009, why is it not right to cover those who have already gone through the same assessment criteria, the “standards of care,” set out by the World Professional Association for Transgender Health (WPATH), regardless of whether they have undergone the surgery or not?

The professional people who make the diagnosis in Canada are members of the Canadian Professional Association for Transgender Health (CPATH), a national section of WPATH, and very active.

Here are some ‘back of the envelop’ calculations.

I have used the cost of male to female surgery performed in the world class clinic of Dr. Pierre Brassard in Montreal—probably in the top three in the world today—because NONE of these procedures are available in any form in the Ontario public system. Various of the procedures that constitute female to male surgery are performed in the public sector—mastectomy and hysterectomy—and are available to trans men. The final procedure is very experimental, very expensive, does not always work and is not available in the public sector.

Smitherman’s own calculations are based on 8 to 10 persons a year at about $200,000 a year—or about $20,000 for each transsexual person starting whenever it will start. The fee in Montreal, including 8 to 10 days recuperation at the clinic, is $18,000 for the male to female basic procedure—breast augmentation, voice surgery are extra. There seems to be no provision for homecare in the most vulnerable week after arriving home.

Estimates are that about 200 people have been assessed according to the “standards of care” but have not yet had surgery. This is about 20 a year for the decade for all of Ontario; they are concentrated in the larger cities, especially Toronto.

Even more of a guesstimate, there are about half as many again who have been approved and funded surgery themselves—100 in total or about 10 a year.

For the first group the one-time cost is $3,600,000. On an annual basis for the decade this is only $360,000—a bit more than the $200,000 Minister Smitherman is proposing, but not much.

For those who have been approved and funded surgery themselves, the one-time cost is $1,800,000; over the decade it is $180,000 a year.

All together, if the province had funded these procedures ongoing, the annual cost would have been $580,000, but now a one-time expenditure of $5,400,000—remember, this is in a total annual health care budget of more than $40 billion. For the immense direct savings and untold amounts that would not otherwise be generated, this investment would have paid for itself MANY times over—and still can.

These estimates are extremely generous and is the absolute outside expenditure; what will actually be spent will be less.

This is the cost of right and its a bargain.

The Ottawa Citizen published an editorial characterizing Poilievre as a bully who picked on a population he believed so marginalized it couldn’t fight back.

Transgendered people are even more marginalized than drug addicts. . . . .Pardon us if we don’t admire his courage for taking on the all-powerful transgendered lobby.

The Courage of Poilievre, The Ottawa Citizen, May 21, 2008

http://www.canada.com/ottawacitizen/news/editorials/story.html?id=f68e086c-6a0e-48b2-b67b-d20d70ab04a7

The arguments in the letter to the editor are commonly used by those who criticize public provision of transsex surgery.

This writer sees something that seems to be being taken from him and it is an understandable concern.

But limitations on the availability of funds cannot be the reason for denying surgery “that would improve quality of life” of transgendered people.

There is another reason.

Its not a pretty one.

Full disclosure: I had surgery in the Montreal clinic of Dr. Pierre Brassard in February of this year.