Apr. 15, 2009 - Issue #704: Mutek

It’s not the economy, stupid

Budget cut to gender reassignment surgery has serious implications for transsexed Albertans' citizenship rights

They say the first cut is the hardest, but transsexed—also known as transsexual—Albertans never expected they would find themselves without access to the only medically recognized therapy for their condition. While public argument since the April 7 provincial budget, which eliminated funding for gender reassignment surgeries in the province, has fallen primarily into a tit-for-tat argument about who should or should not receive funding for various conditions, what the average Albertan likely doesn't know is that without completion of a number of surgeries, a transsexed person by law cannot obtain documentation that reflects their actual identity.

"We can see how [this decision] is ideologically based, yet the government is using the argument that it's strictly an economic decision," says Lane Mandlis, a PhD candidate at the University of Alberta. "[However] the economics fall apart really, really quickly with very little effort and no economics degree required. They're basing this decision on ridiculous math."

Mandlis, himself a transsexed person who transitioned from female to male (FTM), cites numerous costs of cutting 100 per cent of the already limited funding set aside for trans-related treatments.

"You've got incarceration numbers that need to be included," he says, noting that some transsexed people may be sufficiently desperate to turn to illegal activities to gain the tens of thousands of dollars required to pay for surgeries out-of-pocket. "You've got mental health beds—the costs to keep someone in a locked mental health ward if they're a danger to themselves is very expensive and draining on the system, and those costs haven't been included. The costs to access psychologists, psychiatrists and social workers within the system, because some of it is covered within the system, is very expensive, and those costs haven't been included. So you're talking about increasing all of those costs in order to save those $700 000, and that's ridiculous. You aren't saving anything."

The big issue, Mandlis argues, is that this decision prevents some Albertans from having citizenship. He explains that citizenship depends on identity documentation, but the province's decision to de-list services for transsexed people prevents them from obtaining correct identity documents.

Most people rarely give much thought to obtaining a driver's licence, for example, yet under Alberta law, a transsexed person must complete surgical procedures before being granted a licence that is harmonized—or congruent—with the person's identity.

"If an FTM with a beard and a deep voice wants to have a drivers' licence that lists him as male, he has to have gender reassignment surgery," Mandlis says. "Where the congruence comes in is the idea that people will see him and read him as male, recognize him as male, but then when he produces his identification, that's when we have an incongruence, because his identification will list him as female."

Mandlis' research in the U of A's department of sociology focuses more on federal citizenship issues for the transsexed, but issues such as obtaining a provincial driver's licence and other identification are similar.

For the transsexed, "in order to access identity documents that are congruent, there's a requirement to physically transition," Mandlis says. "So in order to have those things be congruent, a person has to have GRS [gender reassignment surgery]. Which means that our citizenship, to some degree, is tied in through law with having GRS. We can't understand citizenship without a call to identity documentation, because without identity documentation we actually don't have citizenship."

Newborn children are usually barely moments old before their sex is declared by someone present at the birth. "Basically what happens is that the doctor makes a decision, which sometimes they feel very confident about and sometimes they don't," he says. "Anyway, they make this decision, it gets registered, and it ends up on our identity documentation and it then constructs us as that thing. So we are who we are because the document says that we are that."

In other words, the information registered on your birth certificate, which carries significant legal weight throughout your life, is information gathered from a cursory examination that may or may not reflect information you gain or experiences you have later in life that conflict with that information.

Mandlis explains that this lack of congruency has a significant and constant impact on the transsexed.

"So what makes us 'male' or 'female' as far as any sort of institutional contact goes, and by institutional contact I don't just mean the government, a hospital, a school, I also mean credit card companies, movie rental stores and so on and so on—any sort of group, codified situation. We're talking about any number of services and practices in the world."

Imagine if your identification caused the clerk at the local movie rental store to wonder about your personal medical situation. What if cancer, heart disease or any other diagnosed medical condition were somehow expressed or hinted at on all your government-issued documentation? Imagine further that this same clerk, without thinking, responds to this discovery with visible shock and questions you further—loudly, in public, not private—before providing the service you are there to access. Imagine the potential for that problem to happen at every single store, every single gas station, every single bar—every single time you might be asked for identification, you will have your personal medical situation "outed" to one person, and often more, whom you did not willingly choose to disclose that information to.

That, says Mandlis, is the situation that transsexed people face every day in Alberta as long as they remain without access to the surgeries the government demands be completed before they are able to access government-issued identification that is congruent with who they are.

Mandlis uses the example of a hypothetical married couple obtaining congruent documentation. He explains that for the wife, she may obtain her driver's licence that shows her female name, her female face and her female sex for well under $100. However, for her FTM husband, obtaining a congruently identified driver's licence requires a legal change of name (a minimum charge of $145 including fingerprinting by the RCMP but excluding surcharges from the registry agency), proof of legally required surgeries (for an FTM, ranging somewhere between $60 000 – $80 000 assuming no post-operative complications) and, finally, the cost of the driver's licence itself.

Additionally, the actual process of obtaining surgery for either MTF (male to female) or FTM transsexed people is one that takes months or years, regardless of whether the individual patient somehow has the means to access the vast sums of money required.

For one citizen, the cost of citizenship is easily within reach. For the other, the costs and timelines are so excessively prohibitive that the person may well never access the legally required surgery, thus the situation remains such that congruent documentation is impossible to obtain. So it's not about the economy, Mandlis concludes, but about the right to full citizenship.

In response to the elimination of funding for gender reassignment surgeries announced in the budget, about 30 members of the trans community and their supporters attended the April 14 question period at the legislature, where Health Minister Ron Liepert responded to opposition questions regarding the cut.

Liepert defended the move, which the province estimates will save about $700 000 annually, saying the province needed to make some hard choices around spending given the current economic climate.

"Each minister was required to go through their budget line by line and in the case of health care meet a budget increase of some 4.9 per cent," Liepert said. "There’s a list of some 30 or 40 different programs and grants and coverages that will not be proceeding going forward. Those are some tough decisions that have to be made."

The minister did confirm that the 26 individuals currently on the list to undergo the surgery will have the procedure covered by the province, and also said that another 20 people who have not yet been approved for surgery but are receiving hormonal drugs will also be funded.

On April 15 members of the trans community filed simultaneous complaints in Edmonton and Calgary against the province cuts with the Alberta Human Rights and Citizenship Commission. A provincial campaign has also been launched encouraging supporters to write to MLAs, specifically members of the standing policy committee on health, urging them to reinstate funding for the surgeries. V 

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