What Is Clinically Appropriate?

In an op-ed in the Washington Post Jennifer Finney Boylan argues that the states that are moving to bar Medicaid from paying for hormone supplementation or other forms of “gender affirming” care:

Many years ago at a wedding reception, a transgender woman showed me a scan of the human brain. One section — the bed nucleus of the stria terminalis, in fact — was highlighted. “You see?” she said. “It’s not my fault!”

The thing that was not her fault (she said) was being trans. Research at the time suggested that this particular brain structure in trans women was much more like that of cisgender women, rather than cis men, lending some support to the idea that transness is a neurological condition, not so different from cerebral palsy or epilepsy.

As opposed to, say, simply being someone who’s obsessed with stilettos and sponge cake.

When I came out in 2000, I remember trying to explain my situation by using some of this same language. I begged people for understanding and kindness. My voice was more than a little apologetic. Please, I said to those I loved. I’m hard-wired this way! It’s not my fault!

Twenty-two years later, the idea that trans people need to explain themselves to others feels a little weird. Being trans is no longer something we believe we need to apologize for. It is, at least in some circles, a thing to celebrate.

Here is the specific object of the author’s ire:

Last month, Florida became at least the ninth state to bar trans people from using Medicaid to help pay for gender-affirming care.

The reason? Transition care is not, the state has determined, a medical necessity.

In a report issued in June, the state went against decades of medical opinion. “Florida Medicaid has determined that the research supporting sex reassignment treatment is insufficient to demonstrate efficacy and safety,” said the report, which is signed by Gov. Ron DeSantis (R).

As a result, many people who have been on hormones for years, and in some cases decades, will be forced to de-transition if they cannot find other coverage, or if they are unable to pay for health care themselves.

The problem with the author’s analysis is that brain scans may not be as dispositive as the author thinks. For one thing it is known that behavior can alter physical brain structure, cf. this study from the National Institute of Health’s library—TL;DR version is that behavior can change brain structure.

Additionally, it is known that the use of pharmaceuticals may change the actual physical structure of the brain and, although it is as you may expect, controversial that supplementation with exogenous hormones may actually change the physical structure of the brain.

My own view is that we should be focusing more on what is clinically appropriate and less on claims of rights to specific kinds of care. That is the direction in which other countries, e.g. United Kingdom, Sweden, Finland, have been moving. There are much less likely to prescribe “gender affirming care” than they used to be.