FGM is a pretty simple issue to a libertarian individualist like me. Nobody gets to mutilate you without your consent, and coerced consent is a fraud. On the other hand, if you want to be mutilated, i.e. to change your genitals, I'm not going to try to stop you, except to make sure you understand that the mutilation can't be reversed as easily as you can change your mind.

But should I help pay for your sex-change surgery? Is it a medical problem? There, I'm kind of a conservative. I'm not inclined to have Medicare pay for Viagra, either. My definition of "need" is stricter than that.

The best argument I can make for tax-funded sex-change surgery is that being born with, say, a male body and female brain is a kind of birth defect, like being born with a brain for two arms but a body with only one arm. And my problem with that argument is that your brain isn't really female; it's got male DNA just like the rest of you. Your claim boils down to a subjective sensation that you really ought to be a woman. And if we start subsidizing surgeries based on subjective feelings of identity, I can't see where to draw the next line.

Good luck to Brazil in drawing it.

Whoops, I forgot to include the <link>.

That's not an accurate picture of transsexualism or how it works though. DNA is only one aspect of human development, and a leading theory right now (which is somewhat supported by tests on brains of the deceased in the early 90's which showed MtF transexxuals to have brains similar in size and structure to women) is that hormones released during a specific point in pregnancy which only affect the brain may sometimes cause the brain to develop as the opposite gender's, causing a person who is literally a man in a woman's body or vice versa. In that case, it is a medical condition and one that ought to be fixed. There's nothing subjective about that.

As it goes, San Fransisco covers the costs of sex change operations and hormone replacement costs for their employees. They were initially fearful of a mad rush of expenses too, only to find it barely increased the amount they spent every year in health coverage. So it can be easily worked into a health care plan.

enigmatose:

a leading theory right now (which is somewhat supported by tests on brains of the deceased in the early 90's which showed MtF transexxuals to have brains similar in size and structure to women) is that hormones released during a specific point in pregnancy which only affect the brain may sometimes cause the brain to develop as the opposite gender's

OK, that's a good start. Next question: Can we establish objective tests for determining whether your brain size/structure is M or F? If you're willing to refuse coverage to an applicant who claims he's F but falls within the M range on the test, I'm willing to go along.

I assume the biggest problem here is that M and F hugely overlap.

I think the problem Brazil is running into is that they want to have it both ways: the universal coverage of state-paid health care without the state setting any limits on what medical care is available.

According to this (<link>), Brazil still has more people pushed into poverty by health care costs than almost any other country. I think they could do a lot more good by targeting their spending.

On the subject of FGM, I find it interesting that most of the western world is rightly against the practice, yet we practice genital mutilation on almost every one of our male children everyday. How is this any different? If you are going to refer to sex re-assignment surgery as mutilation, shouldn't we cast circumcision in the same light?

With regards to transsexualism, one of the biggest issues is the polar nature of our society. All of us are supposed to fit into societal roles. Those roles are clearly defined and society is uncomfortable with existence outside those clearly defined roles. Presenting oneself as a member of the opposite gender, or passing, is the ultimate pursuit of many transgendered individuals. Most don't want to be different. They want to be normal. Does re-assignment surgery get them there? I would imagine that varies from person to person.

As a libertarian myself, I'm against most governement funded endeavors. I don't believe it should pay for re-assignment surgery, but I don't believe the government should pay out welfare or many other social programs. However if someone feels they need re-assigment surgery they are free to finance it themselves.

Even if it were a "birth defect", does that mean we are obligated to fix it? I was born skinny everywhere but my stomach, which means I have an increased chance of heart problems and disease. Also, it looks unappealing to me. So am I entitled to have other people pay for my liposuction surgery?

But then, I am against all publicly-funded health care, not just publicly-funded vanity surgeries. I work in a public high school, and I see the way some of these tenured teachers act...I don't think I'd want a surgeon who was only going through the motions until he retired. Sorry - off topic.

However, my opinion is, I will stay in my country and co-pay for my own health care, but if Brazil wants to establish this health plan, it is up to the Brazilians.

Well transsexuals have to go through several mental health professionals to verify their condition already. Only in that case should this type of surgery be subsidized by a health care system. But no, there's no simple test that's going to reveal something like this, just like there's no objective test to reveal if your brain structure is depressed.

But really, what person that's 100% male is really going to get his junk messed with on a whim?

Very true.

I'm a transsexual and - although it's easy for me to say this because I'm not poor - I'm ambivalent torwards governments funding sex-change surgery. There are distinct advantages to the private market, especially in this area.

I find it interesting though that whenever this funding issue comes up, people focus on the gential surgery. That's only one medical procedure. I wonder if the convesation would be different if we were discussing strictly hormones, or breast removal and hysterectomy.

Mr. Saletan - I was going to lambaste you for failing to do research prior to equating reassignment surgery to mutilation; however, since you seem willing to hold a conversation and listen, I'll be as civil as I can be.

enigmatose is correct in that chromosomes are far from the deciding factor in how an individual develops - hormones have a much larger part. For example, there are intersex individuals who are chromosomally XY, but who have a mutation in their androgen receptor which makes them unable to process testosterone; depending on the degree of insensitivity, they may end up with anywhere from mostly female reproductive systems to being anatomically male but infertile.

Development is especially sensitive to very minute concentrations of hormones, and if things end up being slightly off during one phase, it might cause regions of the brain to develop female while the remainder of the body develops male.

Saletan:

OK, that's a good start. Next question: Can we establish objective tests for determining whether your brain size/structure is M or F? If you're willing to refuse coverage to an applicant who claims he's F but falls within the M range on the test, I'm willing to go along.

I assume the biggest problem here is that M and F hugely overlap.

Currently, the research suggests that the BSTc region of the brain is one of the regions that may be correlated with gender identity; however, the size measurements can currently only be performed post-mortem upon preserved brain tissue.

It's honestly very difficult to define or measure what constitutes a "male" or "female" brain; however, gender identity is something which is deep-seated and cannot be changed or suppressed. Also, gender is a spectrum rather than binary categories, so drawing an arbitrary cutoff would be extremely suspect from a scientific point of view.

The current measure that most reassignment surgeons use in deciding whether or not to perform surgery is, "is this person experiencing significant distress from having mismatched gender identity and genitals?"; they rely on the professional opinion of two separate psychologists in order to make their determination. Additionally, most surgeons require their patients to have spent at least a year of being treated with hormones and a year of living in the intended gender to serve as a check to make sure that they are certain that they will be happier as their intended gender. The psychologists ensure that there is no problem that would cause someone to incorrectly believe that his or her gender identity is at odds with his or her anatomy - it's a very common practice in medicine to perform a differential diagnosis for other conditions as well in order to eliminate alternatives.

I really strongly would urge you, however, to retract the words you used comparing the surgery itself to mutilation, without even bringing the question of whether taxpayers should pay for it into the question. The surgery (at least in the male to female direction) does not remove any function whatsoever; it uses virtually all of the previously existing tissue and creates fully functional labia, vagina, and clitoris.

I had my surgery performed about three months ago, and I've honestly been the happiest that I have ever been in my life ever since. Reassignment surgery is very closely screened, and is the only cure for severe disagreement between one's gender identity and body.

In terms of the cost of surgery:

It really sucked for me to pay $17,000 out of pocket. I wish that my insurer had covered it. In fact, the argument can be very convincingly made that had I NOT had the surgery, I would have needed to be on antidepressants for the rest of my life in order to be at all productive and functional. The coverage of therapy and antidepressants is much, much less debated in terms of coverage, but their cost would certainly be far greater over a lifetime than paying for the medically necessary surgery I needed. It so happens that I was fortunate enough to be able to earn the money, but not everyone has the same earning power, and adequate medical care is a right that should not be reserved only for the very wealthy.

In summary, I urge you to uphold the standard of journalism that Slate has set and to thoroughly do research before voicing opinions that are not substantiated by scientific and medical fact - especially when your column's theme is specifically scientific in nature.

My name is Darlie, I am transsexual and a truly hardcore conservative (not to be mistaken for the faux conservative known as a Neocon) . I started working put myself through school when my father died when I was 13 , I have never taken unemployment or welfare , I have paid up to 90,000 a year in taxes and paid for all my surgery , drugs and care myself. How about you Saletan, could you start by listing your employment and government payoffs ? That would be nice because what is the point of having this conversation with a leech on society. Next , I would love it if you funded research into verifying actual transsexuals. I also would love if this was grouped together with eliminating the "OTHER" mentally ill from the government payrolls. I see no reason to pay for mentally ill people like people who drink, smoke, ride in fast cars, fast boats or airplanes, who eat fattening things,skateboard , sky dive , snow mobile ,ride motorcycles etc etc ..... because to put yourself at risk for no reason means you must be insane correct ? Yes or no will do. Oh , and by the way , I don't think I should have to be giving tax exemptions to lunatics who think they see god , do you ? I mean , if that isn't the most ridiculous form of human mental illness , I don't know what is. Now let me tell you why you think this is mutilation. Your life is your genitals. You think that you don't exist beyond your erections. Oh you and the IRS call it cosmetic trying to keep that surgery from being deducted as needed surgery but ..... it terrifies you more than losing a limb. In fact , given a choice , you would lose the limb rather than your boy bits. Cosmetic ! Lol! It is your life! And you can't imagine not needing it. All you guys , raise your hand if you think having your penis removed is just "cosmetic". If you and the IRS could just get together on this and agree it's cosmetic then we won't need a couple years of therapy to have it done. You would be saving us a fortune! I'm looking forward to your reply.

Why are you so hung up on using the word "mutilate" to describe genital reassignment surgery? Your insistence on that term makes it impossible to believe that your stance on this procedure is really due to your libertarian individualism or any other intellectual analysis; it makes it clear that you're afraid of us.

You join the voices of countless other transphobic people who've used similar terms whenever they wanted to dehumanize us; it used to be common for gay and lesbian people to call us "mutilated transvestites" whenever they wanted to exclude us from the queer community. The popularity of "mutilated" isn't accidental: it suggests our genitals are deformed after we get surgery and that we've turned ourselves into freaks. Nothing could be more offensive or further from the truth. You need to use language that treats us with respect before anyone in our community will respect you or anything you have to say.

-Alice

Those of you who think mutilation is inherently pejorative should talk to the more articulate self-mutilators (<link>). They'd find your some of your comments a bit, er, phobic.

You are twisting semantics. I know that you meant the dictionary meaning when you first wrote it. I know most of your readers interpreted it that way.

<link>

Main Entry: mu·ti·late
Pronunciation: 'myü-t&-"lAt

1 : to cut up or alter radically so as to make imperfect <the child mutilated the book with his scissors>
2 : to cut off or permanently destroy a limb or essential part of : cripple
synonym see maim

<link>

Main Entry: maim
Pronunciation: 'mAm
synonyms MAIM, CRIPPLE, MUTILATE, BATTER, MANGLE mean to injure so severely as to cause lasting damage. MAIM implies the loss or injury of a bodily member through violence <maimed by a shark>. CRIPPLE implies the loss or serious impairment of an arm or leg <crippled for life in an accident>. MUTILATE implies the cutting off or removal of an essential part of a person or thing thereby impairing its completeness, beauty, or function <a tree mutilated by inept pruning>.

I've made a good faith effort to try to point out your ignorance about this issue and try to better educate, but if you're unwilling to listen, then there isn't much of a point, is there?

Others seem to have mutilation covered, so I will tackle a different angle.

There seems to be an impression in the world that SRS is a casual thing that people wake up one day and do. That someone decides 'Huh, I want to change my genitals!' and that's that. The reality is far, far removed from this.

As it is, there is a huge humilation factor in the process. Very, very few surgeons with take you without notes from psychologists and doctors, evidence of passing the so-called 'real life test', in which you are expected to live 'full time' as a woman, and personal interviews with them or their staff.

Getting to the point of being 'allowed' SRS is measured in years. I was a fairly quick example; I had my SRS two and a half years after deciding to transition, and about a good 20 years after I realised I was 'wrong'.

I have known for as long as I can remember that my body is wrong. As young as age 5, I was a girl in my dreams. I lived in a relatively conservative family, and learned early on to hide my difference, but it was there.

It was, for me, /very/ much a physical thing. I've never particularly wanted to wear 'women's' clothing (though I do love the freedom to do so!), or wear pink, or other 'socially feminine' things. But I also knew I wasn't supposed to have the anatomy I did.

In my early teens I found the internet, and outlets for my growing unhappiness. Role playing games where I could be a girl, people who understood, information on it all.

Things went from there, but that's not really relevant. I didn't decide until I was 28 to actually risk transitioning. And yes, it is a risk! First you have to learn to 'pass', which some people do better than others. I am lucky; while I was not attractive as a boy, and am not now, I was also very androgynous.

For the first 3-6 months, I got 'sir' more often than 'ma'am'. Every time I went out was a little more humilation on the fire. I came out to my family, risking losing the people who mean the most to me in the world. I started taking hormones, which can have side effects like any other medication.

People looked at me strange. People got hostile. I got called a freak, and worse.

To say that surgery was 'mutilation', or cosmetic, or unneeded, or unwarrented, is stupid. Who would put themselves through the hell you have to go through to /get/ SRS if it wasn't needed?

SRS as a surgery has a very,very high 'success' rate. Almost noone who gets it regrets it. If /any/ other surgery had the results SRS does, it would be called out as a miracle.

Should insurance and/or public health cover it? Yes. Just as it should cover a broken leg, or an STD, or childbirth, or alzeihmers, or cancer.

What, in your mind, /is/ worthy of coverage? You trivialise this with 'subjective feelings of identity'. I call BS on that. You shouldn't get treatment of your broken toe because of your subjective feelings of pain. You shouldn't get treatment with depression or anxiety because of your subjective feelings of sadness. You shouldn't get help with a heart attack, either, since, y'know, it's not the public's fault your heart seized.

Where do you draw the line?

SRS is not trivial. It is not casual. It is not easy. It is not cheap. My transition to date has probably cost about $50k since I started, $30k of that being getting SRS. I'll be in debt for the next half decade at least, and that's not counting the fact that I have 4 outfits that fit (I've lost 60 pounds since transitioning. Amazing what not hating your body can do for you!), or that I still need electrolysis, or that my reaction to hormones as been mild and the only way I will ever have a proportionate figure is probably implants, which again have to come out of my pocket.

Anyway, I've gone on enough about this. I doubt it will make a difference, but I hope this at least shows a couple people that this is /not/ a trivial thing or a bit of vanity or perversion.