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Cristan Williams

Fact Checking Janice Raymond: The NCHCT Report

By Cristan Williams
@cristanwilliams

 

It has long been asserted that the iconic TERF opinion leader, Janice Raymond, played a part in bringing an end to the public and private coverage of transgender medical care, resulting in measurable death and suffering within the trans community. Unsurprisingly, Raymond rejects any assertion that she has blood on her hands. Over on TheTERFs.com, Raymond objects to the following assertion:

‚ÄúIt was only after the NCHCT [National Center for Health Care Technology] published Raymond‚Äôs bigotry in 1980 that the US government reversed course in 1981 and took up Raymond‚Äôs views and rhetoric. Raymond‚Äôs hate became the government‚Äôs stance. Raymond ‚Äď a Catholic ethicist, not a clinician ‚Äď was the architect of the anti-trans stance the US government adopted in the 1980s‚ÄĚ

She asserts that the above is fiction. Here are her basic points:

  1. The government never funded any trans medical care, therefore her contribution didn’t actually change funding of trans care.
  2. Her contribution to the report in question was simply one voice among many.
  3. Her contribution was small.
  4. She’s not a Catholic ethicist.

To support these claims, Raymond asserts:

  • ‚ÄúHistorically federal and state aid has not funded transsexual treatment for anyone so it could not be ‚Äėeliminated‚Äô by any paper I or anyone else wrote.‚ÄĚ
  • ‚ÄúMy paper was never published by the NCHCT but was treated as a consultative paper among many that were solicited from other experts and groups at the same time.‚ÄĚ
  • ‚ÄúWhenever such papers are commissioned, there are multiple individuals and organizations also requested to submit reviews.‚ÄĚ
  • ‚ÄúOthers asked in 1980 to present opinions were the-then National Institute of Mental Health of the Alcohol, Drug Abuse, and Mental Health Administration who performed a literature review and provided an opinion of the efficacy of sex change surgery.‚ÄĚ Plus several other organizations.
  • “I was not then, nor am I now, a Catholic.”
  • ‚ÄúThe NCHCT took these submissions and published a report on ‚ÄúTranssexual Surgery‚ÄĚ in its 1981 Assessment Report Series.‚ÄĚ
  • ‚ÄúMy findings were quoted neutrally in one sentence of the 15-page final report. ‘Some have held that it would be preferable to modify society‚Äôs sex role expectations of men and women than to modify either the body or the mind of individuals to fit these expectations. (Raymond 1980).’ This was the only part of my paper that made it into the published report.‚ÄĚ
  • ‚ÄúThe conclusion of the report was that transsexual surgery is ‘controversial’ and ‘must be considered experimental.’‚ÄĚ

This article¬†is an evidence-based review of Raymond’s assertions. I muck¬†through Raymond’s obfuscation and half-truths to get down to the reality behind her claims.

Raymond’s rhetorical¬†sleight-of-hand

First of all, you need to know that there wasn’t just¬†one, but TWO reports:

  1. The report the National Center for Health Care Technology (NCHCT) commissioned Raymond to write; and,
  2. The report from the Office of Health Technology Assessment (OHTA) issued which drew upon Raymond’s work to support one of three basic fact claims it made about trans care.

Next, you need to know that the OHTA was, for a brief time, a section of the NCHCT. The NCHCT existed as its own entity for just 3 years and its duties were shifted to OHTA in 1981. NCHCT made 75 coverage recommendations during those 3 years and a recommendation about trans care was one of them. If one wanted to muddy the water, one could technically assert that her research was merely one source from which the NCHCT pulled when writing their report on trans care because, in 1981, NCHCT and OHTA was basically one organization. The fact that gets lost is that, in reality, the NCHCT commissioned ONLY ONE trans ethics report: the one Raymond wrote. It was the OHTA Report – not the NCHCT Report – that drew from the research bodies Raymond claims. Raymond claims that ‚ÄúMy paper was never published by the NCHCT but was treated as a consultative paper among many that were solicited from other experts and groups at the same time.‚ÄĚ Yes, her report was indeed used in this manner for the OHTA report. However, NCHCT commissioned reports ‚Äď such as Raymond‚Äôs NCHCT report – were available, in their entirety, and these reports were targeted to very specific groups. Moreover, Raymond‚Äôs report ‚Äď one of only 2 governmental reports on the efficacy of trans care at the time – was later available through the OHTA after the NCHCT shut its doors.

NCHCT seems to have specifically sought out Raymond because, as the OHTA later said, the NCHCT ‚Äúwas directed to consider broadly the implications of new and existing medical technologies, including their legal, ethical and social aspects.‚ÄĚ[1] As you will see, Raymond‚Äôs work alone represented the whole of NCHCT‚Äôs consideration regarding¬†the ‚Äúethical and social aspects‚ÄĚ of trans care.

To make an informed judgment about the impact of the OHTA and NCHCT reports, you need to know who¬†the NCHCT asserted its audience to be. The reports coming out of the NCHCT, including OHTA reports, were targeted to the following ‚Äúprimary users‚ÄĚ:

‚ÄúProviders, generally; physicians; acute facility administrators; long-term care facility administrators; other care givers; health/medical professional associations; consumer associations; employers; unions and other employee organizations; third party payers; government regulators; biomedical researchers; public policy-makers, legislators; policy research organizations; Federal health programs.‚ÄĚ[2]

Note that these reports were intended to be primarily used by groups such as federal health programs, third-party payers, policy-makers, and legislators. Indeed, NCHCT reports are cited by third-party payers as being a metric they‚Äôve used[3] to determine coverage and, specific to OHTA reports, the NCHCT said that ‚Äú[t]hird party reimbursers, providers, hospital administrators, health policy-makers and analysts, and government officials have reported using the assessments as well.‚ÄĚ

The evidence supports that NCHCT and OHTA reports were used by numerous groups including both public and private insurers for¬†determining the efficacy of healthcare technologies. In fact, both public and private insurers were, according to the NCHCT, two of their ‚Äúprimary intended users.‚ÄĚ

‚ÄúCongress passed legislation in 1978 establishing the National Center for Health Care Technology (NCHCT) to conduct, sponsor, and coordinate the assessment of new and existing technologies. The government’s Health Care Financing Administration, as well as other third-party payers used the information generated by the NCHCT to help in making decisions about coverage and payments. However, the NCHCT was abolished in 1981. The office of Health Technology Assessment, based in the National Center for Health Services Research of the U.S. Public Health Service, has assumed some functions of the NCHCT.‚ÄĚ[4]

Consider the reach NCHCT and OHTA reports had:

“With the creation of NCHCT and the development of a formal assessment process, these third-party payers began to request the results of evaluations. These insurance carriers included both those in the government (CHAMPUS and the Federal Employees Health Benefits Program) and those in the private sector such as Mutual of Omaha, Nationwide, Travelers, Aetna Life and Casualty, ¬†Connecticut General Life, Equitable Life Assurance Society, John Hancock Mutual Life, Metropolitan Life, Prudential Life, and Lincoln National Life.” [5]

About the OHTA report, Raymond claimed that it made two primary assertions and she is mostly correct. As she noted, the OHTA report asserted that trans medical care was: A.) ‚Äúcontroversial;‚ÄĚ and, B.) ‚Äúmust be considered experimental.‚ÄĚShe neglected to note that the third claim was that trans care was ‚Äúexpensive.‚ÄĚ

The overall OHTA report was broken down into the following six sections, four of which references Raymond’s work.

  • Description: An overview of what it means, clinically speaking, to be a transsexual and what treatment is available.
  • Review of Available Information: A review of peer-reviewed papers and books concerning medical outcomes, noting that the medical research from the 60s and 70s wasn‚Äôt very sophisticated.
  • Discussion: Assertions about what is observable about trans care. (Raymond)
  • Summary: Statements of fact (Raymond)
  • Acknowledgment: Noting the major sources which informed the report (Raymond)
  • Bibliography: Noting the cited materials (Raymond)

The ‚ÄúDiscussion‚ÄĚ section of the OHTA report covers three topical areas:

  1. One paragraph supporting the claim that trans care is ‚Äúexperimental‚ÄĚ
  2. One paragraph supporting the claim that trans care is ‚Äúcontroversial‚ÄĚ
  3. Four paragraphs supporting the claim that trans care is ‚Äúexpensive.‚ÄĚ

The OHTA report drew upon several sources to support these three claims. In determining that trans care was ‚Äúexperimental,‚ÄĚ the OHTA relied on numerous sources, none of which were Raymond. To support the claim that trans care was ‚Äúexpensive,‚ÄĚ the OHTA report relied upon a¬†source that wasn’t¬†Raymond. To support the ‚Äúcontroversial‚ÄĚ claim, the OHTA relied upon just two sources, one of which was Raymond. The following is the ‚ÄúDiscussion‚ÄĚ paragraph which supports the ‚Äúcontroversial‚ÄĚ claim:

‚ÄúOver and above the medical and scientific issues, it would also appear that transsexual surgery is controversial in our society. For example, Thomas Szasz has asked whether an old person who desires to be young suffers from the “disease” of being a “transchronological” or does the poor person who wants to be rich suffer from the “disease” of being a “transeconomical?” (Szasz 1979). Some have held that it would be preferable to modify society’s sex role expectations of men and women¬†than to modify either the body or the mind of individuals to fit those expectations. (Raymond 1980).‚ÄĚ

At no point prior to this does the report claim that trans care is ‚Äúcontroversial.‚ÄĚ

Raymond asserts that hers was but one source the OHTA considered and this is true, very strictly speaking. The OHTA report relied upon Raymond‚Äôs NCHCT report for the heavy lifting to support the ‚Äúcontroversy‚ÄĚ claim and the other piece of ‚Äúresearch‚ÄĚ the OHTA considered was‚Ķ wait for it‚Ķ A review of Raymond‚Äôs 1979 book, The Transsexual Empire, The Making of the She-Male that Raymond pointed out¬†in her NCHCT report. Therefore, strictly speaking, Raymond wasn‚Äôt the only source the OHTA considered when supporting their ‚Äúcontroversial‚ÄĚ claim. However, it is false to assert that Raymond‚Äôs work wasn‚Äôt the only source informing the claim that trans care was ‚Äúcontroversial.‚ÄĚ It was her book, The Transsexual Empire and her NCHCT report alone that informed the opinions leading the OHTA to conclude that trans care was ‚Äúcontroversial.‚ÄĚ

The OHTA report made three claims and Raymond‚Äôs work supported 1/3 of the report‚Äôs claims. In order to measure Raymond‚Äôs influence in the OHTA report, one might use the ‚ÄúAcknowledgement‚ÄĚ section of the report as a metric. The ONLY researcher to be acknowledged personally was Raymond. While the report specifically acknowledges numerous organizations, only Raymond was¬†singled out as being a researcher who‚Äôs contribution was worthy of explicit acknowledgment. To drive this point home, here‚Äôs the Acknowledgement section:

The National Institute of Mental Health of the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) performed a literature review and provided an opinion on the efficacy of sex change surgery for transsexualism. The information database on transsexual surgery prepared under contract for HCFA by Health Information Designs, Inc., and a National Center for Health Care Technology commissioned paper on the social and ethical aspects of transexual surgery by Janice G. Raymond, Ph.D., of Hampshire College, University of Massachusetts, were used in this assessment.

Health Information Designs, Inc., contacted the American College of Obstetricians and Gynecologists, American College of Surgeons, American Medical Association, American Psychiatric Association, American Psychological Association, and the American Society of Plastic and Reconstructive Surgeons. None of these organizations had an official position on transsexual surgery when surveyed in 1979.

Here, we find the three major contributors to this report: ADAMHA, Janice Raymond, and Health Information Designs. The ADAMHA looked at ‚Äúefficacy,‚ÄĚ which informed the ‚Äúexperimental‚ÄĚ claim. Raymond looked at the ‚Äúsocial‚ÄĚ and ‚Äúethical‚ÄĚ issues, which informed the ‚Äúcontroversial‚ÄĚ claim, which left the Health Information Designs company to provide¬†the cost analysis, supporting the ‚Äúexpensive‚ÄĚ claim.

Recall that OHTA said the NCHCT ‚Äúwas directed to consider broadly the implications of new and existing medical technologies, including their legal, ethical and social aspects.‚ÄĚ The OHTA report explicitly claims that Raymond‚Äôs NCHCT report functioned to support this purpose.

Echoing the ‚ÄúDiscussion‚ÄĚ section, the OHTA report makes three assertions in the ‚ÄúSummary‚ÄĚ section:

  1. Trans care is controversial.
  2. Trans care is experimental.
  3. Trans care is expensive.

The very first line of the ‚ÄúSummary‚ÄĚ section reads, ‚ÄúTranssexual surgery for sex reassignment of transsexuals is controversial.‚ÄĚ The section then makes four statements about the ‚Äúexperimental‚ÄĚ nature of trans care: ‚ÄúThere is a lack of well-controlled, long-term studies of the safety and effectiveness of the surgical procedures and attendant therapies for transsexualism. There is evidence of a high rate of serious complications of these surgical procedures. The safety and effectiveness of transsexual surgery as a treatment of transsexualism is not proven and is questioned. Therefore, transsexual surgery must be considered still experimental.‚ÄĚ The last line asserts that trans care is expensive: ‚ÄúFinally, although transsexualism seems to be relatively rare, the use of surgery in its treatment can be very expensive (per case).‚ÄĚ

Raymond claims that her NCHCT report was cited only once. She goes on to assert that numerous organizations were consulted. Her claims are technically true. The reality her claim erases is that her anti-trans hyperbole was responsible for a third of the OHTA‚Äôs findings. After obfuscating her fingerprints on the report, Raymond asserts, ‚ÄúTo give my submission credit for these conclusions is fatuous in the context of reading a report that was obviously informed by multiple sources.‚ÄĚ Again, this is technically true. If one dismisses the reality that a third of the report‚Äôs findings were supported by her work alone and therefore choose to only consider that one of the two citations supporting the ‚Äúcontroversy‚ÄĚ claim is Raymond herself (even though the second citation came out of¬†Raymond’s NCHCT report), then one could technically make that claim without totally lying. However, no matter how Raymond would like to spin it, the ‚Äúresearch‚ÄĚ supporting a third of the claims made by the OHTA report was¬†informed by Raymond‚Äôs work. Nonetheless, Raymond goes on to assert, ‚Äúmy 1980 paper on the social and ethical aspects of transsexual surgery did not feature influentially in the NCHCT‚Äôs report [here, Raymond is speaking of the OHTA report, not her NCHCT report] concluding that transsexual surgery was controversial and experimental.‚ÄĚ While there is little evidence to support the claim that Raymond‚Äôs views were used to support the OHTA‚Äôs assertion that trans care was “expensive” and/or ‚Äúexperimental,‚ÄĚ it was her work alone that was used to support the claim that it was ‚Äúcontroversial.‚ÄĚ

Lastly, Raymond asserted that the government commissioned her to write an ethics report on trans care because public funds hadn‚Äôt been paying for trans care.¬† Think about that assertion for just a few seconds. The government paid her to study a procedure it had decided not to fund. In fact, according to Raymond, no public monies had been used up until that point. Raymond asserts, ‚ÄúHistorically federal and state aid has not funded transsexual treatment for anyone so it could not be ‚Äėeliminated‚Äô by any paper I or anyone else wrote.‚ÄĚ Before I get to the truthfulness of this assertion, I want to review one of the primary reasons NCHCT/OHTA issued reports:

‚ÄúPoor dissemination of information from good technology assessment contributes to the rising costs of health care. Conversely, the Blue Cross and Blue Shield Association, for instance, estimates that its Medical Necessity Program has saved premium payers as much as 500 million dollars in its first five years. Studies at UCLA and Harvard commissioned by the NCHCT estimated that 100 to 200 million dollars per year could be saved by the Medicare program if NCHCT recommendations not to reimburse for six technologies were followed (Harvard, 1981; UCLA, 1981). Also, in the training of health professionals, the lack of coordinated dissemination of valid technology assessment information means that curricula quite possibly will not include current clinical knowledge.‚ÄĚ[6]

‚ÄúThe tremendous economic burden associated with health care poses major dilemmas for providers, patients, third-party payers, industry, health planners, and policymakers in and out of the government. Many measures are under consideration to deal with the problems. Recognizing that health care technology and its application, while not the sole cause of the rise in health care costs, were significant factors in the increase, the Congress passed legislation in 1978 to establish the National Center for Health Care Technology (NCHCT) to serve as a focus for examining selected new and existing technologies with the aim of assembling the best current evidence and information about their clinical effectiveness and cost, and the social and ethical issues associated with their use.‚ÄĚ[7]

Upon the demise of the NCHCT by a¬†Republican-controlled government, Democrats attempted to revive NCHCT because the reports resulted in measurable cost cutting. After the NCHCT was shut down, Rep. Henry Waxman, Democrat of California and chairman of the House Energy and Commerce Subcommittee on Health and the Environment, introduced a bill (N.H. 2350) to reauthorize the NCHCT and Sen. Edward Kennedy, Democrat of Massachusetts and ranking minority member of the Senate Committee on Labor and Human Resources, introduced a bill (S. 814) to “control health’s escalating costs.” Clearly, NCHCT was in the business of addressing costs associated with health care.

Raymond would have you believe that NCHCT used its “paltry”[8] budget to study trans care because trans care was a cost wholly unknown to public insurance programs. ¬†Raymond asserts, ‚Äúthe NCHCT report [did not] ‚Äėeliminate‚Äô federal and state funding for transsexual surgery because funding was not approved for this purpose long before my paper was written.‚ÄĚ

The University of Texas Medical Branch (UTMB) began seeing trans clients in the 1960s and developed a trans care program in the early 1970s. Dr. Cole was a resident in 1975 and I briefly interviewed him for this story. He was aware of indigent trans people being served in the early days of that program. ‚ÄúI believe that they did the lab and medical work that way.‚ÄĚ He noted that for some of the early patients, their surgical costs were covered. ‚ÄúSome of those surgeries were totally covered.‚ÄĚ I also interviewed Dr. Meyer, a founder of the UTMB trans program and past president of WPATH. He too noted that indigent trans clients were served. ‚ÄúI remember one particular patient who was on Medicare and that patient was approved for genital surgery.‚ÄĚ He went on to say that this client received publicly insured trans services through UTMB‚Äôs program prior to Raymond‚Äôs NCHCT paper. ‚ÄúThis would have been in the late 70s, maybe 1978 or 79.”

In evaluating Raymond’s claim that the NCHCT used its paltry resources to review trans care because trans care wasn’t supported by public funding at the time, we can measure the value of her claim against the historical record and the NCHCT’s goal of cutting costs directly associated with Medicare. Raymond is either mistaken in her belief that trans care wasn’t supported by public insurance programs or is obfuscating the effect of her work had trans community’s access to care.

Fact Checking:

BSRaymond‚Äôs assertion: ‚ÄúIn 1981, the U.S. government did not ‘reverse course’ by withdrawing federal funds available for transsexual treatment and surgery. Historically federal and state aid has not funded transsexual treatment for anyone so it could not be ‘eliminated’ by any paper I or anyone else wrote.‚ÄĚ

Reality: The fact is that prior to 1981, gender programs had used public funding to support trans care. Ending this practice after the OHTA Report was issued was a reversal of this practice.  Raymond’s assertion is false.

BSRaymond‚Äôs assertion: ‚ÄúThe U.S. NCHCT commissioned this paper, among other reasons, to determine ‚Äėwhether specific procedures are ‚Äėreasonable and necessary‚Äô and thus appropriate for reimbursement by Medicare.‚Äô Whenever such papers are commissioned, there are multiple individuals and organizations also requested to submit reviews. Others asked in 1980 to present opinions were the-then National Institute of Mental Health of the Alcohol, Drug Abuse, and Mental Health Administration who performed a literature review and provided an opinion of the efficacy of sex change surgery. The American College of Obstetricians and Gynecologists, American College of Surgeons, American Medical Association, American Psychiatric Association, American Psychological Association, and the American Society of Plastic and Reconstructive Surgeons were also asked to provide reviews.‚ÄĚ

Reality: The NCHCT commissioned Raymond to write a report exploring a very specific issue. As¬†noted in the OHTA report, Raymond was commissioned to write a paper “on the social and ethical aspects of transexual surgery.‚ÄĚ She was commissioned to do that because the OHTA itself stated that it was directed to consider the implications of medical technologies, including their ‚Äúethical and social aspects.‚ÄĚ Raymond wasn‚Äôt asked to give her anti-trans opinions because she wrote a book about costs associated with trans care, nor did she write a review of the efficacy of trans care. The NCHCT used Raymond’s work because she wrote a TERF book on the social and ethical aspects of trans care. Raymond seems to be saying that many sources were sought to address the topic she addressed. Such conclusions are false. Moreover, Raymond seems to claim that organizations such as the “American College of Obstetricians and Gynecologists, American College of Surgeons…” were contracted by the¬†NCHCT to produce new analysis, which then contributed to the¬†NCHCT. Such representations are false. The¬†OHTA report merely states that these groups didn’t have an official position on trans care.

BSRaymond‚Äôs assertion: ‚ÄúThe NCHCT took these submissions and published a report on ‘Transsexual Surgery’ in its 1981¬†Assessment Report Series. My findings were quoted neutrally in one sentence of the 15-page final report. ‘Some have held that it would be preferable to modify society‚Äôs sex role expectations of men and women than to modify either the body or the mind of individuals to fit these expectations. (Raymond 1980).’ This was the only part of my paper that made it into the published report. The conclusion of the report was that transsexual surgery is ‘controversial’ and ‘must be considered experimental.’ To give my submission credit for these conclusions is fatuous in the context of reading a report that was obviously informed by multiple sources.‚ÄĚ

Reality: The NCHCT commissioned Raymond’s¬†paper to both support and inform only 1 of 3 conclusions found in the OHTA Report. The three conclusions were:

  1. Trans care is controversial. (Raymond)
  2. Trans care is experimental. (Not Raymond)
  3. Trans care is expensive. (Not Raymond)

It was ONLY Raymond‚Äôs work that informed the assertion that trans care was socially and ethically ‚Äúcontroversial.‚ÄĚ The OHTA used Raymond‚Äôs NCHCT paper and a NY Times review of Raymond‚Äôs book –which Raymond included in her NCHCT commissioned paper– to support this claim. While, Raymond asserts that giving her ‚Äúsubmission credit for these conclusions is fatuous,‚ÄĚ Raymond‚Äôs work, nonetheless, directly supported and informed a third of the conclusions found in the OHTA‚Äôs report on trans care. Moreover, Raymond‚Äôs work explicitly made the OHTA‚Äôs report possible because they were required to assert a position on the ‚Äúsocial and ethical‚ÄĚ aspects of trans care.

half-truthRaymond‚Äôs assertion: ‚ÄúI was not then, nor am I now, a Catholic.‚ÄĚ

Reality: Raymond is responding to the claim that, ‚Äú… Raymond ‚Äď a Catholic ethicist, not a clinician ‚Äď was‚Ķ‚ÄĚ This claim was, at the time, viewed as being true because Raymond attended seminary, was awarded an MA in theology in 1971 and joined the Sisters of Mercy ‚Äď a Catholic order ‚Äď and writes about her time as a Sister in her book, A Passion For Friends. However, Raymond did not claim that she was never a ‚ÄúCatholic ethicist;‚ÄĚ rather, she merely claims that both now and when she wrote her NCHCT paper, she was not a ‚ÄúCatholic ethicist.‚ÄĚ While this claim is true, one might be forgiven for concluding from Raymond’s statement that she was never a Catholic, trained in theological¬†ethics, or a Catholic nun.

About the Fact Check rating:

A¬†statement that’s completely true.A statement¬†designed to hide some pertinent facts.A misleading statement designed to hide the truth.
truehalf-truthBS

Raymond’s bloody hands

It is a demonstrable fact that Raymond’s work substantially influenced the OHTA Report. Moreover, Raymond’s NCHCT report was available to the OHTA/NCHCT target audience. We know that¬†OHTA/NCHCT reports were absolutely used to determine both public and private insurance coverage. We know that prior to Raymond’s work with¬†OHTA/NCHCT, trans care –including surgery–¬†¬†was indeed¬†funded through public insurance. We also know that prior to the¬†OHTA/NCHCT trans reports, private insurance companies were losing court cases regarding excluding coverage of trans care. We know that after the OHTA/NCHCT trans reports,¬†private insurance companies –a population designed to be primary OHTA/NCHCT information consumers– had an official government review of trans care to back up their exclusions of trans care for years to come.

We also know something else about the outcome of these types of policies:

One of the most severe results of denying coverage of treatments to transgender insureds that are available to non-transgender insureds is suicidal ideation and attempts.

A meta-analysis published in 2010 by Murad, et al., of patients who received currently excluded treatments demonstrated that there was a significant decrease in suicidality post-treatment. The average reduction was from 30 percent pretreatment to 8 percent post-treatment.

De Cuypere, et al., reported that the rate of suicide attempts dropped dramatically from 29.3 percent to 5.1 percent after receiving medical and surgical treatment among Dutch patients treated from 1986-2001.

According to Dr. Ryan Gorton, ‚ÄúIn a cross-sectional study of 141 transgender patients, Kuiper and Cohen-Kittenis found that after medical intervention and treatments, suicide fell from 19 percent to zero percent in transgender men and from 24 percent to 6 percent in transgender women.‚ÄĚ

Clements-Nolle, et al., studied the predictors of suicide among over 500 transgender men and women in a sample from San Francisco and found a prevalence of suicide attempts of 32 percent. In this study, the strongest predictor associated with the risk of suicide was gender-based discrimination which included ‚Äúproblems getting health or medical services due to their gender identity or presentation.‚ÄĚ According to Gorton, ‚ÄúNotably, this gender-based discrimination was a more reliable predictor of suicide than depression, history of alcohol/drug abuse treatment, physical victimization, or sexual assault.‚ÄĚ

These studies provide overwhelming evidence that removing discriminatory barriers to treatment results in significantly lower suicide rates. –¬†State of California Department of Insurance, 2012

We can safely conclude that the policies Raymond helped create contributed to the death and suffering of trans people. When confronted by such charges, Raymond asserts:

I did not then or now believe that federal or state funds should subsidize transsexual surgery for anyone because, in my view, it is unnecessary surgery and medical mutilation. I would argue the same about healthy limb amputations now justified in some of the clinical literature for those designated as suffering from a Body Integrity Identity Disorder (BIID). BIID subjects have threatened suicide or taken matters into their own hands if deprived of the surgery, as have transgendered [sic] persons who desperately pursue hormones and surgery.

In other words, even if trans people die because they can’t access care, that isn’t important. Obfuscating her callousness, she conflates the trans experience with the experience of wishing to have entire body sections removed or to become paralyzed. It was with the perspective of a mind such as this that the US Government backed a medical standard resulting in the inability of trans people to access transition-related medical care, demonstrably resulting in the death and suffering of trans people.

The Smoking Gun

As noted above, Raymond’s contribution to the¬†OHTA‚Äôs report was to support 1/3 of the report’s findings. Raymond’s contribution satisfied the congressional rule that the report must consider ethical issues related to medical technologies. It was Raymond’s¬†NCHCT report that allowed the¬†OHTA report to assert that trans medical care was ethically controversial. Therefore, exclusionary health policies which appeal Raymond’s to “controversial” claim constitute Raymond’s ethical¬†fingerprint. Consider the following:

1.) In 2013, the¬†Department of Health and Human Services’ (HHS)¬†Departmental Appeals Board reversed the HHS rule banning trans medical care. In the document, HHS reviews the reason HHS had originally banned trans care:

HHS Appeals Board Decision, page 3

The HHS Appeals Board Decision continues (NOTE: “NCD” = National Coverage Determination[9]):

The NCD directly quotes from or paraphrases portions of an 11-page report that the former National Center for Health Care Technology (NCHCT) of the HHS Public Health¬†Service (PHS) issued in 1981, titled ‚ÄúEvaluation of Transsexual Surgery.”¬†NCD Record 4 Service (PHS) issued in 1981, titled ‚ÄúEvaluation of Transsexual Surgery.‚ÄĚ. The NCHCT forwarded its 1981 report to officials of the Health Care Financing Administration (HCFA), now called CMS, with a memorandum dated May 6, 1981 recommending ‚Äúthat transsexual surgery not be covered by Medicare at this time.‚ÄĚ. HCFA issued the NCD language as part of its Coverage Issues Manual of coverage instructions for Medicare contractors; CMS published the manual in the Federal Register on August 21, 1989.

The NCD record also includes three letters that the Transsexual Rights Committee of the American Civil Liberties Union (ACLU) of Southern California sent to HCFA in April 1982 disagreeing with HCFA‚Äôs non-coverage policy. The ACLU letters enclose letters and affidavits from physicians and therapists supporting the medical necessity of transsexual surgery and taking issue with the non-coverage determination. On May 11, 1982, a HCFA Physicians Panel, which had referred the issue of coverage to the NCHCT in September 1980, recommended against referring the ACLU‚Äôs submissions to PHS, ‚Äúon the basis that it does not contain information about new clinical studies or other medical and scientific evidence sufficiently substantive to justify reopening the previous PHS assessment.‚ÄĚ The NCHCT‚Äôs May 6, 1981 memorandum, the 1981 NCHCT report, and the notes of the HCFA Physicians Panel meeting on May 11, 1982, are the materials in the NCD record containing analysis by HCFA or PHS of the issue of Medicare coverage of transsexual¬†surgery. Although the NCD was not issued until 1989, it is clear that the NCD was based on the NCHCT report and memorandum from 1981.¬†

In other words, HHS has concluded that it was the 1981 report that HHS used to issue an NCD banning trans services. [10]

2.) Recall that Raymond’s controversial claim is the very first sentence in HHS’ review of how and why trans services were banned from public health insurance policies. What follows is from a¬†2009 United Health policy banning¬†trans services:

Note that the exclusionary language in this private insurance policy¬†is the same word-for-word language as the exclusionary language from HHS’ public insurance policy, as quoted by HHS:

 

This then is the smoking gun. Here we have a private insurer quoting word-for-word a governmental policy which relied on Raymond for 1/3 of its findings; specifically, it’s finding that trans care is ethically controversial. Thus we can easily follow the timeline for Raymond’s part in the decimation of trans care in America:

From Raymond’s Transsexual Empire (1979)

1979:¬†Raymond writes in her book, “I contend that the problem of transsexualism would best be served by morally mandating it out of existence.‚ÄĚ

1980: Raymond is contracted by the NCHCT to write a report on the ethics of trans medical care because the NCHCT must, by law, report on the ethical implications of medical technologies. In Raymond’s 1980 NCHCT report footnotes,¬†her second citation reads, “See Thomas Szasz, review of THE TRANSSEXUAL EMPIRE: THE MAKING OF THE SHE-MALE by Janice G. Raymond, New York Times Book Review, June 10, 1979, p. 11.”

1981: Raymond’s NCHCT report and Raymond’s own citation are used to make the “ethical” case that trans medical care should be excluded from public insurance policies because it’s “controversial.” Thomas Szasz’s review of Raymond’s 1979 book (in which she calls for trans care to be morally mandated out of existence) is also cited after Raymond drew attention to it in her NCHCT report.

1989: The National Coverage Determination (NCD) to exclude trans care from public insurance is published in the Federal Register.

1989 – 2013: Trans medical care is routinely excluded from both public and private health insurance plans.

2012: The State of California finds that barriers to trans health care “was a more reliable predictor of suicide than depression, history of alcohol/drug abuse treatment, physical victimization, or sexual assault.”

2013: HHS finds that the 1981 rationale for excluding trans care is “no longer reasonable.”

2014: Private healthcare providers, citing HHS’s ruling, begin rolling back their trans healthcare exclusions. Janice Raymond sets up a webpage to publicly¬†diminish her role in the revocation of trans health care (to which this fact-checking article is a response). Raymond clarifies that when,¬†in 1979 she wrote, “I contend that the problem of transsexualism would best be served by morally mandating it out of existence,” she meant, “that I want to eliminate the medical and social systems that support transsexualism…”

NOTES: 

[1] OHTA, Health Care Technology And Its Assessment In Eight Countries, 1994, p 292

[2] National Academy of Sciences, National Center For Health Services Research and Health Care Technology Assessment Office of Health Technology Assessment, 1988

[3] Note: The third party payer that I could find who specifically cited OHTA reports in a lawsuit was Blue Cross Blue Shield. Later in this paper, a governmental review of NCHCT’s work will specifically note that Blue Cross Blue Shield used NCHCT/OHTA reports in making decisions about private insurance coverage.

[4] Institute of Medicine’s A Consortium for Assessing Medical Technology: Planning Study Report, 11/1983, p 3

[5] Seymour Perry, M.D., Health Affairs,  8/1982, p 124

[6] Institute of Medicine’s A Consortium for Assessing Medical Technology: Planning Study Report, 11/1983, p 5

[7] Seymour Perry, M.D., Health Affairs,  8/1982, p 123

[8] ‚ÄúEqually dedicated to evaluating novel biomedical technology‚ÄĒthereby rationalizing decisions about appropriate use‚ÄĒwas the National Center for Health Care Technology (NCHCT), established in the 1970s within the Public Health Service. This agency, too, received paltry funding and was dismantled by the Reagan administration. Replacing it was the Office of Health Technology Assessment (OHTA), with even less financial support.‚ÄĚ – Carolyn L. Wiener, The Elusive Quest: Accountability in Hospitals, p 42

[9] “An NCD is ‚Äúa determination by the Secretary [of Health and Human Services] with respect to whether or not a particular item or service is covered nationally under [title XVIII (Medicare)].‚ÄĚ Social Security Act (Act) ¬ß 1869(f)(1)(B) (42 U.S.C. ¬ß 1395ff(f)(1)(B)).1 NCDs are issued by CMS, apply nationally, and are binding at all levels of administrative review of Medicare claims.” – Page 1 of HHS Appeals Board Decision, 2013

[10]¬†To be pedantic, I need to note that what HHS calls the 1981 “NCHCT Report” I call the 1981 OHTA report because by the end of¬†1981, the NCHCT had become the OHTA. The 1981 report states that it’s the product of the OHTA. If I had to guess, HHS refers to it as the¬†“NCHCT Report” because when the report was being written, OHTA was still NCHCT and it’s easier to just refer to the organization¬†as NCHCT instead of having to go into how and why a report which began life as an NCHCT report was published¬†as an OHTA report.



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Cristan Williams is a trans historian and pioneer in addressing the practical needs of underserved communities. She started the first trans homeless shelter in Texas and co-founded the first federally funded housing-first homeless program, pioneered affordable health care for trans people in the Houston area, won the right for trans people to change their gender on Texas ID prior to surgery, started numerous trans social service programs and founded the Transgender Center as well as the Transgender Archives. She has published short stories, academic chapters and papers, and numerous articles for both print and digital magazines. She received numerous awards for her advocacy and has presented at universities throughout the nation, served on several governmental committees and CBO boards, is the Editor of the TransAdvocate, and is a founding board member of the Transgender Foundation of America and the Bee Busy Wellness Center.

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