The cost of relinquishing U.S. citizenship

If a U.S. national becomes a citizen of a country that does not permit dual citizenship, then they must pay the State Department $2350 to relinquish their U.S. citizenship:

http://www.forbes.com/sites/robertwood/2015/10/23/u-s-has-worlds-highest-fee-to-renounce-citizenship/#77aad6516568

This is by far the most expensive relinquishment fee in the world, more than double that of Jamaica, which is in 2nd place. In some countries, the process is even free.

It appears part of the reason for this is a belief among many Americans that no one in their right mind would want to give up their U.S. citizenship for another citizenship in another country, unless they were wealthy fat cats trying to avoid taxes. However, there are many reasons why someone would want to relinquish their citizenship, as well as the tax obligations it presents (as, other than Eritrea, no other country in the world requires its citizens to pay taxes if they live and work abroad). They include:

- People who have no connection to the United States other than they were born there, their place of birth making them citizens. (But why should they have to pay taxes to the U.S. if they have no interest in the country?)

- People who have moved overseas and are seeking to become a citizen of another country, because that's their home now, where their life is, and they plan to live out the rest of their lives there, but the country requires them to give up all other citizenship.

There are plenty of middle-class and otherwise less wealthy people who fall into the above categories, making the $2350 fee a real burden for them, on top of otherwise having to report their income every year and pay the IRS the difference.

I can understand the desire to go after wealthy fat cats who go offshore to avoid taxes, but a $2350 fee isn't likely to be much of a burden to them,--it's pocket change for them--but I think this is a circumstance where there are unintended consequences and policy-makers should take that into account, and let go of the hubris that no one but a wealthy fat cat could reasonably want to become a citizen of a country other than the U.S.

Why the United States has not adopted the metric system: White supremacy

Much has been made of the failure of the U.S. to convert to the metric system. Proponents have complained that failure to metricate has resulted in economic harm to this country and that further failure will continue to do so, failure to metricate has resulted in many mistakes, and so on and so forth. I agree with these statements, but why won't the U.S. convert?

Opponents have argued that the short-term cost of converting is too high, it would undo our culture, we don't want to, etc. I'm not going to go into details here.

However, I have had the distinct sense that something has been missing from all this debate. I think the main cause of not metricating is simpler, and goes back to why the United States has been so slow to adopt social programs such as universal health care and other such programs: White supremacy.

Of course, you may be asking, what does this have to do with race? I'd say it has everything to do with race. I came across this interesting paragraph on teammetric.org on American students' poor grasp of measurement:

Stated plainly, measurement is “the domain of least relative competence for U.S. students” (Barrett 2012). This finding is supported at the district, county, and state levels. In the U.S., weights and measures are generally learned in the study of spatial measurement (Smith 2012). Extensive evidence has shown, and continues to show, that U.S. students’ grasp of spatial measurement—length, area, and volume—is poor, despite the wealth of spatial experience and knowledge they develop and use outside of school. This evidence includes analyses from the National Assessment of Educational Progress (NAEP) of performance by 4th, 8th, and 12th graders (e.g., Blume, Galindo, & Walcott, 2007); cross-national comparisons such as TIMSS (National Center of Education Statistics, 1997); and smaller research studies that have focused on students’ patterns of reasoning, e.g., studies indicating that students often confuse area and perimeter (Chappell & Thompson, 1999; Woodward & Byrd, 1983). Where the NAEP results show low performance in the entire U.S. population, performance is weakest for low-income and minority students, who lag further behind white students in measurement than in any other content area (Lubienski & Crockett, 2007).

http://www.teammetric.org/measurement/

To me, the most interesting sentence of all is the last one: Students of color lag further behind white students than they do in any other subject, and this is a subject on which American students as a whole do poorly. It appears that people of color are being hurt by this policy of not metricating more than white people are. Think also of the economic effects. Historically, who has born the brunt of poor economic planning in this country? People of color. Thanks to this, white people have generally been able to escape the consequences of such bad decision-making. And who is it that dominates the discussions on metrication? White people. For the proponents, this question often seems like little more than an intellectual exercise engaged in by hobbyists, while for opponents, not converting has become a point of pride for this country, a belief that we are special as a nation. They can afford to argue this issue in such a detached manner because they are not so negatively affected.

The same has been true with health care and a number of other social programs. This is something that has been built into this country for centuries, the elite dividing and conquering the working class on the subject of race, the divide hampering much economic progress in this country.

I suggest that people of color begin to find their voice on this issue and discuss their experiences with our weights and measures and failure to metricate; plus, their experiences with receiving a poor education in measurement, as shown above.

EDIT: TL;DR: Basically, white people are buffeted from the negative effects of bad economic policies, including the policy of not metricating, causing them not to see the need to change. People of color bear the brunt of such negative effects, but on the subject of metrication in the U.S. discussion has been dominated by white people, largely middle-class white people. In addition, there is evidence that students of color lag behind white students in measurement more than in any other area of education, and American students as a whole lag the rest of the world more in measurement than in any other area; failure to metricate likely contributes, because teaching metric units only is far more straightforward than teaching dual units or only customary (as that is a complex collection of units), such straightforwardness saving classroom time and allowing students to get to actual practice. I hope people of color can find their voice on this issue and speak out about how these policies affect them.

Further reading

http://www.vox.com/2014/5/29/5758542/time-for-the-US-to-use-the-metric-system

https://thoughtsandmemory.wordpress.com/essays-2/origins-of-white-supremacy/

http://rationalwiki.org/wiki/Metric_system

https://milebehind.wordpress.com/

The DSM-5 versus popular misconceptions on transgenderism and gender dysphoria

That being transgender is a mental illness.

The DSM-5 does not agree. The problem, according to the DSM-5, is not the gender identity or transgenderism "per se," but the distress that may accompany it in the form of gender dysphoria. From the p. 451 of the DSM-5 in the section on "Gender Dysphoria" (emphases in original):

Gender dysphoria refers to the distress that may accompany the incongruence between one's experienced or expressed gender and one's assigned gender. Although not all individuals will experience distress as a result of such incongruence, many are distressed if the desired physical interventions by means of hormones and/or surgery are not available. The current term is more descriptive than the previous DSM-IV term gender identity disorder and focuses on dysphoria as the clinical problem, not identity per se.

That believing you are of another gender means you are delusional.

 This is not true either. In the differential diagnosis of gender dysphoria with "[s]chizophrenia and other psychotic disorders" (p. 458):

In schizophrenia, there may rarely be delusions of belonging to some other gender. In the absence of psychotic symptoms, insistence by an individual with gender dysphoria that he or she is of some other gender is not considered a delusion. Schizophrenia (or other psychotic disorders) and gender dysphoria may co-occur.

That gender dysphoria is just like body dysmorphic disorder and should be treated as such.

The DSM-5 lists these as distinct conditions, and provides assistance for the differential diagnosis between the two (p. 458):

An individual with body dysmorphic disorder focuses on the alteration or removal of a specific body part because it is perceived as abnormally formed, not because it represents a repudiated assigned gender. When an individual's presentation meets criteria both for gender dysphoria and body dysmorphic disorder, both diagnoses can be given. Individuals wishing to have a healthy limb amputated (termed by some body integrity identity disorder) because it makes them feel more "complete" usually do not wish to change gender, but rather desire to live as an amputee or a disabled person. 

Looking at every plan for 2016 available to me at healthcare.gov (I live in Shelby County, TN): Blanket exclusions for transgender health care

Introduction

In the USA, it has long been the case that coverage for transgender health care has been specifically excluded, meaning indigent patients simply get nothing. There have been signs of a change in the past few years, with more and more employers adding coverage to their group plans, Medicare's exclusion of sex reassignment surgery being overturned, state regulators requiring coverage, and a proposed rule from the feds that may require coverage.

We've still got a long way to go, however, and for the past few years when it comes to coverage for sex reassignment surgery I've been on the outside looking in as none the plans I've been on have added coverage. Basically, the changes made so far do not seem to have reached me and blanket exclusions of transgender health care appear to remain common. It seems to still be common industry practice to exclude coverage of transgender health care.

There has been a lot of confusion, however, about the current status of coverage in this country. Some people think the feds have already outlawed these blanket exclusions, which is not true. Lots of people seem to think there is a "medical necessity" exception to these blanket exclusions, which is largely not true.

To rectify this confusion and to show the extent of the problem, I wanted to document all the health plans that are available to me for 2016 for these blanket exclusions of transgender health care on the healthcare.gov exchange, to help determine how things are on the ground. I live in Shelby County, TN, so I will reference all the plans available to me. Open enrollment is not until November 1, but on healthcare.gov plan previews for 2016 have already become available. I found 67 plans sold by a total of 4 health insurance companies, BlueCross BlueShield of Tennessee, Cigna Healthcare, Humana, and UnitedHealthcare. This is what I found.

BlueCross BlueShield of Tennessee

This is the coverage policy for gender reassignment:

https://www.bcbst.com/mpmanual/Gender_Reassignment.htm

Note this statement, which says gender reassignment may be excluded (all caps in original):

THIS GENDER REASSIGNMENT ADMINISTRATIVE POLICY ONLY APPLIES TO PLANS/POLICIES THAT EXPRESSLY COVER GENDER REASSIGNMENT.  THIS ADMINISTRATIVE POLICY DOES NOT PERTAIN TO, NOR APPLY TO, ANY OTHER INSURANCE POLICIES OR HEALTH PLANS ISSUED BY BLUECROSS BLUESHIELD OF TENNESSEE, INC. THROUGH ANY OTHER MEANS, EITHER PUBLIC OR PRIVATE.

I was able to find the full policies for the BCBST plans:

http://www.bcbst.com/sbc/plans.do?plan=marketplace-health-insurance-plans&year=2016

On p. 72 of all policies except the Multi-state policies, this exclusion can be found under "V. Reconstructive Surgery" -> "2. Exclusions":

c. Surgeries and related services to change gender (transgender Surgery) [sic].

Interestingly, mental health care and hormones do not seem to be excluded, because of the way this policy is put under reconstructive surgery. I am currently on a BCBST plan and I've gotten psychotherapy and hormones covered even with the providers telling me they are billing GID/gender dysphoria.

On the Multi-state policies, the exact same exclusion can be found on p. 71 (which is specified). Here is a list of all plans, along with each plan's policy document:

 Bronze B07E, Network E (Bronze PPO) Plan ID: 14002TN0330049
http://www.bcbst.com/sbc/2016/127600/B07E_Policy.pdf

 Bronze B02E, Network E (Bronze PPO) Plan ID: 14002TN0330044
http://www.bcbst.com/sbc/2016/127600/B02E_Policy.pdf

 Bronze B07S, Network S (Bronze PPO) Plan ID: 14002TN0330051
http://www.bcbst.com/sbc/2016/127600/B07S_Policy.pdf

 Bronze B02S, Network S (Bronze PPO) Plan ID: 14002TN0330041  
http://www.bcbst.com/sbc/2016/127600/B02S_Policy.pdf

 Bronze B04E, Network E (Bronze PPO) Plan ID: 14002TN0330045 
http://www.bcbst.com/sbc/2016/127600/B04E_Policy.pdf

 Bronze B01E, Network E (Bronze PPO) Plan ID: 14002TN0330043 
http://www.bcbst.com/sbc/2016/127600/B01E_Policy.pdf

 Bronze B04S, Network S (Bronze PPO) Plan ID: 14002TN0330042 
http://www.bcbst.com/sbc/2016/127600/B04S_Policy.pdf

 Silver S04E, Network E (Silver PPO) Plan ID: 14002TN0330013 
http://www.bcbst.com/sbc/2016/127600/S04E_Policy.pdf

 Bronze B01S, Network S (Bronze PPO) Plan ID: 14002TN0330040 
http://www.bcbst.com/sbc/2016/127600/B01S_Policy.pdf

 Silver S02E, Network E (Silver PPO) Plan ID: 14002TN0330012 
http://www.bcbst.com/sbc/2016/127600/S02E_Policy.pdf

 Silver S09E, Network E (Silver PPO) Plan ID: 14002TN0330016 
http://www.bcbst.com/sbc/2016/127600/S09E_Policy.pdf

 Silver S19E, Network E (Silver PPO) Plan ID: 14002TN0330031 
http://www.bcbst.com/sbc/2016/127600/S19E_Policy.pdf

 Silver S16E, Network E (Silver PPO) Plan ID: 14002TN0330020
http://www.bcbst.com/sbc/2016/127600/S16E_Policy.pdf

 Bronze B04P, Network P, a Multi-State Plan (Bronze PPO) Plan ID: 14002TN0330034 
http://www.bcbst.com/sbc/2016/127600/B04P_Policy.pdf (exclusion on p. 71)

 Silver S04S, Network S (Silver PPO) Plan ID: 14002TN0330003 
http://www.bcbst.com/sbc/2016/127600/S04S_Policy.pdf

 Silver S08E, Network E (Silver PPO) Plan ID: 14002TN0330015 
http://www.bcbst.com/sbc/2016/127600/S08E_Policy.pdf

 Silver S02S, Network S (Silver PPO) Plan ID: 14002TN0330002 
http://www.bcbst.com/sbc/2016/127600/S02S_Policy.pdf

 Silver S09S, Network S (Silver PPO) Plan ID: 14002TN0330006 
http://www.bcbst.com/sbc/2016/127600/S09S_Policy.pdf

 Silver S19S, Network S (Silver PPO) Plan ID: 14002TN0330033 
http://www.bcbst.com/sbc/2016/127600/S19S_Policy.pdf

 Silver S01E, Network E (Silver PPO) Plan ID: 14002TN0330011 
http://www.bcbst.com/sbc/2016/127600/S01E_Policy.pdf

 Silver S11E, Network E (Silver PPO) Plan ID: 14002TN0330017 
http://www.bcbst.com/sbc/2016/127600/S11E_Policy.pdf

 Silver S12E, Network E (Silver PPO) Plan ID: 14002TN0330018 
http://www.bcbst.com/sbc/2016/127600/S12E_Policy.pdf

 Silver S16S, Network S (Silver PPO) Plan ID: 14002TN0330010 
http://www.bcbst.com/sbc/2016/127600/S16S_Policy.pdf

 Silver S14E, Network E (Silver PPO) Plan ID: 14002TN0330019 
http://www.bcbst.com/sbc/2016/127600/S14E_Policy.pdf

 Silver S08S, Network S (Silver PPO) Plan ID: 14002TN0330005 
http://www.bcbst.com/sbc/2016/127600/S08S_Policy.pdf

Silver S09P, Network P, a Multi-State Plan (Silver PPO) Plan ID: 14002TN0330035
http://www.bcbst.com/sbc/2016/127600/S09P_Policy.pdf (exclusion on p. 71)

 Silver S01S, Network S (Silver PPO) Plan ID: 14002TN0330001 
http://www.bcbst.com/sbc/2016/127600/S01S_Policy.pdf

 Silver S11S, Network S (Silver PPO) Plan ID: 14002TN0330007 
http://www.bcbst.com/sbc/2016/127600/S11S_Policy.pdf

 Silver S12S, Network S (Silver PPO) Plan ID: 14002TN0330008 
http://www.bcbst.com/sbc/2016/127600/S12S_Policy.pdf

 Silver S14S, Network S (Silver PPO) Plan ID: 14002TN0330009 
http://www.bcbst.com/sbc/2016/127600/S14S_Policy.pdf

 Gold G10E, Network E (Gold PPO) Plan ID: 14002TN0330060 
http://www.bcbst.com/sbc/2016/127600/G10E_Policy.pdf

 Silver S11P, Network P, a Multi-State Plan (Silver PPO) Plan ID: 14002TN0330036  
http://www.bcbst.com/sbc/2016/127600/S11P_Policy.pdf (exclusion on p. 71)

 Silver S12P, Network P, a Multi-State Plan (Silver PPO) Plan ID: 14002TN0330037 
http://www.bcbst.com/sbc/2016/127600/S12P_Policy.pdf (exclusion on p.71)

 Gold G08E, Network E (Gold PPO) Plan ID: 14002TN0330059 
http://www.bcbst.com/sbc/2016/127600/G08E_Policy.pdf

 Gold G01E, Network E (Gold PPO) Plan ID: 14002TN0330057 
http://www.bcbst.com/sbc/2016/127600/G01E_Policy.pdf

 Gold G10S, Network S (Gold PPO) Plan ID: 14002TN0330055 
http://www.bcbst.com/sbc/2016/127600/G10S_Policy.pdf

 Gold G11E, Network E (Gold PPO) Plan ID: 14002TN0330061 
http://www.bcbst.com/sbc/2016/127600/G11E_Policy.pdf

 Gold G08S, Network S (Gold PPO) Plan ID: 14002TN0330054 
http://www.bcbst.com/sbc/2016/127600/G08S_Policy.pdf

 Gold G06E, Network E (Gold PPO) Plan ID: 14002TN0330058 
http://www.bcbst.com/sbc/2016/127600/G06E_Policy.pdf

 Gold G01S, Network S (Gold PPO) Plan ID: 14002TN0330052 
http://www.bcbst.com/sbc/2016/127600/G01S_Policy.pdf

 Gold G11S, Network S (Gold PPO) Plan ID: 14002TN0330056 
http://www.bcbst.com/sbc/2016/127600/G11S_Policy.pdf

 Gold G08P, Network P, a Multi-State Plan (Gold PPO) Plan ID: 14002TN0330038 
http://www.bcbst.com/sbc/2016/127600/G08P_Policy.pdf (exclusion on p. 71)

 Gold G06S, Network S (Gold PPO) Plan ID: 14002TN0330053 
http://www.bcbst.com/sbc/2016/127600/G06S_Policy.pdf

 Platinum P01E, Network E (Platinum PPO) Plan ID: 14002TN0330070 
http://www.bcbst.com/sbc/2016/127600/P01E_Policy.pdf

 Platinum P02E, Network E (Platinum PPO) Plan ID: 14002TN0330071 
http://www.bcbst.com/sbc/2016/127600/P02E_Policy.pdf

 Gold G11P, Network P, a Multi-State Plan (Gold PPO) Plan ID: 14002TN0330039 
http://www.bcbst.com/sbc/2016/127600/G11P_Policy.pdf (exclusion on p. 71)

 Platinum P03E, Network E (Platinum PPO) Plan ID: 14002TN0330072 
http://www.bcbst.com/sbc/2016/127600/P03E_Policy.pdf

 Platinum P01S, Network S (Platinum PPO) Plan ID: 14002TN0330067 
http://www.bcbst.com/sbc/2016/127600/P01S_Policy.pdf

 Platinum P02S, Network S (Platinum PPO) Plan ID: 14002TN0330068 
http://www.bcbst.com/sbc/2016/127600/P02S_Policy.pdf

 Platinum P03S, Network S (Platinum PPO) Plan ID: 14002TN0330069 
http://www.bcbst.com/sbc/2016/127600/P03S_Policy.pdf

Cigna Healthcare

Here is Cigna's coverage policy for gender reassignment surgery:

https://cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/medical/mm_0266_coveragepositioncriteria_gender_reassignment_surgery.pdf#__utma=149406063.1761118586.1402926656.1407417514.1407421027.129&__utmb=149406063.1.10.1407421027&__utmc=149406063&__utmx=-&__utmz=149406063.1407342625.125.16.utmcsr=americansformarriageequality.org|utmccn=%28referral%29|utmcmd=referral|utmcct=/&__utmv=-&__utmk=260421901

Naturally, this statement is found in the policy, informing the reader that there may be plans that exclude gender reassignment surgery:

For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document.

On p. 7 of the plan brochures, under "2016 PLAN EXCLUSIONS AND LIMITATIONS" (emphases in original):

Procedures, surgery or treatments to change characteristics of the body to those of the opposite sex, including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery. This also includes any medical, surgical or psychiatric treatment or study related to sex change.

This exclusion was found for all of the plans on the exchange. Here are all the plans and their plan brochures (with the exclusion on p. 7):

 Cigna Health Savings 6000 (Bronze PPO) Plan ID: 99248TN0020001 
http://www.cigna.com/assets/docs/individual-and-families/2016/medical/tn/884853-sob-cigna-health-savings-bronze-6000-memphis-tn.pdf

 Cigna Health Flex 6400 (Bronze PPO) Plan ID: 99248TN0020002 
http://www.cigna.com/assets/docs/individual-and-families/2016/medical/tn/884857-sob-cigna-health-flex-bronze-6400-memphis-tn.pdf

 Cigna Health Savings 2700 (Silver PPO) Plan ID: 99248TN0020003 
http://www.cigna.com/assets/docs/individual-and-families/2016/medical/tn/884861-sob-cigna-health-savings-silver-2700-memphis-tn.pdf

 Cigna Health Flex 4000 (Silver PPO) Plan ID: 99248TN0020005 
http://www.cigna.com/assets/docs/individual-and-families/2016/medical/tn/884875-sob-cigna-health-flex-silver-4000-memphis-tn.pdf

 Cigna Health Flex 2250 (Silver PPO) Plan ID: 99248TN0020004 
http://www.cigna.com/assets/docs/individual-and-families/2016/medical/tn/884868-sob-cigna-health-flex-silver-2250-memphis-tn.pdf

 Cigna Health Flex 1200 (Gold PPO) Plan ID: 99248TN0020007 
http://www.cigna.com/assets/docs/individual-and-families/2016/medical/tn/884882-sob-cigna-health-flex-gold-1200-memphis-tn.pdf

Humana

I could not find a coverage policy for Humana.

The exclusion is under "Limitations and exclusions (things that are not covered)" -> "Pregnancy and sexuality services" on p. 7 of the plan brochures:

Sex change services and sexual dysfunction.

Here are all the plans with the plan brochures:

 Humana Bronze 6450/Memphis PPOx (Bronze PPO) Plan ID: 82120TN0600022
http://apps.humana.com/marketing/documents.asp?file=2593526

 Humana Silver 3800/Memphis PPOx (Silver PPO) Plan ID: 82120TN0600023 
http://apps.humana.com/marketing/documents.asp?file=2624258

 Humana Gold 2250/Memphis PPOx (Gold PPO) Plan ID: 82120TN0600024 
http://apps.humana.com/marketing/documents.asp?file=2593552
 

UnitedHealthcare

Here is the coverage policy for gender dysphoria:

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Gender_Identity_Disorder_CD.pdf

Again, this sort of statement appears, saying that transgender health care may be excluded:

In the event of a conflict, the enrollee's specific benefit document supersedes these guidelines.

I could not find the exclusion in the plan brochures, but on p. 12 of the plan brochures, it says that the list is not complete, directing the reader to this link, which contains sample medical policies for individual and family plans in each state:

http://www.uhc.com/individual-and-family/medical-policy

I selected Tennessee:

http://www.uhc.com/content/dam/uhcdotcom/en/iex-marketplace/sample-medical-policy/TN-UHCIC-Compass_Plus-Policy.pdf

I found the exclusion under "Section 2: Exclusions and Limitations" -> "M. Procedures and Treatments" on p. 31:

Sex transformation operations and other services.

It was not clear whether this Compass Plus Policy for Tennessee applied to 2015 or 2016, so I called UnitedHealthcare up. They said that the information about 2016 will be updated this Sunday, November 1, when next year's enrollment begins.

Here is the plan brochure which is used by all the plans:

http://www.uhc.com/iex/doc?id=tn0035&st=tn

Here is a list of all the plans sold by UnitedHealthcare on the healthcare.gov exchange for me in Shelby County, TN:

 Bronze Compass 4200 (Bronze POS) Plan ID: 69443TN0070008

 Bronze Compass HSA 5200 (Bronze POS) Plan ID: 69443TN0070006 

 Bronze Compass 6400 (Bronze POS) Plan ID: 69443TN0070007

 Silver Compass 5000 (Silver POS) Plan ID: 69443TN0070005

 Silver Compass HSA 3600 (Silver POS) Plan ID: 69443TN0070004 

 Silver Compass 2000 (Silver POS) Plan ID: 69443TN0070003 

 Gold Compass HSA 1600 (Gold POS) Plan ID: 69443TN0070002 

 Gold Compass 1000 (Gold POS) Plan ID: 69443TN0070001 

I will update the information on UnitedHealthcare on Sunday. 

Update: Sunday came, and the same information was still there. It is currently there as of this edit.

Conclusion

As you can see, the market for individual health insurance on the healthcare.gov exchange for Shelby County, Tennessee is not very friendly to trans people. All plans I could verify I have shown have blanket exclusions for transgender health care, at least for surgery, with no exception or qualification. There is no statement qualifying the exclusions that says "unless it is medically necessary" in any of these plans This is surprising in light of the companies, except Humana, being lauded for selling plans that cover transgender health care. Apparently, none of those plans are being sold in Shelby County, Tennessee, though I need to still verify the story for UnitedHealthcare. People reading about insurers providing coverage should keep in mind that such coverage decisions may not apply to any of the plans available to them.

Back in 2014, Medicare overturned its exclusion of sex reassignment surgery and it was said that private insurers and Medicaid take their cue from Medicare on what to cover:

http://www.huffingtonpost.com/2014/05/30/medicare-transgender-gender-surgery_n_5418899.html

Unfortunately, when it comes to the plans available on the exchange in Shelby County, TN for 2016, it seems they've not taken any such cue.

I wanted to document these blanket exclusions to show everybody that these exclusions remain the norm, and depending on which way UnitedHealthcare turns, they seem to be ubiquitous, with no plan avaialble that provides coverage. BCBST possibly covering psychotherapy and hormones is helpful, but it does not go nearly far enough. Some employers cover it and some states require coverage, but the effects of such decisions are limited in their extent, as this map shows for states requiring coverage:

http://www.transequality.org/issues/resources/map-state-health-insurance-rules

I would like to see others document the exclusions in their health plans. I think if we have thorough documentation of this, we can make a difference with regulators such as HHS, who may or may not understand the full extent of these blanket exclusions. Documenting these facts should bring the full extent of these exclusions into view, showing that contrary to popular misconception insurers in most states remain free to make blanket exclusions on transgender health care, and they have largely NOT changed their practice.

If you want, you may document exclusions on your own blog or in the comments section of this blog post. I intend to send this post to HHS once I receive confirmation on UnitedHealthcare's policies, and I intend to share it with various LGBT and trans groups. Let's all do the same!

Update: I have used this to comment on the proposed regulation.

The true cost of denial

Today, I am on disability. A couple years ago, however, I was fairly productive, working at a job that paid low but was good and reasonably matched my skills. What happened? What happened is that something that people think will save money and not have any extra costs actually ended up costing everybody a lot.

I am a transgender woman who has been for most of my life very dysphoric regarding my male genitals. For me, sex reassignment surgery is a necessary solution. I worked at a decent job and the insurance at the job actually paid for my hormones, even though they were billed GID. I wanted to try to get surgery. This was something that had worried me for a long time, because I was not sure if I could ever get it. Some might say, Why don't you save for it? But my issues are that I am very poor when it comes to working over long time horizons and even simple organization. I knew that unless I made a hefty income, I would probably never be able to save for it. It would have to be made available to me, like it is to people in many other developed countries.

The summary plan description for my medical plan mentioned nary a word regarding sex reassignment They were paying for hormones, so I wondered: Would they pay for my surgery? I called them up and they said that nothing regarding transgender care was supposed to be covered, which I didn't buy because they covered the hormones under the diagnosis of GID. I had checked that with my endo's billing office and they confirmed that yup they were billing GID. I spoke to the corporate office, since this medical plan was self-funded, and they said what's on the summary plan description was supposed to be complete. Wanting to make sure, I spoke to a lawyer from a trans advocacy organization and he said yup they should cover surgery as long as it is medically necessary.

I found a surgeon to perform the surgery who was in network and then worked with my mental health professionals. I got surgery letters from both my psychiatrist and my psychologist. I also doubled-checked with my endo and he thought I was good to go, and also wrote me a letter. I submitted the letters and my insurance information to the surgeon's office in February, 2014. It would take a while before the info came back as there was a back log at the surgeon's office.

On April 24, 2014, I got the notice back that it was denied. This was very heavy for me and I began to feel incredible anger and despair. I started becoming unable to work and had to take leave. The lawyer helped me out more, but I eventually got the message that surgery was excluded, and they gave me the page from the Evidence of Coverage that said that. They had simply neglected to mention that on the summary plan description. My motivation was zero at this point. I would go on leave for good in August 2014. I applied for Social Security Disability and was awarded it. I also began receiving long-term disability for work. But before I could qualify for all these, I had to run up my credit card for my living expenses. I had to spend time in a mental hospital later that year.

Today, I am still on disability and have incredible resentment over the lack of access to surgery, not because I was unqualified but because I didn't have the money and no one else would pay for it. There is lingering anger that comes and goes, but for the most part I have become quite indifferent to life. Currently, I am in a state of anger which has motivated me to write this, but it will probably give way to indifference again at some point. Basically I am not working and I am receiving payments so I can live. My productive capacity was quashed and now quite a bit of money has to be paid to me. How much does that cost, all you out there who complain that sex reassignment surgery would cost too much to cover?

Self-disorders selectively aggregate in the schizophrenia spectrum

Self-disorders, according to the Examination of Anomalous Self-Experience (EASE) which is a semi-structured interview manual published in Psychopathology in 2005 that measures self-disorders both qualitatively and quantitatively, all share in common "a disorder or deficiency in the sense of being a subject, a self-coinciding center of action, thought, and experience" (footnote removed). A link to the manual's full-text can be found here:

http://www.nordlandssykehuset.no/getfile.php/NLSH_bilde%20og%20filarkiv/Pulsen/Kunnskapsbygging/Tekstfiler/EASE.pdf

Self-disorders include dissociative-like phenomena, disturbances in the stream of consciousness, transitive phenomena, and changes in basic world experience. Studies have shown self-disorders to selectively aggregate in the schizophrenia spectrum:

RESULTS:

Basic self-disturbance scores [measured using the EASE] were significantly higher in patients with a schizophrenia spectrum diagnosis (n = 8) compared to patients with other psychotic diagnoses (n = 8).

CONCLUSIONS:

The findings are consistent with previous work indicating that the disturbance of the basic sense of self is more characteristic of schizophrenia spectrum psychosis than other psychoses. This may have implications for early diagnosis, clinical formulation and intervention.

http://www.ncbi.nlm.nih.gov/pubmed/22759705

This shows that people with schizotypal disorder have similar levels of self-disturbance to non-affective psychosis (mostly schizophrenia patients), showing significant differences from other mental illness (which includes patients with bipolar disorder, major depression, OCD, etc.):

http://schizophreniabulletin.oxfordjournals.org/content/40/6/1300.long

Another study with the same result (emphasis added):

Converging evidence indicates that self-disorders (SDs) selectively aggregate in schizophrenia spectrum conditions. The aim of this study was to test the discriminatory power of SDs with respect to schizophrenia and nonschizophrenia spectrum psychosis at first treatment contact. SDs were assessed in 91 patients referred for first treatment through the Examination of Anomalous Self-experience (EASE) instrument. Diagnoses, symptoms severity, and function were assessed using the Structural Clinical Interview for the DSM-IV, Structured Clinical Interview for the Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, Young Mania Rating Scale, and Global Assessment of Functioning-Split Version. Most patients found it highly relevant to talk about SDs. EASE total score critically discriminated between schizophrenia, bipolar psychosis, and other psychoses. The EASE total score was the only clinical measure that showed a significant and robust association with the diagnosis of schizophrenia. Systematic exploration of anomalous self-experiences could improve differential diagnosis in first-treatment patients.

http://www.ncbi.nlm.nih.gov/pubmed/22759943

Though we don't have the full-text here, another article cites the above article, saying that it shows that when controlling for the "symptomatic PANSS dimensions" self-disorders still aggregated in the schizophrenia spectrum:

The difference in SD between schizophrenia and bipolar psychosis, observed by Haug et al,59 remained significant after controlling for the differences between the groups on the symptomatic PANSS dimensions.

http://schizophreniabulletin.oxfordjournals.org/content/40/6/1300.full

This shows another look at the unity between schizophrenia and schizotypal disorder in terms of self-disorders, again showing their "selective aggregation" in the schizophrenia spectrum:

http://schizophreniabulletin.oxfordjournals.org/content/37/2/344.long

This study uses a pre-EASE scale of self-disorders and compares them in "residual schizophrenia and psychotic bipolar illness in remission":

Results: Diagnosis of schizophrenia was associated with elevated scores on the scales measuring perplexity (loss of immediate meaning), disorders of perception, disorders of self-awareness, and marginally so, disorders of cognition.

http://onlinelibrary.wiley.com/doi/10.1034/j.1600-0447.2003.00105.x/abstract;jsessionid=D2717824A891EB491D3725FECEA1656A.f04t02

This look at self-disorders is interesting and can possibly bring about greater insight into the schizophrenia spectrum as a whole, showing where and how it differs from other mental illnesses, like psychotic bipolar disorder and OCD, thus bolstering the Kraepelinian dichotomy. Here is a study that looks at a possible relationship between self-disorders and insight in schizophrenia, and actually gives a very good introduction to self-disorders. For example, it mentions that in all the foundational texts on schizophrenia, self-disorders were seen as important:

The notion of disordered self as the core disturbance of schizophrenia appears in all foundational texts on schizophrenia (eg, Kraepelin, Bleuler, Minkowski, Jaspers, and Schneider) but was only recently revived in contemporary psychiatry.

This is under the section "The Disordered Self in Schizophrenia," a very interesting read into the core of the schizophrenia spectrum. Here is the link to the full text:

http://schizophreniabulletin.oxfordjournals.org/content/40/3/542.long

This explores those self-disorders in that section (footnote removed):

This basic self-world structure is disturbed in schizophrenia spectrum disorders, ie, it is constantly challenged, unstable, and oscillating, resulting in alarming and alienating anomalous self-experiences (also termed “self-disorders”), typically occurring already in childhood or early adolescence. The patients feel ephemeral, lacking core identity, profoundly, yet often ineffably different from others (Anderssein) and alienated from the social world. There is a diminished sense of existing as a bodily subject, distortions of the first-person perspective with a failing sense of “mineness” of the field of awareness (eg, “it feels as if the thoughts aren’t really mine”), and a deficient sense of privacy of the inner world. There is a significant lack of attunement and immersion in the world, inadequate prereflective grasp of self-evident meanings (perplexity), and hyper-reflectivity (eg, “I only live in my head” and “I always observe myself”). Although patients often suffer from self-disorders, the latter are usually lived in an ego-syntonic way, as modes rather than as objects, of the patients’ experience, ie, often affecting more the “how” than the “what” of experience. What is important to emphasize at this point is that the self-disorders, reflecting the unstable basic self-world structure, destabilize the natural ontological attitude and may throw the patient into a new ontological-existential perspective, an often solipsistic framework, no longer ruled by the “natural” certitudes concerning space, time, causality, and noncontradiction. Unconstrained by these certitudes, the world may appear as only apparent or staged, ontologically mind-dependent, prone to noncausal relations, and the patient may experience a unique access to deeper layers of reality, which are inaccessible to others. Often, these experiences evoke a specific sense of grandiosity, leaving others to be seen as oblivious to the true nature of reality and only concerned with everyday trivialities.

Self-disorders seem like they can discriminate between the schizophrenia spectrum and other mental illnesses and seems to show traits present in the schizophrenia spectrum that are typically absent outside of it, even in other psychoses. Even the non-psychotic schizotypal disorder has an aggregation of self-disorders, which suggests that self-disorders are more of a "schizophrenia spectrum thing" than a "psychosis thing."

Why I hate all the sensationalist news about Bruce Jenner possibly undergoing gender transition

Note: Because I have not seen confirmation that Bruce Jenner actually identifies as a woman and has actually denied that he is undergoing gender transition, I will use male pronouns to refer to him.  This decision is also supported by the current state of his Wikipedia page, which currently uses male pronouns to refer to him.

Bruce Jenner, the former Olympic Track runner, has long been known for exhibiting vanity about his appearance, undergoing plastic surgery at several points in his life, among the latest a tracheal shave because he didn't like his trachea.  Apparently, at that point, a whole bunch of sensationalist new articles were all up in arms about his supposed pending gender transition.  I cringe when I search "sex reassignment" on Google News to try to see our country's (USA's) progress toward making full gender reassignment accessible to all and see that half the results page is filled with articles with rumors about Bruce Jenner.  It really rubs me the wrong way and I'll tell you why.

Bruce Jenner is well known for his vanity, so having so many sensationalist articles saying he is undergoing gender transition poisons the concept of gender transition, making it seem like nothing more than just another vain undertaking, I think.  Not only that, but there's talk of an expensive divorce in the news, so adding to its possibly being viewed as a vain undertaking, gender reassignment may come to be seen as the province of the rich and famous, and more so if it has already come to be seen as that.  Because of the tendency of many people to confuse is and should be, many may come to see that it should be a vain undertaking that is the province of the rich and famous and resist efforts to make full gender reassignment accessible to all people.  This is why the rumors about Bruce Jenner really trouble me.

I don't know if there is anything we can do to stop the sensationalist articles about Bruce Jenner's supposed gender transition, as the guy probably likes all the attention, but when I look with hope for news that coverage of gender reassignment may increase I really hate seeing Bruce Jenner's name come up and take up such a huge portion of the page.

I hope and pray, for my sake (because I really need it) and for others' sake, that we can accelerate the expansion of coverage and access to full gender reassignment in this country.