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October 1, 2014

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:

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

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:

  • “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.”
  • “My 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.”
  • “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.” Plus several other organizations.
  • “I was not then, nor am I now, a Catholic.”
  • “The 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’s 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.’”

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 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 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 “My 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.” Yes, her report was indeed used in this manner for the OHTA report. However, NCHCT commissioned reports – such as Raymond’s NCHCT report – were available, in their entirety, and these reports were targeted to very specific groups. Moreover, Raymond’s report – 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 “was directed to consider broadly the implications of new and existing medical technologies, including their legal, ethical and social aspects.”[1] As you will see, Raymond’s work alone represented the whole of NCHCT’s consideration regarding the “ethical and social aspects” 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 “primary users”:

“Providers, 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.”[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’ve used[3] to determine coverage and, specific to OHTA reports, the NCHCT said that “[t]hird party reimbursers, providers, hospital administrators, health policy-makers and analysts, and government officials have reported using the assessments as well.”

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 “primary intended users.”

“Congress 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.”[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.) “controversial;” and, B.) “must be considered experimental.”She neglected to note that the third claim was that trans care was “expensive.”

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’t very sophisticated.
  • Discussion: Assertions about what is observable about trans care. (Raymond)
  • Summary: Statements of fact (Raymond)
  • Acknowledgement: Noting the major sources which informed the report (Raymond)
  • Bibliography: Noting the cited materials (Raymond)

The “Discussion” section of the OHTA report covers three topical areas:

  1. One paragraph supporting the claim that trans care is “experimental”
  2. One paragraph supporting the claim that trans care is “controversial”
  3. Four paragraphs supporting the claim that trans care is “expensive.”

The OHTA report drew upon several sources to support these three claims. In determining that trans care was “experimental,” the OHTA relied on numerous sources, none of which were Raymond. To support the claim that trans care was “expensive,” the OHTA report relied upon a source that wasn’t Raymond. To support the “controversial” claim, the OHTA relied upon just two sources, one of which was Raymond. The following is the “Discussion” paragraph which supports the “controversial” claim:

“Over 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).”

At no point prior to this does the report claim that trans care is “controversial.”

Raymond asserts that hers was but one source the OHTA considered and this is true, very strictly speaking. The OHTA report relied upon Raymond’s NCHCT report for the heavy lifting to support the “controversy” claim and the other piece of “research” the OHTA considered was… wait for it… A review of Raymond’s 1979 book, The Transsexual Empire, The Making of the She-Male that Raymond pointed out in her NCHCT report. Therefore, strictly speaking, Raymond wasn’t the only source the OHTA considered when supporting their “controversial” claim. However, it is false to assert that Raymond’s work wasn’t the only source informing the claim that trans care was “controversial.” 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 “controversial.”

The OHTA report made three claims and Raymond’s work supported 1/3 of the report’s claims. In order to measure Raymond’s influence in the OHTA report, one might use the “Acknowledgement” 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’s contribution was worthy of explicit acknowledgement. To drive this point home, here’s 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 “efficacy,” which informed the “experimental” claim. Raymond looked at the “social” and “ethical” issues, which informed the “controversial” claim, which left the Health Information Designs company to provide the cost analysis, supporting the “expensive” claim.

Recall that OHTA said the NCHCT “was directed to consider broadly the implications of new and existing medical technologies, including their legal, ethical and social aspects.” The OHTA report explicitly claims that Raymond’s NCHCT report functioned to support this purpose.

Echoing the “Discussion” section, the OHTA report makes three assertions in the “Summary” section:

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

The very first line of the “Summary” section reads, “Transsexual surgery for sex reassignment of transsexuals is controversial.” The section then makes four statements about the “experimental” nature of trans care: “There 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.” The last line asserts that trans care is expensive: “Finally, although transsexualism seems to be relatively rare, the use of surgery in its treatment can be very expensive (per case).”

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’s findings. After obfuscating her fingerprints on the report, Raymond asserts, “To give my submission credit for these conclusions is fatuous in the context of reading a report that was obviously informed by multiple sources.” Again, this is technically true. If one dismisses the reality that a third of the report’s findings were supported by her work alone and therefore choose to only consider that one of the two citations supporting the “controversy” 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 “research” supporting a third of the claims made by the OHTA report was informed by Raymond’s work. Nonetheless, Raymond goes on to assert, “my 1980 paper on the social and ethical aspects of transsexual surgery did not feature influentially in the NCHCT’s report [here, Raymond is speaking of the OHTA report, not her NCHCT report] concluding that transsexual surgery was controversial and experimental.” While there is little evidence to support the claim that Raymond’s views were used to support the OHTA’s assertion that trans care was “expensive” and/or “experimental,” it was her work alone that was used to support the claim that it was “controversial.”

Lastly, Raymond asserted that the government commissioned her to write an ethics report on trans care because public funds hadn’t 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 the Raymond, no public monies had been used up until that point. Raymond asserts, “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.” Before I get to the truthfulness of this assertion, I want to review one of the primary reasons NCHCT/OHTA issued reports:

“Poor 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.”[6]

“The 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.”[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, “the NCHCT report [did not] ‘eliminate’ federal and state funding for transsexual surgery because funding was not approved for this purpose long before my paper was written.”

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. “I believe that they did the lab and medical work that way.” He noted that for some of the early patients, their surgical costs were covered. “Some of those surgeries were totally covered.” 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. “I remember one particular patient who was on Medicare and that patient was approved for genital surgery.” He went on to say that this client received publicly insured trans services through UTMB’s program prior to Raymond’s NCHCT paper. “This 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 through public insurance programs or is obfuscating the effect of her work had trans community’s access to care.

Fact Checking:

BSRaymond’s assertion: “In 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.”

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’s assertion: “The U.S. NCHCT commissioned this paper, among other reasons, to determine ‘whether specific procedures are ‘reasonable and necessary’ and thus appropriate for reimbursement by Medicare.’ 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.”

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.” She was commissioned to do that because the OHTA itself stated that it was directed to consider the implications of medical technologies, including their “ethical and social aspects.” Raymond wasn’t 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’s assertion: “The 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’s 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.”

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

half-truthRaymond’s assertion: “I was not then, nor am I now, a Catholic.”

Reality: Raymond is responding to the claim that, “… Raymond – a Catholic ethicist, not a clinician – was…” 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 – a Catholic order – 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 “Catholic ethicist;” rather, she merely claims that both now and when she wrote her NCHCT paper, she was not a “Catholic ethicist.” 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.
true half-truth BS

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, “In 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.”

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 “problems getting health or medical services due to their gender identity or presentation.” According to Gorton, “Notably, this gender-based discrimination was a more reliable predictor of suicide than depression, history of alcohol/drug abuse treatment, physical victimization, or sexual assault.”

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’s report was to support 1/3 of the report’s findings. Raymond’s contribution satisfied the 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 “Evaluation of Transsexual Surgery.” NCD Record 4 Service (PHS) issued in 1981, titled “Evaluation of Transsexual Surgery.”. 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 “that transsexual surgery not be covered by Medicare at this time.”. 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’s 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’s submissions to PHS, “on 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.” The NCHCT’s 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 it’s 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.”

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 rational 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] “Equally dedicated to evaluating novel biomedical technology—thereby rationalizing decisions about appropriate use—was 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.” – Carolyn L. Wiener, The Elusive Quest: Accountability in Hospitals, p 42

[9] “An NCD is “a 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)].” Social Security Act (Act) § 1869(f)(1)(B) (42 U.S.C. § 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
Cristan Williams

Cristan Williams is a trans historian and pioneer in addressing the practical needs of the transgender community. She started the first trans homeless shelter in the South and co-founded the first federally funded trans-only homeless program, pioneered affordable healthcare 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. Cristan is the editor at the social justice sites TransAdvocate.com and TheTERFs.com, is a long-term member and previous chair of the City of Houston HIV Prevention Planning Group.

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  • It would be very interesting to know more about the exact sourcing of the US public funding for medical transition in the 1970s that you have evidenced from witnesses.

    At the same time – and right through until the 1990s – public money was being used to lock up trans people in mental hospitals, and us torture with electro shocks, whilst also, in the 1970s, as painstakingly detailed in the book ‘Gender Shock’, HHS pumped over a million dollars, mostly to Christian therapist George Reckers through Richard Green at SUNY, into researching “curative” “reparative” therapy on supposedly trans children (who turned out to be gay boys, as they always were), which was later reported as the “Sissy Boys” Study, and is still cited as (false and highly damaging) evidence that almost all trans children desist at puberty.

    In a wider context, several other countries started publicly funding medical transition in the 1960s and 70s, and some passed legislation in support of that too. To my knowledge the only country to dramatically change course in the same way as the US (and indeed worse) was France, where SRS and legal transition was stopped and banned, until the European Court of Human Rights forced a reversal, but that is understood to have been mostly the work of influential psychoanalysts.

  • Three points to add to your pretty remarkable analysis, Cristin.

    Suzy Cooke has reported that staff at Stanford in the 70s were part of an effort pressing for nation-wide coverage of all medical transition costs, and asked her to participate in research towards that end. That effort was ended, and indeed most of the gender clinics in the US were closed after the reports mentioned, and McHugh’s hatchet job at Johns Hopkins. McHugh was an adviser to the Vatican, at least until the current Pope, so there is another Roman Catholic connection.

    You may have missed the significance of the word “controlled” in the condemnations of the quality of pre-1980 research on SRS. They – as have many ethics and funding researchers since – were showing huge bias in trying to hold SRS to an impossible level of research quality; indeed one it would be completely unethical to attempt: doing SRS on some randomly chosen but judged suitable patients whilst ensuring it was denied to otherwise identical patients, over a long period, simply for research. Even with that (which has only once been slightly simulated in a study comparing private patients who had paid for SRS at a clinic after 1 year of RLE compared to publicly funded patients who had to endure 2yrs RLE and were still stuck on a 5year surgery waiting list) only a low “evidenced-based” score would be awarded, compared to double-blind research. But obviously no one can do SRS (indeed any surgeries) without patients knowing they have had that specific surgery, or clinicians knowing what treatment they are administering, yet SRS, as a “new” procedure is marked low for not having that level of evidence.

    Raymond’s book, and paper, were strongly advocating against medical care on the basis of belief, not clinical evidence. If people listened to that the author cannot say there is no blood on her hands.

    She is of course by no means alone in hold the belief that a changed society would eliminate the need for medical transition; most staff of equalities groups, and most graduates of women’s and gender studies programs believe that. Most LGBT programs, including the UN’s Free and Equal, and the Yogyakarta Principles facilitate that belief by at most talking of accessing healthcare, and implying that SRS is seen by all trans people as forced sterilization. I had a very pleasant researcher on trans issues confess that was her personal hope and belief only weeks ago, but she was easily converted by explaining that a need for vaginal penetration had been an inescapable part of my sexuality since the age of 11. She agreed that no societal changes could alter that. Those of us that need, or needed SRS for physical reasons must talk about that and flush away that widely held and very false belief. Those who need SRS only for social reasons, or don’t need it, must hold off their silencing of such testimony until that has been completed, and understand that they will otherwise have some of the same blood on their hands and does Raymond.

  • Amalthea

    As a Lesbian feminist as well as a transsexual, I was actually one of the targets for Janice Raymond’s famous double anathema, being accused of the heresies of not only appropriating a womon’s body, but of appropriating the spirit of Lesbian feminism! And I’ve been reflecting over the past few weeks on how her anathemas do sort of seem to reflect some Catholic theological formulation. As someone influenced by that tradition myself, and also a Jew, I can’t help picking that up.

    However, I consider her correct if she is saying that at the time she wrote the relevant words or document or whatever, she had broken from Catholic doctrine, and so was an ethicist — but not a “Catholic ethicist.”

    By the same token, Martin Luther was certainly trained in Catholic theology, but after his break from Rome was still a theologian, but no longer a “Catholic” one!

    At any rate, while I respect Janice Raymond and a human being and a sister, the xenophobia and paranoia of The Transsexual Empire are quite astonishing in the least pleasant sense. It’s almost like — and I say this as a Jew — Protocols of the Elders of Transsexualism.

    Xenophobia in the name of “feminism” isn’t new. The exclusion of intersectionalist feminist Ida B. Wells (also a great civil rights and anti-lynching activist) by some of her sisters with white privilege a century ago, and also the role that some feminists fighting for suffrage in the UK played as cheerleaders for the First World War, are sobering reminders that there are many intersections of oppression, and that xenophobia is not a “privilege” but an affliction that divides womyn who should be sisters and allies.

  • And thus began the micro-genocide….making victims out of a populace few by census yet no less in possession of the most valuable essence within the known & unknown universes, whether parallel, inter-dimensional, invisible: life. It is life that makes a rock move…a tree rock, a pebble slither, for what at first glance appears to be static objects are anything but. A rock with life is a small creature in disguise. A tree with life provides sustenance, and is a giver of life. A pebble that moves is but a tiny creepy crawler that also employs disguise to survive.

    We peer through super scopes to travel back in time…in pursuit of life beyond our blue marble. We will scream, shout, and jump for joy if and when life is discovered light years beyond our galaxy, even if such life is so micro in footprint that only the strongest microscope will reveal it. Oh life..you are so precious that many a biped has rotted away in prison for taking it away. Oh life you are so precious that many a biped has been strung from trees for having deprived others of their precious life juice.

    And yet, there have been since time immemorial….those that assign value to human life as no more than that of a rock…so say sacred scriptures as they tell the story of a Cain who struck down Abel….about battles and wars that left behind many a widow. There have been those who see life as merely a drop from a spring that will bring forth more drops—psychopaths on two feet that so loath others of the same species that they first dehumanize them before moving in for the lethal blow. The most potent instrument of dehumanization is always the word–either spoken or written. Words sway opinions. Words damn others. Words paint pictures. Words have the power over life and death.

    So it was that Raymond pretended to be an expert on the real life experiences of others—and turned words into spears. The messenger of death unleashed her message brewed in hate and marinated in toxic wrath, knowing full well that she knew not from whence she spoke. A spear unleashed causes none to fall if no target is found…or if some are poised to deflect the lethal blow, but yet her message, cloaked and wrapped in lethal authenticity was received and stamped “approved”. Rather than question and challenge such a life-impacting “body of work”, Raymond’s work of literary fiction, now thoroughly debunked and void of any credibility, was blessed, accepted and her suggestions implemented–and our trans sisters fell, one…..by….one…..by one. In succession they did fall over three + decades even they fell, never to arise or breathe again.

    These were the trans children we hear from today. These were the trans adults we are today. These were someone’s son, daughter, brother and sister. They were in possession of that trace element so rare within any universe, known or unknown…that makes rocks move, trees rock, and pebbles slither: life. Writing a work of fiction as fact, one that unleashes a weapon of propaganda….that, like a spear that strikes no target hurts no one. Writing a work of fiction as fact, one that unleashes a weapon of propaganda, targeted at a vulnerable few so desperately in need of medical attention, that, like a spear that finds its mark, causes many to fall sans life, is a weapon that must be addressed…even if 3 decades later. Clearly, Raymond’s targeted spears found not only an audience, but many a target as well. Blood has spilled. It cries out from the ground for due justice, for the forever countless lost lives stand as proof that something went wrong in 1981…something by someone that deprived them of medical care and thus life itself.

    Mortal blows beg not for forgiveness, but recompense and justice. The Medicare reversal of 2014 stands on the record admitting that separating trans persons from medical care for 33 years was a decision that was on the WSH. A wrong was righted….but this wrong will never be righted until the author or authors of this micro-genocide is or are held accountable for the lost lives of many of our sisters. Perhaps the scales of justice, which often lie still for decades, will be dusted off and once more used to speak up in defense of those unable to defend themselves, for death is as final as yesterday.

    We who still possess the trace element of life call for an inquiry….as to why a lesbian pretended to know the A-Z of a trans experience, one that no lesbian without gender dysphoria cannot and will not ever know, much less remotely understand. Perhaps 2015 will be the year that the 1980 travesty of justice will, like a ship that is listing, finally right itself. No one can speak of a journey that has not been traveled. No one can speak of a book that has not been read. No one can tell of what lies beyond the vast oceans, except the sailor who has returned. No one can ever speak of a trans experience other than those of us who matured within it…suffered its anguish and angst….lost a childhood…endured an abrasive puberty. There will always be those in our midst who become “learn-ed” and abuse academia to forward an agenda…establish a false paradigm….mold lies as truth, and impact lives, both for sustenance or deprivation. Thank you Cristan once again for literary excellence.

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