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Photo: Melissa Gerr |
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In this year's prioritization process, Oregon Health Plan ranked 717 procedures, with the top 572 qualifying for coverage. Transsexualism services ended up on line 688, well below the cut-off.
The long-term effects of large doses of estrogen in men are unclear, but Jaquay's doctors are concerned. Possibilities of liver damage, blood clotting problems, even cancer are listed on the tablets' packaging.
Dr. Bruce Goldberg, associate medical director of CareOregon, stated during the OMAP hearing that the HMO became aware Jaquay was a transsexual only at the receipt of her third sex-change referral, in April 1997. CareOregon's records show it received--and rejected--the first referral in 1995.
Over the years, Jaquay responded well to estrogen therapy, and has slowly developed breasts and experienced voice change and hair loss. |
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Olivia Jaquay says she will continue to seek a state-sanctioned sex-change.Olivia Jaquay stands at the rim of the gender divide, knowing it's too late to go back. The 16 years of estrogen therapy have given her a convincingly feminine presence. Now, at age 42, Jaquay wants to complete the transition and, through surgery, re-enter society as the woman she believes she was meant to be. But one thing stands between Jaquay and her life-long dream: the Oregon Health Plan. Last week, the Office of Medical Assistance Programs, which operates the Oregon Health Plan, denied Jaquay's request for a sex-change operation. Jaquay was the first transsexual to contest the state's denial of a sex-change operation, and her challenge drew a flurry of media attention. The short story, as portrayed in the local press, is pretty simple. The state's health-care plan for low-income residents rations medical procedures based on their effectiveness and value to society. Sex change operations, which run about $11,000 for someone like Jaquay, were not ranked high enough to be covered. At first glance, the decision to deny the operation may seem logical. But a closer look at Jaquay's complex situation reveals a persuasive argument that her surgery is not only medically necessary, it also is in the best interest of taxpayers. Born in Texas as Oliver Jaquay, Olivia has struggled with her gender identity since childhood. She says she began sneaking into her mother's closet at age 8 to find attire that reconciled her exterior appearance with her inner feelings. Even into adulthood, however, Jaquay tried to fit the stereotypical male role. Oliver joined the military, got married and fathered two children in the Portland area. "I tried to do what mama wanted," says Jaquay. "I just got tired of trying to be something I wasn't." After a nomadic life filled with abuse and chaos, Jaquay returned to Portland in 1992. When the Oregon Health Plan was implemented in 1994, Jaquay qualified and chose CareOregon as her HMO. Like many transsexuals, Jaquay has struggled not only financially but emotionally. Her first of three suicide attempts came in 1995. She was hospitalized in a psychiatric ward and sent to a drug detox program. CareOregon records show that it paid for her treatment. In fact, since her enrollment on the OHP, CareOregon has covered not only costly hospitalization and extensive psychiatric care, but also hormones, anti-depressants like Prozac, therapy groups and endocrinology specialists. Jaquay's medical regime follows the standard procedural outline for sexual transitions: psychotherapy, living as the desired gender for at least two to three years, hormone replacement therapy and, eventually, surgery. In 1995, Jaquay requested a sex change, and her primary-care doctor sent the first of three referrals. Although CareOregon was paying for her therapy and hormones, the HMO balked at the request. Jaquay's attorney, Rick D. Klingbiel, says discontinuing treatment is a breach of contract. "They led her down the garden path towards the surgery and paid for it every step of the way," he says. Carole Romm, health services manager for CareOregon, sees it differently. She says that if sex changes were covered under the Oregon Health Plan, it would open the door to claims for breast implants, liposuction, vasectomies and other elective procedures. In a rationed system, she argues, such operations shouldn't be covered--a sentiment voiced often during Jaquay's fight for surgery. Gender Identity Disorder, however, is recognized by the American Psychiatric Association as a bona fide mental illness. Jaquay, her doctors and her therapists were convinced that in her case, surgery was needed. Jaquay appealed CareOregon's decision to OMAP. But rather than assess her health needs, the hearing focused on her HMO's administrative bungling. CareOregon claims it was not aware that Jaquay was a biological male. Although Jaquay says she was open about her transsexualism from the beginning, CareOregon claims that until her most recent request for a sex change--in April 1997--it thought Jaquay was a woman taking estrogen, a common practice. Two other factors were not considered, although under OMAP guidelines, they could be. First, CareOregon's decision may actually be more costly in the long run. Although Romm says CareOregon cannot disclose how much it has spent on Jaquay, a conservative estimate of her care is in the range of $40,000 over the past four years. By not providing the $11,000 surgery, CareOregon may spend more money in the end as bills for Jaquay's treatment mount. Second is the issue of "co-morbidity." This refers to an existing ailment or disability that could lead to worsening of the condition or possible death if left untreated. Given Jaquay's psychiatric history, including the suicide attempts, and complications from long-term high-dosage estrogen therapy in a biological male, her health could deteriorate without surgery. Research indicates that psychiatric and social problems drop significantly after the surgery, and suicide attempts drop to zero. |
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