Gender identity is basic to one’s humanity? You have to do more that just state that for it to be true. But assuming that it is, why is gender identity constrained by one’s physical body? One could very conceivable by physicall male, but behaviorally female. It’s unclear that that situation is cruel.
So if I want a sex change, but couldn’t afford it, I could just kill somebody and go to prison, and then the state would pay for it!
No, wait. Then I’d be the other sex, but I’d be in jail. Would it really be worth it? Something to ponder.
Devils Advocate for a moment - it seems like the state is also denying him psychological treatment (as well as the physical treatment, surgery, and horomone therapy.) And having prisoners denied psychiatric treatment on the decision of corrections officers and professionals (rather than on the analysis of psychiatric professionals) is not something I’m automatically comfortable with. (But I am willing to listen to arguments on either side.)
If the thread title were changed from “Sex Change Operations for Muderers” to “Psychiatric Evaluations and Therapy for Murderers” would that alter or influence anyone’s opinons?
Being male or female - biologically, sexually, behaviorally, psychologically - seems to me to be a rather basic tenant of being a human being. I’m not sure how to prove that per se, but I can go poking about on some professional resources. Didn’t think that one needed proving. 
Furthermore, gender identity is not the same as behavior (or sexual orientation, for that matter). Here’s what the APA says:
So, essentially, your biological sex, your gender identity, your social gender role, and your sexual orientation are four entirely separate concepts - related, but separate.
I know, it’s hard to wrap your mind around it. I had trouble for years. But I finally “got it.” It’s not that hard, actually.
Esprix
Why is the state under any obligation to pay for a convict working out his gender identity issues?
This is cosmetic surgery, similar to a face lift or a hair transplant, so that one’s physical appearance coincides with one’s inner desires. Paying for such cosmetic surgery should be 100% the responsibility of the person who wants it.
I don’t believe that you can create an obligation on someone else’s part by announcing what you want your gender identity to be. If this convict can’t pay for everything he wants, he will have to learn to do without.
Regards,
Shodan
Esprix: I understand the concempt of gender identity being different from behavior. My point is that you’d need to prove that withholding a sex change operation from a prisoner is “cruel and unusual punishment” (like witholding food) before the state could say that the prison authorities are in the wrong. But even then, it’s not like the state is saying the prison can’t get one (if he pays for it himself). It’s just saying that the state will not pay for it.
So what sorts of mental health treatment and physical health treatment do you consider appropriate for inmates? If a prisoner is going blind, do you give him anti-blindness surgery or do you ignore it because it is non fatal? If a prisoner is hearing voices, do you provide treatment for him or not? If a prisoner disfigured in a horrible accident, do you provide reconstructive surgery? Prisoners are entitled to some degree of health care, what do you think the standard is?
Anyone that has known a transgendered person for any amount of time will realize that sex change operations are not at all cosmetic, they are reconstructive, and they usually represent a person’s only hope for phsychological well-being.
But then again, I’m still laughing about the idea of a prisoner that is so eager to get into women’s prison they’d cut off their balls, risk never reaching orgasm again, and wreak various unreversable physical changes on their bodies.
Changing your biological sex is so much more than changing “one’s physical appearance to coincide with one’s inner desires.” If I were a human being who was born a muskrat, I’d think that getting surgery to turn me back into a human being would be more than “a face lift or hair transplant,” and I find it rather insulting to compare sex reassignment surgery to such frivolous cosmetic surgeries.
In this case, I’d say there is a case to be made. I do not think sex reassignment surgery (if a legitimate case, mind you, but that would be for health care professionals to decide, not me nor a corrections organization) is something someone can “do without.” Do I agree he should pay for it on his own? Yes. But being in prison precludes him from doing that. What other options are there?
Esprix
If you want help, understanding and sympathy, then dont commit murder.
Esprix brings up an interesting point that makes me wonder about the entire notion of sex-change operations to accomodate “gender identity” in general.
Say that Esprix’s example was reversed - you were a person who thought he was a muskrat. What would the recommended treatment be? IANA psychiatrist, but I’m guessing some sort of therapy to convince the person that he’s not a muskrat, he’s a human. At no point do I imagine that a shrink would say, “Well, okay, he’s not responding to therapy. Let’s graft some fuzzy ears and a tail on him.” In other words, you try to change the mind to accomodate the realities of the body, not change the body to accomodate the (false) perceptions of the mind.
However, with gender identity issues, we seem to acknowledge that a sex change is standard operating procedure - in the extreme case, if nothing else. Why the difference? Is it simply because we have the technology to convert someone from a man into a woman, and vice versa? If we had the means to change a man into a muskrat, would we do so in the “muskrat trapped in a man’s body” case? Or is there something specific about the belief that someone is a man/woman trapped in a woman’s/man’s body that makes it somehow fundamentally different from the muskrat case?
This would seem to be rather relevant in this case. If a sex change is something that would be considered by professionals to be absolutely, positively, the only solution, that seems different if a sex change is simply the treatment this guy desires from a wide range of different, equally effective treatments.
And FTR, I don’t think this guy should get his operation, based solely on the cost. Similarly, if he needed a $500k heart operation to stay alive, I’d tell him very politely that he was just going to have to get started on his will. Actually, given the nature of his crime, I probably wouldn’t be that polite about it.
Jeff
**
Because therapy doesn’t work. All scientific evidence points to the fact that gender as indicated in the brain (e.g. what gender you think you are) is the only gender that a person will ever feel comfortable with. The arrangement of one’s genitals, one’s hormones, and one’s social upbringing are all trumped by thebrain.
Science is working on finding out exactly what parts of the brain determine gender and why it is so compelling. They have some ideas involving intrauterine hormonal washes and the like, but so far all they know is that it involves the structures of the brain. It really is the body that is wrong, not the thoughts.
In any case, therapy generally doesn’t do anything, except maybe make the person involved feel even more harrassed and outcast. There is no “getting over” or “learning to live with” something that your brain is constantly telling you is wrong.
It’s all pretty facinating stuff…
Why do you believe that surgery to ensure the mental health of a prisoner is elective surgery? Or rather, what do you hold to be true of this type of surgery that differentiates it from, say, some other form of therapy or live-preserving surgery?
Why is that?
Is Brooks able, in prison, to pay for it himself? Further, as a ward of the state are they not charged with responsibilities to that effect in maintaining him?
His unhappiness is not so much with being in prison as it is with being in the wrong body. For example, would you feel comfortable feeling like a stranger in your own body? That the phenotypical expression of your genes did not match your identity?
Googling various terms I was unable to find what year he will be eligible for parole. Do you happen to know?
The validity of that assertion would require, IMO, some proof that it would be easier for him to do time in a women’s prison than in a men’s. Admittedly I don’t know much about this, but nothing seems to favor one over the other.
Would you, to continue that thought, allow for the paying of the state some percent of the surgery (the rest to be paid by some other agent, for example Brooks [though I am loathe to call him that given that his preferred name now is Jessica Lewis])? Say 1%? 5%? I promise to avoid “well, if not 5%, why not 5.5 or 5.55 or 5.6%?” arguments, as this question does lend itself to an unavoidable slippery slope.
Looking at this from a purely pragmatic viewpoint, gender re-assignment surgery does not seem to have any more benefit to the patient than a combination of counselling and medication. Both groups tend to have the same outcomes, as measured in degree of life dysfunction, self-reported satisfaction levels, job and family stability, and general ability to deal with life. There are success as well as failure stories for both treatment modalities, and it really is not clear that one is better than the other.
Given those facts, it is imperative to first do no harm. If a particular medicine is not helpful, one can stop it. Reattaching a penis, or putting breasts back on is more problematic.
And I’ve taken care of both pre- and post-op transsexuals, mainly M to F, but also F to M. I’ve even seen one patient who had gender re-assignment male to female, then went back to male again.
Gender identity is more than in the brain. It is also in the entire nervous system. And while I truly believe gender identity disorders are real, they are generally also more complex than just that.
And don’t get me started on Healthcare and Prisoners! 
QtM, MD
Physician to the Felons
I didn’t think they could do the re-re-assignment - how well does that work (or not work)?
So, I wasn’t the only one appreciating the irony of folks saying prisoners shouldn’t get better treatment than the non-confined, when, in many instances, they do? :dubious:
Just let me state for the record, Qadgop the Mercotan is utterly wrong about the efficacy of reassignment surgeries. Please search other threads on this topic for references; I am not in a position to do so right now, but the evidence is pretty starkly clear on this. QtM is apparently not up to speed on current gender identity research. And I question whether his patient base is a representative cross-section of gender-dysphoric individuals.
He actually sounds like he’s parroting Dr. John Money, whose theories and conclusions have been soundly debunked that they have no probative value at all.
Federal case law has already held that prisoners who are on the reassignment track must be maintained at their current position (so if they’re on doctor-prescribed hormones, hormones must be continued) but the prison is not required to advance their reassignment progress. Of course, a prison could elect to do more, but I don’t imagine many will elect to do so. There are also rulings related to housing transsexual prisoners and the duty of the prison to protect them from assault.
Broomstick, rereassignment is vaguely possible. For FtMtF rereassignment, breast prostheses are used, along with neovaginal construction techniques similar to those used in intersexual assignment surgeries for patients who are identified as female but who lack a patent vagina. The results are generally not very satisfactory. For MtFtM rereassignment, mastectomy is used to remove the breasts, the neovagina is closed, and the labia sewn closed, with or without the insertion of prosthetic testes. There are grafting techniques that can be used to create a prosthetic phallus, although again the results are generally not very satisfactory. These also resemble techniques used for severe hypospadias, another form of intersexuality.
Rereassignment is requested in something like 1% of cases where the Standards of Care are followed. Most rereassignments are the result of the failure to follow the Standards of Care. Some of them were due to incompetent practitioners who sought to treat homosexuality with reassignment (a practice not uncommon even through the 1970s). Most individuals who end up seeking rereassignment are relatively wealthy individuals with significant comorbidities that, under proper adherence to the Standards of Care, would never have been approved for surgery (under the SoC, a candidate for reassignment must not have any significant psychological condition comorbid with gender dysphoria). There are surgeons (in places such as Mexico and Thailand) who will overlook the Standards of Care and perform surgery on unqualified patients, if paid enough.
I will not debate the underlying issues that have been raised in this thread by the Usual Suspects. I’ve done that before, and I don’t particularly want to do it again. The SDMB has an excellent search engine; I recommend making use of it.
KellyM, if you can point me to good studies showing better outcome with sex reassignment surgery vs. therapy and meds (including hormones), I’d love to see it. I’m not aware of any, nor have I found any in my (admittedly not quite thorough) search of the SDMB and the web today. I’m not ideology driven, I’ll respect good data.
And I always considered myself to not be in the good Dr. Money’s camp, with his assertion that gender identity is all nurture, and not nature. Dr. Money was one of my professors, whom I studied under in two disparate courses on human sexuality, but frankly I never bought into his basic premise. And I was completely unsurprised when the “John/Joan” outcome blew up in his face.
Nor do I object to the surgery itself. But when the state, acting “in the best interests” of incarcerated felons, must decide what medical care to deliver, it must consider outcomes data. We know a felon who gets a kidney transplant will fare better than if he stays on dialysis, so the state pays for transplants (when available). It’s not so clear with sex reassignment.
I should also make clear that when I said treatment with medication in my first post, I meant (but did not state) to include “hormonal sex reassignment”, without which there is significantly worse outcome data.
To summarize, I’m pragmatic. Show me good data indicating that those who have the surgery do statistically significantly better than those who have therapy & medication (especially hormonal sex reassignment meds, ie estrogens), and I’ll advocate for my patients to have surgery be a possible option. But I’ll need evidence to be pursuaded. The funds we get to care for prisoners are not infinite, and we’re being asked to cut out all but the “necessities” by the public and the government.
As a prison physician, I would bet his representative cross-section is right on the money. These are, after all, the sorts of people we are talking about - convicted and imprisoned felons who want sex-change surgery.
If we are going to accept arguments from authority, I would take his word over yours. If you could provide your cites, I will read them. Then we can all judge for ourselves.
Sex-change surgery is not life-preserving, for one thing. “Gender dysphoria” has no physical symptoms that threaten this person’s life or physical well-being. He is unhappy, allegedly because he has gender identification issues. He isn’t going to die without the surgery, which is extremely expensive. Therefore, he can’t have it.
Because he is a murderer, and, as I mentioned earlier, his happiness or otherwise is not a matter of great concern to me. In fact, I would prefer that he be unhappy. He is being punished for murder, after all.
No, he probably cannot pay for the operation himself. There are relatively few rich murderers.
But no, the state has no obligation to pay for elective surgery. If he wanted a hair transplant because he was miserable being bald, or a nose job because he couldn’t get dates, he should not be provided with either operation. Similarly, if he wants to be a woman, the state is not obligated to pay for his efforts to become one.
Let’s not treat the “right” to decide what sex you are differently than other rights. I have the right to own a house, and I might be awfully unhappy without one. But the state does not have to make my mortgage payments. I might really, really want better clothing than a prison uniform. But the state does not have to provide me with any. And so on.
As I mentioned earlier, I could not care less whether he is happy or not. I don’t value his happiness at half a million dollars, or ten cents for that matter.
Are you saying that if I felt like a stranger in my own body, and the only thing that would cheer me up was getting drunk and screwing, I should send you the bill for my beer and hookers? Why is it any of my concern whether or not someone else wants to be a woman?
Someone wants to be a woman, go ahead. Someone wants to be a woman and make me pay for it, no. Someone wants to waste scarce prison funds on making a silk purse out of a sow’s ear, especially no.
Even if the sow is really, really convinced he is really a silk purse.
Nope, not a dime.
If he wants to pass the hat, fine with me. He gets nothing from me, and should be prevented from trying to force anyone to contribute. Like the state government, for instance.
Regards,
Shodan
Let me clarify, as I may have misunderstood QtM’s point. I believe that QtM is wrong with respect to the general population of transsexuals. He very well may be right with respect to the specific population of “transsexuals incarcerated for life” or even “transsexuals incarcerated in prison”.
There are studies examining quality of life for pre- and post-surgical transsexuals. One I am familiar with found that 93% of male to female and a 97% of female-to-male patients had better or substantially similar quality of life before and after surgery. Another I read several years ago found that transsexuals who are unable to obtain surgery commit suicide at a rate of one in four. (I’ve been told by others that at some times this has been as high as one in two.) I don’t know (been too long) if this covers those also refused hormones or those who received hormones but never received reassignment.
It should be noted that current practice calls for orchiectomy or oophrectomy after two to three years of hormone therapy in order to avoid the increased risk of cancer. In the case of FTM, if you’re going to do an oophrectomy, you might as well do the entire reassignment (excepting perhaps mastectomy). In the case of MTF, doing an orchiectomy without a reassignment at the same time or in the near future decreases the likelihood of a successful neovaginal construction should reassignment eventually be desired (due to increased shrinkage). In addition, after a few years on hormone replacement, the birth genitalia and gonads are pretty much useless, so removing them is not “doing harm” in my opinion.
I don’t have references at the moment, and as I am posting during breaks on an off-site business trip, it will be some time before I can even hope to locate them. I might suggest looking at the Harry Benjamin International Gender Dysphoria Association’s website for further information. They are pretty conservative in their recommendations for treatment, and you may be able to find studies referenced either on their site or on the sites they link to.
So Shodan, are you advocating that we deny depressed prisoners Prozac? Do we deny anti-psychotics to prisoners with schizophrenia? Should we halt all treatment of mental disorders- which can be just as deadly as heart disease- just because we like to see prisoners suffer? Why stop at the mental? Why not deny all medical treatment for prisoners?
Or is this all your refusal to believe that transgendered people exist? If you are in the camp that they all want to change their genitals because they are bored or something, I don’t know what to say. Gender Dysmorphia is a well-documented disorder that has been present in all cultures throughout time. The only treatment that provides positive results and a chance at a mental health is to correct the problem of the mismatched body (which does not always have to extend to surgery, but often does). Steps towards sex reassignment (which does not always include surgery, but almost always involves hormones) is the medically accepted thing to do in these situations.
It’s kind of like gay people. For whatever reason, some people are attracted to people of the same sex. You might one day be able to do neurosurgery to make them not gay, but the gay person involved probably wouldn’t want that and it’s a bit unneccesary anyway. You could try to make a gay person go to therapy, but that wouldn’t change them and would probably just piss them off. You could expect them to get married and live as straight people and pretend that the gayness is ‘all in their heads’, but that is going to really piss them off and probably lead to a lot of unnecessary mental anguish and suicide. You could change all of society to abolish the idea of gender so that nobody would be gay or straight, but thats a pretty big project.
So you let them be gay. And you let the transgendered people be who they are. Because there is no other good way to do things.
So what i want to know from you is why gender dysmorphia warrents a different standard of care then other similer issues and why you are willing to let this particular subset of prisoners suffer from an untreated medical problem.