Elon Musk: Always A Douche

[crazy canuck]

In the military I'm the employer and I get a say in how much money gets spent.

For sure.

Three questions:

1) Do you also want a say in what sort of medical services are available to federal and state civil servants, to those employed emergency services, to municipal employees, and the judiciary - all of which are also funded by your tax dollars?

2) The US military spends a lot money on many many things. Do you think that the employer (you) should be involved at a granular level determining which specific medical services should be made available for things other than gender affirming care? For example breast reduction surgery? Should you be involved in that deciding whether the US military pays for that, or can that decision be left to the military (and the medical personnel they trust to make the appropriate determinations)? Are there other areas of spending outside of medical services where the employer (you) should be involved in spending decisions at the same level of detail?

3) As the employer do you personally think that the US military should not pay for gender affirming medical services (hormone therapy and/ or surgery) under any circumstances whatsoever, or do you imagine there could be situations in which paying for such medical services is in fact the right thing to do for the US military?

I am not sure what you are getting at Jacob.

In answer to question 1, the issue of the level of benefits public sector employees get is largely a political question resolved through elections.  Some governments will be more giving in bargaining and others not.  Voters get an at least indirect say.

The answer to question 2 is employers always get to decide what benefits will be provided to their employees, including medical benefits the employer chooses to provide.

I don't understand the third question from the perspective of an analysis used by employers when deciding what benefits to provide.  Rather it is always a question of what coverage insurers provide for all employees and what is the cost of those various forms of coverage.  The analysis then becomes what is the best coverage, for a reasonable cost for all employees.  The analysis is not about whether special riders should be added to the coverage. 

All of that means that if insurers are offering this therapy as part of their general coverage then it will be included.  If not, then not.

[Tamas]

I would say prisoners should receive medical care to save their lives and to prevent/cure conditions that make it more difficult to keep them incarcerated. To that you could add medications/procedures necessary for rehabilitation, if you believed in rehabilitation, and the gender transition thing could fall under that, I guess.

However none of the above (trans or not) should result in more state-sponsored care that non-prisoner citizens are eligible for.

[The Minsky Moment]

For a number of reasons, mental health issues are probably a disproportionately more common in the prison population than in the gen pop. Mental health care is also expensive. So to what extent should it be provided? The obvious populist response is to say let them rot, but a volatile population with untreated mental health conditions creates greater risks of violence and likely higher long term costs.  And if it is conceded that mental health care generally can be appropriate for the population, then it seems reasonable to conclude that gender affirming care made be appropriate in individual cases.

[Barrister]

For a number of reasons, mental health issues are probably a disproportionately more common in the prison population than in the gen pop. Mental health care is also expensive. So to what extent should it be provided? The obvious populist response is to say let them rot, but a volatile population with untreated mental health conditions creates greater risks of violence and likely higher long term costs.  And if it is conceded that mental health care generally can be appropriate for the population, then it seems reasonable to conclude that gender affirming care made be appropriate in individual cases.

So there are two different, but related, questions here.

There is the question of "what health services should be provided to prisoners" (or military, emergency services, police, etc.).

There is also the question of "should the provision of health services to prisoners (or whomever) be a political issue".

I think reasonable health services should be provided to prisoners and public servants.  And I also think that is absolutely a legitimate issue for political debate - even if I think the voters get it wrong.

The one exception I will make is it shouldn't be personal.  We can 100% have the debate whether prisoners should get medical assistance in transitioning.  We should not however debate it at the level of individual prisoners - e.g. should Chelsea Manning be given gender-affirming care.

I've only been involved in one court case involving the rights of a trans prisoner.  It wasn't specific to medical care (as far as I know this transwoman was receiving hormones in custody) but more about what other accommodations should be made to her.

But while issues like that are absolutely political hot potatoes, and I don't know that making election issues is the absolute best way to deal with them - I can't possible say that the public shouldn't be allowed to discuss or debate them.

[Jacob]

yes

yes

What is your opinion on breast surgery reduction for civil servants? What is the bar for approving different types of orthopedic surgery for government employees? Should addiction counselling be available? What about mental health services?

If the military is having a hard time finding recruits and gender affirming stuff is needed to fill the ranks I would approve.

So essentially you see "gender affirming stuff" as a perk, which is justified if perks are needed to attract required talent. Would it also be justified to retain highly trained talent that it would be difficult or expensive to retain (e.g. due to their length of training - so say, if it costs $500,000 to train someone to an equivalent level, it'd be okay to spend $200,000 on "gender affirming stuff" to retain them)?

Would you have a similar view on something like breast-reduction surgery? Should that be available for people who have a legitimate need for it, or is it a perk that should only be offered if there's a recruiting (or retention) issue?

[Admiral Yi]

Breast reduction has actual health implications.  I.e. back pain.

I think of sex reassignment as closer to cosmetic surgery.  I.e. breast implants as opposed to breast reduction.

Is cosmetic surgery "appearance affirming medical care?"  Is it medical "care" at all? 

I really hate all these attempts to circumvent debate on the merits by inventing new magic words.

[Admiral Yi]

Yes to the retention question.

[grumbler]

I think of sex reassignment as closer to cosmetic surgery. 

Just. Wow.

[Jacob]

Breast reduction has actual health implications.  I.e. back pain.

So I was researching this a bit, and as far as I understand it both gender affirming care and breast reduction surgery have the same criteria for being covered by Tricare (which I understand to be the network that covers military and possibly other civil servants) - namely that it is "medically required".

You don't get to have your breasts reduced just because you prefer the look of smaller breasts, but because medical establishment agrees that it's medically required (i.e. back pain, as you say).

Similarly, you can't get gender affirming care just because you feel like looking different. The medical establishment has to agree that it's medically required (I'm imagining this is primarily based on mental health care but there might be other reasons, I don't know).

I think of sex reassignment as closer to cosmetic surgery.  I.e. breast implants as opposed to breast reduction.

As for other forms of cosmetic surgery, from my reading it's not covered precisely because it's cosmetic. But if it is medically required - say because it'll remove pain or restore normal functionality that is missing or has been damaged due to an accident or disease, then I believe it's covered. This seems consistent across multiple related areas - cosmetic surgery, breast reduction, gender affirming care, and I expect pretty much everything else.

So - for gender affirming care - the military does not just hand it out to any enlistee willy-nilly on demand; the medical establishment has to deem it medically necessary (which is, by Sophie's account, a long drawn out process that is not guaranteed to succeed, and very much goes case by case).

To me that leaves four possible options for deciding it's bad policy for the military to deliver gender affirming care:

1) It may or may not be medically necessary for someone to receive gender affirming care, but the military shouldn't provide it anyhow because I think "trans stuff is just wrong".

2) It is simply not possible for gender affirming care to be medically necessary. When the medical establishment says it's medically necessary, they're wrong. It isn't.

3) Medical care (for the military and public services) shouldn't cover mental health. If gender affirming care is medically necessary due to a mental health diagnosis it should be not covered. Similarly, other forms of mental health care (say for PTSD, addiction, depression, etc) should not be covered. That stuff isn't real and those people should just pull themselves together.

4) Gender affirming care can be medically necessary, but some types of medically necessary care should be denied to civil servants and the military for reasons that are not related to "trans stuff just being wrong." Personally I'm not sure what that reason would be, but I acknowledge it might exist.

[HVC]

I'm agnostic on the issue because I don't know enough either way, but for point 3 a distinction could be made for mental health issues caused by military action such as PTSD and Depression and those that are not like (pre-existing) addiction, Neurodevelopmental disorders, and one could argue mental health issues due to lack of gender affirming care.


*edit* changed *i would argue" to "one could argue" because again, on reflection, I don't know enough about the issue.

[Jacob]

Is cosmetic surgery "appearance affirming medical care?"  Is it medical "care" at all?

Cosmetic surgery is obviously a medical procedure. In my lexicon the "care" component of "medical care" doesn't distinguish it from other kinds of "medical somethings". As far as I know, you're the one who's pushing for a distinction and I'm trying to accommodate you as I don't really care that much. From my point of view "medical care" simply means "services delivered through the medical establishment."

In other words, in this case you're the one using new (at least to me) categories because you believe we should distinguish between "medical care" and "medical something" (which by implication is not "care" and/ or not "medical").

I really hate all these attempts to circumvent debate on the merits by inventing new magic words.

For my part I find the terms "warfighter" and "warrior" to mean soldier to be pretty ridiculous, but semantic drift is what it is.

For the topic at hand "gender affirming care" is obviously political, in that it makes clear an assumption that the person is the gender they say they are, and they are getting medical care to affirm that. Personally I'm okay with making that political statement, but I can see why someone might prefer a term that has a different bias (since all terminology does have a bias).

The term also conveniently bundles in all the categories of medical care that is related to... well... gender affirmation (or gender change, if you prefer) - whether it be psychological counselling, hormonal treatment, physiotherapy, externally visible surgery (cosmetic, if you will), and surgery which is not externally visible.

I assure you that I'm not attempting to circumvent debate on the merits at all - but I'm not aware of another term that covers the same concept. If there is I'd be happy to hear it.

[Jacob]

I'm agnostic on the issue because I don't know enough either way, but for point 3 a distinction could be made for mental health issues caused by military action such as PTSD and Depression and those that are not like (pre-existing) addiction, Neurodevelopmental disorders, and I would argue mental health issues due to lack of gender affirming care.

For sure.

That would mean that someone in the military suffering from PTSD due to being assaulted or raped outside of military action, or suffering depression for reasons similarly unrelated (i.e. because of a genetic disposition or because the proximate cause is something like the death of a loved one) should not receive mental health care.

For other folks covered by government health care (IIRC about 1/3 of Americans, according to one website) it would mean they get no mental health care at all if they're not active service military (i.e. they're a municipal worker, they're a spouse or dependent, etc).

It seems kind of cruel to me, but I suppose "no mental health care unless it's directly related to military action" is a consistent position of a sort.

EDIT to add: There's also the bit that - at least as I understand it - it can be complicated to diagnose what the causes are for mental health issues. Often you start with the symptoms and only end up with the causes much later in the course of treatment (if at all). That is going to potentially complicate the determination of whether any given mental health issue was caused by military action or not.

[Jacob]

Yes to the retention question.

Cool.

[HVC]

I'm agnostic on the issue because I don't know enough either way, but for point 3 a distinction could be made for mental health issues caused by military action such as PTSD and Depression and those that are not like (pre-existing) addiction, Neurodevelopmental disorders, and I would argue mental health issues due to lack of gender affirming care.

For sure.

That would mean that someone in the military suffering from PTSD due to being assaulted or raped outside of military action, or suffering depression for reasons similarly unrelated (i.e. because of a genetic disposition or because the proximate cause is something like the death of a loved one) should not receive mental health care.

For other folks covered by government health care (IIRC about 1/3 of Americans, according to one website) it would mean they should get no mental health care at all if they're not active service military (i.e. they're a municipal worker, they're a spouse or dependent, etc).

It seems kind of cruel to me, but I suppose "no mental health care unless it's directly related to military action" is a consistent position of a sort.

I was thinking more in the context of military insurance rather than general insurance. Assuming they're different, but you know what they say about assuming. The American medical system in general is baffling to me. More of a thought exercise I suppose. Not a long thought out one, I admit.

[Admiral Yi]

Sophie didn't say it is not guaranteed to succeed in the military.  You made that part up.

#2 is closest to what I believe.  Nobody has bothered to explain to me how reassignment is a medical necessity.  None of the advocacy I've been exposed to has discussed the medical necessity.  My first exposure to transgenderism was probably Silence of the Lambs.  The discussion there was limited to those cases in which reassignment is advisable.  No discussion of medical necessity. 

Mental health as constituting the medical necessity is IMO the most plausible and reasonable route to get me to where you want me to be in my thinking.  But that is a testable hypothesis.  Are you aware of any attempts to measure mental health of transgender people before and after reassignment?  I am not.  I take a cursory look at Caitlyn Jenner and I can't see any obvious improvement in mental health.

I have immense respect for the medical profession and expect that since I am placing myself in opposition to their collective wisdom I will probably end up being wrong.  But I still want to see the proof.