海角大神

A federal judge has ordered the people of California to foot the聽$100,000 bill for sexual reassignment surgery for someone serving a life sentence for murder.

础笔听("Judge orders California to pay for inmate鈥檚 sex change"):

Not much has changed in either my thinking or legal precedent since my August 2013 posting on 鈥淐helsea Manning and the Law.鈥� 聽In Manning鈥檚 case, the US taxpayer is paying for hormone treatment. On balance, that strikes me as reasonable. Gender dysphoria is a serious medical condition and, as a general rule, prisoners are entitled to proper medical care.

This case takes it quite a bit further. Sexual reassignment surgery is much more drastic a measure than hormone therapy and much more expensive. The AP story estimates that it 鈥渃ould run as high as $100,000 depending on the circumstances.鈥�

This raises at least two issues. First, given that this is a state action, how do we assess the moral tradeoffs in authorizing the surgery? Second, presuming that this surgery is the ethical course of treatment, should the public pay for it?

Answering the first question is well outside my expertise and comfort zone. Under normal circumstances, I鈥檓 reasonably comfortable in allowing the conflicted individual to make decisions with mental health professionals. The聽Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People聽established by the World Professional Association for Transgender Health have been evolving for decades and strike me as rigorous. Indeed, some argue that it places too onerous a burden on those seeking reassignment surgery.

But, surely, a convicted murderer who presents with gender dysphoria has more complicated聽mental health issues? Aside from whatever wiring issues made them commit the violent act to begin with, the additional stresses of prison life make it much more challenging to untangle the gender issues. And that鈥檚 especially true in a case, like this one, where the individual is imprisoned with others of their apparent sex聽while presenting as someone of the opposite sex. Again, it鈥檚 just beyond my present knowledge levels to untangle.

Presuming, however, that we鈥檝e successfully navigated those complexities and become comfortable with the decision that, yes, gender reassignment surgery is in the best interests of the patient, is it reasonable that the taxpayers of California should pay for it? The default answer would be yes. Given that prisoners are wards of the state, they鈥檙e generally entitled to essential medical care free of charge.

Yet聽sexual reassignment surgery may be different. It鈥檚 quite expensive 鈥� $100,000 actually strikes me as an absurdly low estimate, given how much almost any surgical treatment requiring hospitalization costs 鈥� and generally considered elective surgery in the United States. Most insurance plans won鈥檛 cover it. (Hell, most won鈥檛 pay for LASIK surgery, which is cheap and life-changing.) As noted in the above-cited piece on the Manning case, the Veterans Administration will pay for hormone treatment but not sexual reassignment surgery. So, Tigar has basically ruled that convicted murderers have more rights than honorably discharged veterans.

I haven鈥檛 the foggiest idea how this case will fare on appeal, presuming California petitions. But, as weird as it seems now, it likely won鈥檛 be long before this treatment becomes 鈥渞outine鈥� and the very question being addressed here will seem silly.聽Medicare began covering the treatment last year and there鈥檚聽growing momentum聽to include coverage in insurance plans. The European Court of Human Rights declared that the treatment was a basic right way back in 2002.

James Joyner is editor of the Outside the Beltway blog at http://www.outsidethebeltway.com/.