Originally published June 17, 2011 in Just Out.

By Erin Rook, Just Out

Portland became the third municipality in the country to eliminate all transgender-related health coverage exclusions June 8 when the Portland City Council voted unanimously to approve Mayor Sam Adams’ proposal to include medically necessary surgeries to the health plan for city workers.

The mayor said in his opening comments that extending full coverage to transgender city employees is both good business and the right thing to do. Adams pointed out that, in addition to Multnomah County and San Francisco, a number of major corporations such as Nike, Kraft and Coca-Cola already provide such benefits, but said that, above all, extending coverage is an issue of basic fairness.

“To the trans community of Portland, who each and every day makes this city a better place, it is my honor and privilege to serve on a city council that can bring an ounce of fairness in return,” Adams said.

About 130 trans folks and allies showed up to the meeting wearing blue and stickers provided by Basic Rights Oregon. As Commissioner Amanda Fritz pointed out, both levels of the chambers were standing room only.

Of the 16 people who gave testimony, only two were opposed to the mayor’s proposal. One argued that the city already provided “Cadillac” health care coverage, and that the crowd ought to be offering thanks rather than asking for more. The other claimed that God doesn’t support gender transition and that trans folks ought to seek spiritual solutions.

Though neither of those opposed addressed the issue of medical necessity, it is a question many have posed on the mayor’s Facebook page, in comments on news sites and in private conversations even within the LGBTQ community.

Jeana Frazzini, executive director of Basic Rights Oregon, tackled the topic head-on in her opening remarks.

“The American Medical Association has identified transgender health care as being medically necessary,” Frazzini said. “Yet many transgender Oregonians are routinely denied the ability to purchase health insurance or are denied coverage for basic, medically necessary care solely because they are transgender.”

The World Professional Association for Transgender Health, whose standards of care are internationally accepted, has released a statement on the “Medical Necessity of Treatment, Sex Reassignment and Insurance Coverage in the United States” that makes clear that sex reassignment surgery is neither cosmetic nor elective and ought to be considered as any other medically necessary treatment would be.

“Sex reassignment, properly indicated and performed as provided by the Standards of Care, has proven to be beneficial and effective in the treatment of individuals with transsexualism, gender identity disorder and/or gender dysphoria. Sex reassignment plays an undisputed role in contributing toward favorable outcomes, and comprises Real Life Experience, legal name and sex change on identity documents, as well as medically necessary hormone treatment, counseling, psychotherapy and other medical procedures,” WPATH wrote.

“The medical procedures attendant to sex reassignment are not ‘cosmetic’ or ‘elective’ or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition.”

One transgender city employee spoke to the issue of medical necessity from a personal perspective, via an anonymous statement read aloud during the meeting. He explained that the specific exclusion of medically necessary care for transgender people not only prevented him from using his health benefits to cover the cost of surgery, but also barred him from using his flexible spending account, due to similar exclusions in the federal tax system.

“It is important to note that trans-related care is a treatment process that involves the support and approval of a team of medical professionals,” the employee wrote. “I can also tell you that these services are absolutely vital to maintain a healthy, productive life. I am lucky enough that I was in a position to attain this care on my own. My ability to get this care enabled me to thrive as a person and function more effectively in my job. But not every transgender city employee is this lucky.”

While some critics have expressed concern about the potential cost to taxpayers, the mayor and commissioners made clear that the ultimate costs will be negligible, and a tiny percentage of the amount currently being spent on the city’s health plan.

According to Adams, the city is setting aside $32,302 to cover the cost of extending coverage for sex reassignment surgery. That figure is about .08 percent of the $41,615,000 the city expects to spend on its health care plan for 2011-12. The mayor anticipates that the actual cost to the city will be less than the budgeted amount, as has been the case in other jurisdictions.

“This is not about costs and benefits,” said Promise King, executive director of the Oregon League of Minority Voters. “This is about the sanctity of human life and respect for human dignity. So we cannot sidestep that as we talk about policy.”

Commissioner Dan Saltzman agreed that the price tag is not the most important issue. After hearing testimony about the high rate of suicide among transgender people, he said the cost is worth the benefits.

“This is going to be one of my proudest legacies: helping people to live as who they are in all aspects,” Saltzman said. “This is a small price to pay to help people live better lives.”

Following the city council’s unanimous vote, Adams put down his gavel and those gathered in support rose to their feet and cheered.

“I cried. I had emotion. I was nervous,” attendee Wyatt Riott confessed after the decision. “It’s also just exciting to see people come out for this.”