Sex change at taxpayer expense?

Though the psychiatric world recognizes and treats gender identity disorder — defined by the National Institutes of Health as a disconnect between a person’s physical gender and the gender the person identifies with — that recognition hasn’t translated into widespread insurance coverage for sex-change operations that some patients feel is the only solution to their turmoil. Most private insurance and Medicaid programs do not pay for the surgery, viewing it as elective; neither does Medicare.

Yet a Massachusetts judge has ordered the state to pay for sex-reassignment surgery for an imprisoned murderer.

There is little doubt that Michelle Kosilek — known as Robert in 1990, when he killed his wife after she discovered him dressing in her clothes — struggles with the disorder. After entering prison, Kosilek took hormone therapy, switched sexual identity and chose a new first name, though she is still in a men’s prison serving a sentence of life without parole. According to doctors, she has attempted both self-castration and suicide because her image of her gender is so at odds with her body.

At first it might seem ridiculous for a person guilty of a heinous crime to receive taxpayer-funded surgery that is not necessary to save life or limb. But prisons do not deny psychiatric drugs to inmates who need them. Nor is it a simple matter of saving taxpayers money. Kosilek’s surgery would cost only about $20,000; by contrast, if she doesn’t undergo the surgery, the added cost for housing her in a men’s penitentiary (she would be moved to a women’s prison after surgery) would be significant over her lifetime; so would the expense of preventing further attempts at suicide or self-castration, or treating injuries sustained in those attempts.

Nevertheless, we see no reason for a convicted criminal to receive medical attention that is above and beyond the community standard of care. A year ago, a California court rightly rejected a similar lawsuit by a convicted killer.

Society’s understanding of disorders and illnesses evolves over time. Less than half a century ago, hyperactive youngsters were labeled, and punished, as bad children; now we know there is a neurological basis for this behavior and that attention-deficit disorder can be treated. Should the generally recognized standard of insurance coverage change for gender identity disorder, it would be right for prisons to follow that standard. For the moment, though, the Massachusetts prison system should have been allowed to follow the current standard.