A few weeks back, I told you about my left knee. It’s wearing out. When I was young and immortal, no one told me that I had a limited number of knee bends and straightens. After running a couple thousand miles when I was much younger and riding my bike more than 30,000 miles in recent years, I’ve hit the limit of bends and straightens. For my left knee anyway.
I went to an orthopedic surgeon to have my knee looked at. At that time, my symptoms were intermittent. Sometimes my knee would lock up and sometimes it wouldn’t. Sometimes I’d limp and sometimes I wouldn’t. When she first examined my knee, it wasn’t locking, and I wasn’t limping. She only had my word that it sometimes didn’t function properly.
But that wasn’t enough.
My doctor ran some tests to prove my knee was indeed bad. After an x-ray and an MRI, she told me that what she recommended was that I get a cortisone injection. I asked about orthoscopic surgery (i.e., worn-out-knee affirming surgery). I was politely informed that an injection is the first step because it’s the procedure with the least amount of risk involved.
So, we’d try that first to see if it helped. If it was effective, then we’d continue to do cortisone shots every few months until they stopped working. Any talk of surgery would need to happen after we found out whether the cortisone would fix my problem.
It didn’t.
Doctor Club
Do you know what the first rule of Doctor Club is? It’s not “Don’t talk about Doctor Club.” It’s “primum non nocere”. For those of you who don’t understand Latin, that translates to “first, do no harm”.
Every doctor essentially promises not to make things worse than they already are. Not on purpose anyway.
Now, I already had x-rays and an MRI done on the knee. It’s quite likely that the doctor already guessed that the injections might not help. But she recommended it anyway. Because it might work. And because there was absolutely no downside to giving it a try.
But like I said, the injection wasn’t helpful. So, on to Plan B. And Plan B is the procedure with the next to the least amount of risk. That would involve poking a camera in my knee and trying to fix what they can. Hopefully, they’ll be able to get rid of my symptoms with a minimally-invasive orthoscopic procedure because Plan C would involve some major surgery in the form of a total knee replacement.
I say she “recommended” we do Plan A, B, and C in that order, but it’s not like I have any choice. It’s not like I can say, “nope, let’s skip A and B and go right to Plan C”. It doesn’t work like that. Not for most people anyway.
No pun intended, but I’m a little attached to my knee. Sure, it hurts like a mofo sometimes, but I know that once a surgeon cuts it out and replaces it with an artificial one, there is no possible way for me to get my OEM knee back. Once it’s gone, it’s gone forever.
But we’re not there yet. Because before I do something permanent, I’m going to try all the other, less-potentially-harm-causing-and-less-permanent treatments. And Plan B is next on the list.
However, before we could attempt Plan B, we needed to get the insurance company to sign off on it. The doctor’s staff filled out the required paperwork, hit the “send” button, and we waited for approval.
It didn’t come.
Not Medically Necessary
I received a letter from the insurance company yesterday. My request for them to pay for orthoscopic surgery was denied because they had determined that it wasn’t “medically necessary”.
Really. With the x-rays and MRI, they don’t have to take my word for it. I have physical proof that there’s something wonky with my knee. We already tried the cortisone, and I had to limp back into the doctor’s office to tell her it didn’t work. But the insurance company still feels that a simple outpatient procedure isn’t medically necessary.
So, an appeal was filed. My doctor talked with their doctor and discussed my case. All the appropriate forms were filled out, t’s crossed and i’s dotted. No dice. I just got off the phone where I was told the nearly routine surgery I need to be able to walk without a limp is still considered not medically necessary.
One of the reasons they gave was that I hadn’t first tried therapy. OK. I guess they don’t quite understand the concept of cause and effect. If my knee has worn out because I’ve used it too much, how is using it more going to help?
Let’s unpack this a bit. The doctor did nothing wrong. Her recommended course of treatment is a good balance of risk-vs-reward. Clearly, we should attempt all non-permanent options before hacking out one of my body parts.
Technically, the insurance company didn’t do anything wrong either. In their minds, therapy is a non-invasive step that should occur before even the minimally-invasive orthoscopic procedure. Therapy is also cheaper. If there was some sort of stretching exercise I could do that would postpone or eliminate a more expensive treatment, it makes sense for them to require me to try that first.
The approach taken by my doctor, my insurance company, and me was to do as little harm as possible and still fix the problem. And possibly save a little money at the same time. That’s been the standard operating procedure for more than 2,500 years.
If I want the surgery, I have to jump through all the hoops that the insurance company wants me to jump through. Or there’s another option, I can pay for it out of my own pocket. But, if I have to pay for it myself, I’d probably just tough it out. At least for a while. My desire to have surgery is directly proportional to how much the insurance company is going to pay.
The Loophole
So, I need another plan. I need a plan where the insurance company has no choice but to approve my surgery and pay for it. Don’t tell anybody, but I’m thinking I can use this “gender identity” thing to my advantage.
See, if I go to my doctor and tell her I believe I’m a woman, it’s actually illegal for her to disagree with me. She can’t legally even ask me a question about my delusion. All she can do is to write me a prescription for whatever drug I think will make me more lady-like and give me a fast ticket to Surgeryland.
As dysphoric people go, I’m one of the lucky ones. It turns out that I’m mostly OK with my body image. The only thing I have a problem with is the torn meniscus and bone fragments floating around in my left knee. That makes it impossible to walk around in heels. Which makes me feel sad. And less feminine.
So, you see, having my knee repaired is vital to affirming my gender identity. After all, as we all know, nothing says “woman” like a man with a beard walking around in high heels. And because I’m dysphoric, the whole “do no harm” idea doesn’t apply. I get to skip all those pesky low-risk things like therapy and medication, and go right to irreversible chemicals and major surgery.
Now all I have to do is convince the insurance company to pay for it. That won’t be a problem. Because more often than not, insurance companies are deciding that “gender affirming care” is medically necessary. As a dysphoric person, no one is allowed to question my desire for gender affirming surgery. Which, in my case, includes repairing my knee.
I know it might not be quite as easy as I make it out to be. If I have to, I’ll also sign up for top and bottom surgery. But we’re going to start with my knee. Once I’m able to comfortably prance around in heels, I’ll decide if I want to continue with my transition <here’s a secret: I’m not going to continue with my transition>.
The Problem
I think I understand the problem. Insurance companies are willing to pony up hundreds of thousands of dollars to pay for elective surgeries and millions more to cover a lifetime of complications and ill health which are the direct result of those elective surgeries.
However, insurance companies are in the business of making money. They have a responsibility to their stockholders to do so. Which means that to provide coverage for someone else’s imagined issues, they have to deny coverage for my real ones. Like my worn-out knee.
But, if I say that being able to walk in high heels is vital to my gender identity, then, like magic, fixing my knee becomes “medically necessary” and I get priority treatment.
Doctors have treated patients with the same standard of care for thousands of years. That standard of care includes “first do no harm”. But for some reason, when it comes to dysphoric affirmation, that doesn’t apply.
Even if a doctor wanted to push back on a delusional patient, doing so can cost them their license and livelihood. So, instead of trying the least-invasive/non-permanent solutions first, physicians simply give the patient what they want and go immediately from “I think I may be a woman” to “let’s get you scheduled for surgery”.
Definitely NOT Harmless
I might be the only one, but I can say with absolute certainty that before I had any body part cut off, I’d make damn sure that it’s the only solution left on the table. If I started believing I’m a woman, then I’d want to try everything possible BEFORE I did something permanent like injecting myself with female hormones or getting my dick chopped off.
Anyone who doesn’t first exhaust all other options before permanently changing their body is obviously mentally ill and not fit to make their own medical decisions.
So, why are we making it easy for them to do so? If I’m required to have therapy before I can get my knee fixed, then I don’t think it’s unreasonable to expect someone to have months of intensive therapy before they can have body parts remodeled. If I have to jump through hoops for the insurance company, then they should have to as well.
Where gender dysphoria is involved, the medical establishment has gone from “first, do no harm” to “do as much harm as you can in as little time as possible”. That has to change.
And the easiest way to do that, is to simply recategorize body mutilation as “not medically necessary”. Because I guarantee you, a dysphoric person’s desire to have their junk cut off is directly proportional to how much of the procedure their insurance company is willing to pay for.
If the people wanting “gender affirming surgery” had to pay for it out of their own pocket, we’d have a lot fewer people lining up to have their gender surgically affirmed.
Allowing people to skip all the non-invasive steps and jump right to inflicting permanent damage on themselves does nothing but harm, and it certainly isn’t necessary.
