Doe v. State, Dept. of Public Welfare, 47131

• Decision Date: 19 August 1977
• Docket Number: No. 47131,47131
• Citation: 257 N.W.2d 816
• Parties: Jane DOE, Appellant, v. STATE of Minnesota, DEPARTMENT OF PUBLIC WELFARE, Respondent, Hennepin County Welfare Board, Respondent.
• Court: Minnesota Supreme Court

Page 816

257 N.W.2d 816

Jane DOE, Appellant, v. STATE of Minnesota, DEPARTMENT OF PUBLIC WELFARE Respondent Hennepin County Welfare Board, Respondent.

No. 47131.

Supreme Court of Minnesota.

Aug. 19, 1977.

Syllabus by the Court

1. The total exclusion of transsexual surgery from eligibility for medical assistance (M.A.) benefits appearing in the Minnesota Department of Public Welfare's publication entitled the Medical Assistance Program Physician's Handbook and employed by the state welfare department to justify its denial of benefits is void. Future applications for M.A. benefits to fund transsexual surgery must be considered by the agencies on a case-by-case basis involving a complete and unbiased medical evaluation to determine the medical necessity of the requested operation.

2. A standard of medical necessity requiring an applicant for M.A. benefits to prove by conclusive evidence that the requested medical treatment will eliminate the applicant's disability and render him self-supporting is invalid.

3. The determination by the state welfare department to deny M.A. benefits in the present case was arbitrary and unreasonable.

Michael R. Fargione, Legal Aid Society, Minneapolis, for appellant.

Warren Spannaus, Atty. Gen., Thomas L. Fabel, Deputy Atty. Gen., Marianne D. Short, Special Asst. Atty. Gen., St. Paul, for State.

Gary Flakne, County Atty., James F. Bares, Asst. County Atty., Minneapolis, for Hennepin County Welfare Bd.

Heard before TODD, MacLAUGHLIN, and YETKA, JJ., and considered and decided by the court en banc.

TODD, Justice.

Jane Doe is an adult male transsexual. After an initial screening process, Doe was selected to undergo sex conversion surgery at one of the University of Minnesota Hospitals (university hospital) in its original transsexual program. The Federal funding of the university hospital's program ended before surgery was performed on Doe. Thereafter, Doe, an eligible recipient of medical assistance (M.A.) benefits, applied to the Hennepin County Welfare Department (county welfare department) to fund the operation under its M.A. program. After an initial denial of his request, a hearing was conducted before a hearings officer for the county welfare department who determined to grant Doe benefits for the surgery. The county welfare department appealed this decision to the Minnesota Department of Public Welfare (state welfare department), which reversed the hearings officer's decision, concluding in part that Doe should not be granted benefits because he failed to prove that the requested surgery would allow him to become self-supporting. Doe appealed to the district court which affirmed the state welfare department's decision to deny benefits. We reverse and remand.

Jane Doe is a female pseudonym for appellant, a 45-year-old genetic male, who is a transsexual. As a transsexual, Doe began cross-dressing as early as 1950. For the past 10 years, Doe has attempted to live his entire life as a female, including changing his name. Since 1968, Doe has been undergoing hormonal therapy at the university hospital. The purpose of hormonal therapy is to assist an individual in developing female characteristics while also preparing him for sex conversion surgery.

Doe was one of 25 candidates selected from a large number of applicants to undergo sex conversion surgery at the university hospital in its original transsexual program. Sex conversion or reassignment is a complicated procedure which involves the removal of the male sex organs and construction of female genitalia to replace the male organs. Stoller, Sex and Gender, p. 247. Prior to his admission into the university hospital's transsexual program, Doe underwent extensive evaluation and testing by the university hospital's gender committee in order to determine the propriety of surgery in his case. Apparently, by the time the program was terminated, Doe had developed all the physical characteristics of a female absent the removal of the male sex organs and the construction of the female sex organs. The surgical procedure was not ultimately performed on Doe because funding for the university hospital's program for transsexuals was ended.

After the termination of the university hospital's program, Doe applied to the county welfare department to fund the surgical procedure under its M.A. program. Since 1972, Doe has been an eligible recipient of benefits under the M.A. program because he was certified as totally disabled for psychological reasons resulting from his transsexual condition.

Doe was informed by his social worker that his application for M.A. benefits had been denied. Thereafter, Doe filed an appeal from the denial of M.A. benefits with the county welfare department. An evidentiary hearing was conducted by a local hearings officer who reversed the original decision of the county welfare department and granted Doe benefits for the surgery.

The county welfare department appealed to the state welfare department which reversed the hearings officer's decision and determined that Doe was ineligible to receive M.A. benefits for the proposed surgical procedure, stating:

"1. The DPW Physician's Handbook 205 (10) states that the cost of transsexual surgery is not payable under the Medical Assistance Program.

"2. No conclusive evidence was presented to support the petitioner's contention that, if she has the surgery, her psychological problems will be alleviated to the point that she will no longer be disabled and will become self-supporting."

Doe then filed an appeal from the state welfare department's decision with the district court pursuant to Minn.St.1974, § 256B.11. ¹ After a hearing, the trial court affirmed the state welfare department's decision denying Doe benefits.

The following issues are raised on appeal:

(1) Whether the absolute prohibition against the funding of transsexual surgery through the use of M.A. benefits included in the state welfare department's publication, the Medical Assistance Program Physician's Handbook, is valid.

(2) Whether the standard employed by the state welfare department requiring Doe to prove that the surgical treatment requested would eliminate his disability and render him self-supporting is legally permissible.

(3) Whether the decision of the state welfare department denying Doe M.A. benefits for sex conversion surgery was arbitrary and unreasonable.

Initially, a general discussion concerning transsexualism is in order. A transsexual male is a person anatomically male who psychologically identifies himself as and believes himself to be a woman. In discussing the problem of transsexualism, medical experts have found it useful to distinguish between the terms "sex" and "gender." Sex connotes the anatomical qualities that determine whether one is male or female, while gender relates to behavior, feelings, and thoughts and does not always correlate with one's physiological status. See, generally, Stoller, Sex and Gender.

Although for most members of society sex and gender are synonymous, it is possible for each to develop independently. Ibid. In cases when sex and gender do develop independently, the end product is often a transsexual person plagued by the serious problem of "gender role disorientation, a painful cross-gender identity." Benjamin, Should Surgery be Performed on Transsexuals, 25 Am. J. of Psychotherapy 74, 75. See, also, Pauly, Adult Manifestations of Male Transsexualism, Transsexualism and Sex Reassignment, p. 37. The problem of gender role disorientation that often produces an adult transsexual occurs very early in life, occasioned primarily from postnatal psychodynamic factors. See, Benjamin, supra, p. 75; Stoller, supra, p. 83; Green, Childhood Cross-Gender Identification, Transsexualism and Sex Reassignment, p. 23.

The adult male transsexual ² is an anatomical male who has irreversibly accepted a gender identification as a female. He considers himself a normal woman trapped inside a male body. The transsexual male consciously views his male genitals as a symbol of maleness which runs directly contrary to his gender identity as a female. Since his male sex organs are a source of immense psychological distress, the male transsexual seeks their removal and construction of female sex organs in order to make both his sexual identity and his gender identity consistent. See, Stoller, supra, p. 260; Pauly, supra, p. 58.

Given the fact that the roots of transsexualism are generally implanted early in life, the consensus of medical literature is that psychoanalysis is not a successful mode of treatment for the adult transsexual. See, Benjamin, supra, p. 78; Stoller, supra, p. 249. The only medical procedure known to be successful in treating the problem of transsexualism is the radical sex conversion surgical procedure requested by Doe in the present case:

"It is the alternative that is sobering. In the light of present knowledge, there is no known approach to treatment of transsexualism other than the surgical route. Nothing else holds promise. Granted that the surgical route is difficult and clearly second-best to a method of preventing these tragic reversals of gender identity and role, yet it seems to be all that there is to offer at present." Hastings, Postsurgical Adjustment of Male Transsexual Patients, 1 Clinics in Plastic Surgery 335, 344.

See, also, Benjamin, supra, p. 80.

Thus, it is not unreasonable to conclude that transsexualism is a very complex medical and psychological problem which is generally developed by individuals early in life. By the time an individual reaches adulthood, the problem of gender role disorientation and the transsexual condition resulting therefrom are so severe that the only successful treatment known to medical science is sex conversion surgery.

1. The medical assistance program under which benefits are being sought in the present case is funded through Title XIX of the Social Security Act, 42 U.S.C.A. § 1396. It...