Smith v. Rasmussen, C97-3055-MWB.
| Decision Date | 14 July 1999 |
| Docket Number | No. C97-3055-MWB.,C97-3055-MWB. |
| Parties | John SMITH, Plaintiff, v. Jessie K. RASMUSSEN, in her Official Capacity as Director of the Iowa Department of Human Services, Defendant. |
| Court | U.S. District Court — Northern District of Iowa |
Thomas A. Krause of Max and Associates, P.C., Des Moines, IA, for Plaintiff.
Daniel W. Hart, Asst. Iowa Atty. Gen., Gordon E. Allen, Deputy Iowa Atty. Gen., Des Moines, IA, for Defendant.
TABLE OF CONTENTS
I. INTRODUCTION .................................................................. 740
A. Initial Findings Of Fact ................................................... 740
1. Gender identity disorder ................................................ 740
2. Smith's condition ....................................................... 743
B. Procedural Background ...................................................... 744
II. LEGAL ANALYSIS ............................................................... 746
A. Subject Matter Jurisdiction ............................................... 746
1. Arguments of the parties ............................................... 746
2. Justiciability ......................................................... 747
a. Standing ............................................................ 749
i. Constitutional and prudential requirements ..................... 749
ii. Smith's standing ............................................... 750
b. Ripeness ............................................................ 751
i. Constitutional and prudential requirements ..................... 751
ii. Ripeness of Smith's claim ...................................... 752
3. Disposition of the motion to dismiss ................................... 752
B. The Merits ................................................................ 753
1. The legal basis for Smith's claims ..................................... 753
a. The Director's arguments ............................................ 753
b. Analysis ............................................................ 753
2. Iowa's denial of coverage for sex reassignment surgery ................. 756
a. The Pinneke decision ................................................ 756
b. Reasonableness of the rule promulgation process ..................... 757
c. Reasonableness of the rule .......................................... 760
i. Medicaid coverage for "experimental" treatments ................ 761
ii. Defendant's evidence that sex reassignment surgery is
experimental .................................................. 763
iii. Other evidence ................................................. 769
3. Is sex reassignment surgery "medically necessary" for Smith? ........... 771
4. Is Smith "ready" for the final stage of sex reassignment surgery? ...... 771
III. CONCLUSION .................................................................. 772
Resolution of this lawsuit is not as simple as deciding whether the plaintiff should be left "betwixt and between" genders as he seeks completion of female-to-male sex reassignment surgery at the expense of the Iowa Medicaid program. Probably nobody familiar with the record in this case would disagree with the observation of plaintiff's treating psychiatrist that being "left in the middle" would be "just a nightmare for anyone." However, the ultimate question before the court is not whether the plaintiff's sex reassignment should be completed, but whether Medicaid should have to pay for it. Before even reaching the merits of that multifaceted question, the court must also determine whether this litigation, like the plaintiff, is caught "betwixt and between," this time somewhere between plaintiff's concerns and a justiciable Article III "case or controversy."
Plaintiff "John Smith"1 filed this action on May 19, 1997, seeking reimbursement under the Iowa Medicaid program for medically necessary surgical procedures, specifically, female-to-male sex reassignment surgery, as treatment for his gender identity disorder. He2 originally asserted that denial of Medicaid payments for his sex reassignment surgery was in violation of both Medicaid statutes and regulations and the due process clause of the Fourteenth Amendment to the United States Constitution. He has since withdrawn his due process claim, and at trial asserted only his claim that denial of payments for his sex reassignment surgery was in violation of the Medicaid statutes and regulations. Defendant Jessie K. Rasmussen,3 in her official capacity as the Director of the Iowa Department of Human Services (the Director),4 resists Smith's claim for payment for the final stages of his sex reassignment surgery.
What follows is not an exhaustive recitation of the court's findings of fact, but a statement of sufficient of the court's findings and the parties' factual contentions to provide a context for the legal analysis to follow. Because many of the issues that must be resolved in this case involve a complex intertwining of facts and law, pertinent findings of fact are interlaced with identification and application of the proper legal standards for resolution of those issues.
Plaintiff John Smith suffers from "gender dysphoria" or "gender identity disorder," sometimes known as "transsexualism." "Transsexualism" was in fact a diagnostic category under the criteria found in the third edition of the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, the so-called DSM-III-R, but the pertinent diagnosis is now "gender identity disorder." See DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed.) (DSM-IV). The DSM-IV identifies the general diagnostic features of this gender identity disorder as follows:
There are two components of Gender Identity Disorder, both of which must be present to make the diagnosis. There must be evidence of a strong and persistent cross-gender identification, which is the desire to be, or the insistence that one is, of the other sex (Criterion A). This cross-gender identification must not merely be a desire for any perceived cultural advantages of being the other sex. There must also be evidence of persistent discomfort about one's assigned sex or a sense of inappropriateness in the gender role of that sex (Criterion B). The diagnosis is not made if the individual has a concurrent physical intersex condition (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia) (Criterion C). To make the diagnosis, there must be evidence of clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion D).
DSM-IV, 532-33.5
Gender identity disorder is suffered by people of all ages, although it manifests differently at different ages:
Distress or disability in individuals with Gender Identity Disorder is manifested differently across the life cycle. In young children, distress is manifested by the stated unhappiness about their assigned sex. Preoccupation with cross-gender wishes often interferes with ordinary activities. In older children, failure to develop age-appropriate same-sex peer relationships and skills often leads to isolation and distress, and some children may refuse to attend school because of teasing or pressure to dress in attire stereotypical of their assigned sex. In adolescents and adults, preoccupation with cross-gender wishes often interferes with ordinary activities. Relationship difficulties are common and functioning at school or at work may be impaired.
Id. at 534. More particularly, because the plaintiff here is an adult with gender identity disorder, it is pertinent to note the DSM-IV's description of adults with gender identity disorder:
Adults with Gender Identity Disorder are preoccupied with their wish to live as a member of the other sex. This preoccupation may be manifested as an intense desire to adopt the social role of the other sex or to acquire the physical appearance of the other sex through hormonal or surgical manipulation. Adults with this disorder are uncomfortable being regarded by others as, or functioning in society as, a member of their designated sex. To varying degrees, they adopt the behavior, dress, and mannerisms of the other sex. In private, these individuals may spend much time cross-dressed and working on the appearance of being the other sex. Many attempt to pass in public as the other sex. With cross-dressing and hormonal treatments (and for males, electrolysis), many individuals with this disorder may pass convincingly as the other sex. The sexual activity of these individuals with same-sex partners is generally constrained by the preference that their partners neither see nor touch their genitals. For some males who present later in life, (often following marriage), sexual activity with a woman is accompanied by the fantasy of being lesbian lovers or that his partner is a man and he is a woman.
The Harry Benjamin International Gender Dysphoria Association, Inc., often called the "Harry Benjamin Society," is a professional organization for persons involved in the diagnosis and treatment of gender identity disorder and related conditions. It is named after the first person to describe the syndrome, and the results of recent research into the nature or treatment of the condition are often first presented at its meetings. The Harry Benjamin Society has drafted the recognized standards of care...
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