A gag policy memo from Bishop Robert Duncan to the Presiding Bishop

I'm starting my first year in the School of Public Health at the University of Michigan. We were required to write a ficticious policy memo for one of my classes. I chose to write on transgender rights in healthcare. I also chose to take some fictional license and to make it from one bishop to another in my beloved Episcopal Church. And, in a joke that I doubt my professor will understand, I chose to ghost-write for Bishop Robert Duncan, the notoriously homophobic bishop of the Episcopal Diocese of Pittsburgh, who is trying to lead his diocese and some others out of the church. I decided to post this to enlighten my readers (however many of you there may be) on the health care issues facing the transgender community, which is especially marginalized. And if you know anything about me, you also know that I have a slightly twisted sense of humor.

Cheers, Bob! Love what you're doing!

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To: Rt. Rev. Katharine Jefferts Schori, Presiding Bishop, The Episcopal Church

From: Rt. Rev. Robert Duncan, MPH, Bishop, Episcopal Diocese of Pittsburgh

Re: Transgender Rights Legislation

Dear Bishop Jefferts Schori,

I am writing to urge you to ensure that the Episcopal Church provides for the health of the transgender community. Keeping in mind Christ’s admonishment that “whatever you did to the least of these, you did it to me,” my diocese is taking steps to provide full insurance coverage for transgender individuals. We have amended our canons to ban discrimination based on gender identity as well as sexual orientation. And, since Pennsylvania law protects neither sexual orientation nor gender identity, we are joining in advocacy efforts to reach our state legislators. The University of Michigan, my alma mater, is soon expected to take similar steps, and a number of States, municipalities, companies, and other organizations have already done so. We should do likewise at the Diocesan and the national level, and take leadership among the major American religious bodies.

According to the Human Rights Campaign (2004), “transgender” is a broad term encompassing all persons who “live all or substantial portions of their lives expressing an innate sense of gender other than their birth sex.” Gender identity is “a person’s innate sense of gender.” Discrimination based on gender identity is legal in most states, and the transgender community is very marginalized as a result. Transgender people may experience discrimination when their transgender status is discovered, revealed, or suspected, or when they transition to another gender. The persistent workplace discrimination they face results in underemployment and unemployment, which reduces access to healthcare.

Insurance providers usually refuse to cover medical services relating to transitioning, such as hormone treatments and sex-reassignment surgery. Some ordinary surgeries may not be covered if they are seen as related to transgender status. The Transgender Law Center (2006) cites an interview with a female to male (FTM) transsexual who developed uterine cancer after transitioning, but whose insurance would not “treat uteruses in men.” Even if insured, doctors may refuse treatment because of personal prejudice; the Human Rights Campaign (2004) gives the example of an FTM transsexual who developed cervical cancer, but was refused treatment by 20 doctors. He found a willing doctor 130 miles from his residence, but died as a consequence of delayed treatment. Experiences and rumors of discrimination may stop transgender individuals from seeking or continuing medical treatment. (Lombardi, 2001)

Clements et al (1999) found that transgender individuals may be at higher risk for HIV and other STDs, and were unable to fully access HIV prevention and health services. In focus groups conducted in San Francisco, they found that many participants had engaged in sex work at some point in their lives, due to economic necessity. Participants felt that discrimination contributed to low self-esteem, which in turn led to taking risks with unprotected sex. The relief at being able to pass as their chosen gender, and being able to find a partner who accepted them sexually, also contributed. The participants also discussed high community levels of intravenous drug use. Healthcare providers were seen as insensitive to the needs of the transgender community. They felt that, for HIV prevention programs to be successful, the transgender community’s needs for successful employment, housing, and substance abuse and mental health programs had to be addressed first.

Hormone treatments and sex reassignment surgeries are expensive for individuals. Costs of FTM surgery from websites of prominent plastic surgeons range from $4,000 to $60,000; MTF surgery is slightly cheaper (Horton, 2006). Also, patients require mental health consultations to be diagnosed with “gender identity disorder” before they can undergo surgery or receive hormones. A myth prevails that transgender health benefits will drive up insurance costs. A former parishioner at the University of Michigan recalled how she was harassed when the University was debating whether to include transgender health benefits in insurance. Someone accosted her, and screamed, “I don’t want to pay for your sex change, you freak!” (Smith, 2005). However, the prevalence of transgenderism is low. Horton estimates that if spread over the entire population of people with health insurance, the maximum cost for all transgender health benefits, surgical and non-surgical, is a maximum of $3.64 per insured person, and a minimum of $0.16. She estimates that, in 2001, up to 1495 sex-reassignment surgeries were performed nationwide.

Frankly, there are few transgendered people. We may get a few or no transgender clergy candidates. Some might say we raised our premiums, albeit not by much, for nothing. That is not the point. We are sending a message to society that we are prepared to provide for the physical, me0ntal, and spiritual health of transgender employees. We are saying that discrimination is unacceptable, that it is not wrong to be in a minority as regards gender identity. We believe that we are playing some role in decreasing the physical and psychic violence that the transgender community faces. There is no theological justification for discrimination against them. I am proud of my diocese for saying so, and I pray the wider Church will take similar action.


Anonymous. (2006). Recommendations for transgender health care. Available: http://www.transgenderlaw.org/resources/tlchealth.htm October 9, 2006.

Anonymous. (2004). Transgender basics. Available: http://www.hrc.org/Content/NavigationMenu/HRC/Get_Informed/Issues/Transgender_Issues1/Transgender_Basics/Transgender_Basics.htm October 9, 2006.

Crea, J. (January 7, 2005). Trans inclusion dooms Md. Hate bill: delegate. Available: http://washblade.com/2005/1-7/news/localnews/inclusion.cfm October 9, 2006.

Clements K., Wilkinson W., Kitano K., Ph.D., Marx R., Ph.D. (1999) HIV Prevention and Health Service Needs of the Transgender Community in San Francisco. IJT 3,1+2, http://www.symposion.com/ijt/hiv_risk/clements.htm

Horton, M. A. (January 14, 2006). The cost of transgender health benefits: transgender at work. Available: http://www.redace.com/thb2006/THBCostTechReportDraft4.2.pdf October 7, 2006.

Smith, J, personal communication, September 20, 2005.

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PS Take note, some events in the article are fictional. The real Bob Duncan never wrote this memo. He will not write anything like it in his lifetime. His successor will certainly not. The U of M is not Duncan's alma mater, and I do not expect it to provide transgender health benefits in the near future, although I believe it will at some point. And there is no Smith, J, whose ficticious personal communication I cite. The line is real, though. The partner of a transgendered individual testified at a Regents' meeting, and she mentioned that someone had shouted those words at her.