Commentary Law and Policy

What’s the Use of Private Insurance If You Don’t Feel Safe Using It?

Renee Bracey Sherman

Bills like SB 138 in California will enable people like me to access health care, mental health services, birth control, and substance treatments without fear that a parent or partner will find out about it, saving out-of-pocket and state costs along the way.

“Do you have insurance?” the nurse asked me as I checked in for my abortion. “Yep,” I replied and handed her the card. She asked if I was the policyholder; I was not. “Just so you know,” she said, “the insurance company will send a list of benefits used to the policyholder and they will see your abortion listed. Are you okay with that?” My heart sunk. While my parents identified as pro-choice, I hadn’t told them about the decision my partner and I made to have an abortion. They didn’t even know I was pregnant. I was planning on telling them, but not until I was ready.

I took back the insurance card and gave her my credit card, which I was privileged enough to have. The cost: $450. It was unreal. How was I going to afford that when I only worked part time for $8.50 an hour at a retail store? Here I was with insurance that covered my abortion-related care, but I couldn’t use it without my parents finding out. People who are lucky enough to have private insurance through another person, like a parent or partner, should feel safe enough to use it.

Fortunately, California is leading the way with a national model for protecting the privacy of the insured. With SB 138—the Confidential Health Information Act—introduced by Sen. Ed Hernandez (D-West Covina) and co-sponsored by groups like the American Civil Liberties Union, the California Family Health Council, and the National Center for Youth Law—loopholes that lead to the disclosure of sensitive and personal health information in the Explanation of Benefits letter and other health plan communications will be closed. The bill updates California law to include existing federal HIPAA (Health Insurance Portability and Accountability Act) provisions; so if you are seeking services that are sensitive, such as a sexually transmitted disease checkup, an abortion, or mental health services, you can keep that private and not have to fear someone will find out. SB 138 currently is making its way through the California legislature. After having made its way out of the California senate, it now awaits clearance out of the Assembly Appropriations Committee.

Thanks to the Affordable Care Act, young people can stay on their parent’s insurance until they turn 26 and more people will move into private insurance thanks to more affordable options that will be made available through Covered California, the state’s insurance marketplace. SB 138 would make sure that patients have the privacy they need and deserve when using their insurance.

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If bills like SB 138 were law when I had my abortion, I could have opted in to keeping my personal and sensitive health matters between me and my health-care provider. SB 138 also goes beyond sensitive health services. If you feel like disclosure of your health information for any health service could put you in danger, you could also opt in to privacy protections, and insurance companies will have to accept and honor your request.

Bills like this one will enable people like me to access health care, mental health services, birth control, and substance treatments without fear that a parent or partner will find out about it, saving out-of-pocket and state costs along the way. I hope you’ll join me in fighting for the Confidential Health Information Act in California and urging leaders in other states to do more to protect patient privacy in our new health-care delivery system and economy.

Roundups Sexual Health

This Week in Sex: Some Men Base Condom Use on Women’s Looks

Martha Kempner

This week, a study suggests some men are less likely to have safer sex with women whom they find attractive. There's now a study of women's pubic hair grooming habits, and a lot of couples don't have wedding-night sex.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Men Less Likely to Have Safer Sex If Partner Is ‘Hot’

The old adage “Never judge a book by its cover” is apparently easily forgotten when it comes to judging potential sex partners. A new study in BMJ Open found that men said they were less likely to use a condom if their potential partner was hot.

In this small study, researchers showed pictures of 20 women to 51 heterosexual men. The men were asked to rank how attractive the woman was, how likely they would be to have sex with her if given the opportunity, and how likely it was they would use a condom if they did have sex with her. The results revealed that the more attractive a man found a woman, the less likely he was to intend to use a condom during sex with her.

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Men also rated how attractive they consider themselves, and the results showed that this was also related to condom use. Men who thought of themselves as more attractive were less likely to intend to use a condom.

Researchers also asked the men to estimate how many out of 100 men like themselves would have sex with each woman given the opportunity and finally, how likely they thought it was that the woman in the picture had a sexually transmitted infection (STI).

The results of these two questions turned out to be related: The men assumed that women whom other men would want to sleep with were more likely to have STIs.

This did not make the men in the study any more likely to intend to use a condom with those women. In fact, the men were most likely to intend condom use with women they found less attractive, even though they considered these women less likely to have an STI.

This was a small study with a relatively homogenous group of men ages 18 to 69 near Southhampton, England, and it measured intention rather than behavior.

Still, the results could present a challenge for public health experts if men are making condom decisions on a broader scale based on attraction rather than risk assessment.

How and Why Women Groom Their Pubic Hair

A new study published in JAMA Dermatology is the first nationally representative survey of U.S. women’s pubic hair grooming habits. The study included more than 3,300 women ages 18 to 64.

Overall, 84 percent of women had engaged in some pubic hair grooming. Pubic hair grooming was more common among younger women (ages 18 to 24); among white women; and among women who had gone to college.

Before you start thinking everyone is out getting Brazilians, however, grooming means different things to different women. Only 21 percent of women said they took all their pubic hair off more than 11 times, and 38 percent of women say they’ve never done so. Moreover, waxing lags behind the most popular hair removal methods; only 5 percent of women say they wax compared with 61 percent who shave, 18 percent who use scissors, and 12 percent who use electric razors. (Respondents could choose more than one answer in the survey.)

Most women (93) do it themselves, 8 percent have their partners help, and 6.7 percent go to a professional.

The researchers were most interested in the most common reason women groom their pubic hair. The most common reason was hygiene (59 percent), followed by “part of my routine” (46 percent), “makes my vagina look nicer” (32 percent), “partner prefers” (21 percent), and “oral sex is easier” (19 percent).

Tami Rowen, the lead author of the study and a practicing gynecologist at the University of California, San Francisco, told the New York Times, “Many women think they are dirty or unclean if they aren’t groomed.”

But while people may think that, it’s not true. Pubic hair actually exists to help protect the delicate skin around the genitals. Rowen and other doctors who spoke to the Times believe that women, especially teenagers, are taking up grooming practices in response to external pressures and societal norms as reflected in images of hairless genitals in pornography and other media. They want young people to know the potential risks of grooming and say they’ve seen an increase in grooming-related health issues such as folliculitis, abscesses, cuts, burns, and allergic reactions. As some may remember, This Week in Sex reported a few years ago that emergency-room visits related to pubic hair grooming were way up among both women and men.

This Week in Sex believes that women should be happy with their genitals. Keeping the hair that grows does not make you dirty—in fact, it is there for a reason. But if shaving or waxing makes you happy, that’s fine. Do be careful, however, because the doctors are right: Vulvas are very sensitive and many methods of hair removal are very harsh.

Wedding-Night Sex May Be Delayed, But That’s OK With Most Couples

Summer is a popular wedding season, with couples walking down the aisle, exchanging vows, and then dancing the night away with friends and families. But how many of them actually have sex after the caterer packs up and the guests head home?

According to lingerie company Bluebella—about half. The company surveyed 1,000 couples about their postnuptial sex lives and found that 48 percent of them said they did “it” on their wedding night. Most women in those couples who did not get it on that night said they were just too tired. The men, on the other hand, said they were too drunk or wanted to keep partying with their friends. (It is unclear whether the survey included same-sex couples.)

By the next morning, another 33 percent of couples had consummated their marriage, but about 10 percent said it took 48 hours to get around to it.

But whenever couples did have that post-wedding sex, the overwhelming majority (84 percent) said it lived up to their expectations.

Analysis Politics

Advocates: Bill to Address Gaps in Mental Health Care Would Do More Harm Than Good

Katie Klabusich

Advocates say that U.S. Rep. Tim Murphy's "Helping Families in Mental Health Crisis Act," purported to help address gaps in care, is regressive and strips rights away from those diagnosed with mental illness. This leaves those in the LGBTQ community—who already often have an adversarial relationship with the mental health sector—at particular risk.

The need for reform of the mental health-care system is well documented; those of us who have spent time trying to access often costly, out-of-reach treatment will attest to how time-consuming and expensive care can be—if you can get the necessary time off work to pursue that care. Advocates say, however, that U.S. Rep. Tim Murphy’s (R-PA) “Helping Families in Mental Health Crisis Act” (HR 2646), purported to help address gaps in care, is not the answer. Instead, they say, it is regressive and strips rights away from those diagnosed with mental illness. This leaves those in the LGBTQ community—who already often have an adversarial relationship with the mental health sector—at particular risk.

“We believe that this legislation will result in outdated, biased, and inappropriate treatment of people with a mental health diagnosis,” wrote the political action committee Leadership Conference on Civil and Human Rights in a March letter to House Committee on Energy and Commerce Chairman Rep. Fred Upton (R-MI) and ranking member Rep. Frank Pallone (D-NJ) on behalf of more than 100 social justice organizations. “The current formulation of H.R. 2646 will function to eliminate basic civil and human rights protections for those with mental illness.”

Despite the pushback, Murphy continues to draw on the bill’s mental health industry support; groups like the American Psychiatric Association (APA) and the National Alliance on Mental Illness (NAMI) back the bill.

Murphy and Rep. Eddie Bernice Johnson (D-TX) reintroduced HR 2646 earlier this month, continuing to call it “groundbreaking” legislation that “breaks down federal barriers to care, clarifies privacy standards for families and caregivers; reforms outdated programs; expands parity accountability; and invests in services for the most difficult to treat cases while driving evidence-based care.”

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Some of the stated goals of HR 2646 are important: Yes, more inpatient care beds are needed; yes, smoother transitions from inpatient to outpatient care would help many; yes, prisons house too many people with mental illness. However, many of its objectives, such as “alternatives to institutionalization” potentially allow outpatient care to be mandated by judges with no medical training and pushed for by “concerned” family members. Even the “focus on suicide prevention” can lead to forced hospitalization and disempowerment of the person the system or family member is supposedly trying to help.

All in all, advocates say, HR 2646—which passed out of committee earlier this month—marks a danger to the autonomy of those with mental illness.

Victoria M. Rodríguez-Roldán, JD, director of the Trans/GNC Justice Project at the National LGBTQ Task Force, explained that the bill would usurp the Health Insurance Portability and Accountability Act (HIPAA), “making it easier for a mental health provider to give information about diagnosis and treatment … to any ‘caregiver’-family members, partners or spouses, children that may be caring for the person, and so forth.”

For the communities she serves, this is more than just a privacy violation: It could put clients at risk if family members use their diagnosis or treatment against them.

“When we consider the stigma around mental illness from an LGBT perspective, an intersectional perspective, 57 percent of trans people have experienced significant family rejection [and] 19 percent have experienced domestic violence as a result of their being trans,” said Rodríguez-Roldán, citing the National Transgender Discrimination Survey. “We can see here how the idea of ‘Let’s give access to the poor loved ones who want to help!’ is not that great an idea.”

“It’s really about taking away voice and choice and agency from people, which is a trend that’s very disturbing to me,” said Leah Harris, an organizer with the Campaign For Real Change in Mental Health Policy, also known as Real MH Change. “Mostly [H.R. 2646] is driven by families of these people, not the people themselves. It’s pitting families against people who are living this. There are a fair number of these family members that are well-meaning, but they’re pushing this very authoritarian [policy].”

Rodríguez-Roldán also pointed out that if a patient’s gender identity or sexual orientation is a contributing factor to their depression or suicide risk—because of discrimination, direct targeting, or fear of bigoted family, friends, or coworkers—then that identity or orientation would be pertinent to their diagnosis and possible need for treatment. Though Murphy’s office claims that psychotherapy notes are excluded from the increased access caregivers would be given under HR 2646, Rodríguez-Roldán isn’t buying it; she fears individuals could be inadvertently outed to their caregivers.

Rodríguez-Roldán echoed concern that while disability advocacy organizations largely oppose the bill, groups that represent either medical institutions or families of those with mental illnesses, or medical institutions—such as NAMI, Mental Health America, and the APA—seem to be driving this legislation.

“In disability rights, if the doc starts about talking about the plight and families of the people of the disabilities, it’s not going to go over well,” she said. “That’s basically what [HR 2646] does.”

Rodríguez-Roldán’s concerns extend beyond the potential harm of allowing families and caregivers easier access to individuals’ sensitive medical information; she also points out that the act itself is rooted in stigma. Rep. Murphy created the Helping Families in Mental Health Crisis Act in response to the Sandy Hook school shooting in 2012. Despite being a clinical psychologist for 30 years before joining Congress and being co-chair of the Mental Health Caucus, he continues to perpetuate the well-debunked myth that people with mental illness are violent. In fact, according to the Department of Health and Human Services, “only 3%-5% of violent acts can be attributed to individuals living with a serious mental illness” and “people with severe mental illnesses are over 10 times more likely to be victims of violent crime than the general population.”

The act “is trying to prevent gun violence by ignoring gun control and going after the the rights of mentally ill people,” Rodríguez-Roldán noted.

In addition, advocates note, HR 2646 would make it easier to access assisted outpatient treatment, but would also give courts around the country the authority to mandate specific medications and treatments. In states where the courts already have that authority, Rodríguez-Roldán says, people of color are disproportionately mandated into treatment. When she has tried to point out these statistics to Murphy and his staff, she says, she has been shut down, being told that the disparity is due to a disproportionate number of people of color living in poverty.

Harris also expressed frustration at the hostility she and others have received attempting to take the lived experiences of those who would be affected by the bill to Murphy and his staff.

“I’ve talked to thousands of families … he’s actively opposed to talking to us,” she said. “Everyone has tried to engage with [Murphy and his staff]. I had one of the staffers in the room say, ‘You must have been misdiagnosed.’ I couldn’t have been that way,” meaning mentally ill. “It’s an ongoing struggle to maintain our mental and physical health, but they think we can’t get well.”

Multiple attempts to reach Murphy’s office by Rewire were unsuccessful.

LGBTQ people—transgender, nonbinary, and genderqueer people especially—are particularly susceptible to mistreatment in an institutional setting, where even the thoughts and experiences of patients with significant privilege are typically viewed with skepticism and disbelief. They’re also more likely to experience circumstances that already come with required hospitalization. This, as Rodríguez-Roldán explained, makes it even more vital that individuals not be made more susceptible to unnecessary treatment programs at the hands of judges or relatives with limited or no medical backgrounds.
Forty-one percent of all trans people have attempted suicide at some point in their lives,” said Rodríguez-Roldán. “Once you have attempted suicide—assuming you’re caught—standard procedure is you’ll end up in the hospital for five days [or] a week [on] average.”

In turn, that leaves people open to potential abuse. Rodríguez-Roldán said there isn’t much data yet on exactly how mistreated transgender people are specific to psychiatry, but considering the discrimination and mistreatment in health care in general, it’s safe to assume mental health care would be additionally hostile. A full 50 percent of transgender people report having to teach their physicians about transgender care and 19 percent were refused care—a statistic that spikes even higher for transgender people of color.

“What happens to the people who are already being mistreated, who are already being misgendered, harassed, retraumatized? After you’ve had a suicide attempt, let’s treat you like garbage even more than we treat most people,” said Rodríguez-Roldán, pointing out that with HR 2646, “there would be even less legal recourse” for those who wanted to shape their own treatment. “Those who face abusive families, who don’t have support and so on—more likely when you’re queer—are going to face a heightened risk of losing their privacy.”

Or, for example, individuals may face the conflation of transgender or gender-nonconforming status with mental illness. Rodríguez-Roldán has experienced the conflation herself.

“I had one psychiatrist in Arlington insist, ‘You’re not bipolar; it’s just that you have unresolved issues from your transition,'” she said.

While her abusive household and other life factors certainly added to her depression—the first symptom people with Bipolar II typically suffer from—Rodríguez-Roldán knew she was transgender at age 15 and began the process of transitioning at age 17. Bipolar disorder, meanwhile, is most often diagnosed in a person’s early 20s, making the conflation rather obvious. She acknowledges the privilege of having good insurance and not being low-income, which meant she could choose a different doctor.

“It was also in an outpatient setting, so I was able to nod along, pay the copay, get out of there and never come back,” she said. “It was not inside a hospital where they can use that as an excuse to keep me.”

The fear of having freedom and other rights stripped away came up repeatedly in a Twitter chat last month led by the Task Force to spread the word about HR 2646. More than 350 people participated, sharing their experiences and asking people to oppose Murphy’s bill.

In the meantime, Sen. Lamar Alexander (R-TN) has introduced the “Mental Health Reform Act of 2016” (SB 2680) which some supporters of HR 2646 are calling a companion bill. It has yet to be voted on.

Alexander’s bill has more real reform embedded in its language, shifting the focus from empowering families and medical personnel to funding prevention and community-based support services and programs. The U.S. Secretary of Health and Human Services would be tasked with evaluating existing programs for their effectiveness in handling co-current disorders (e.g., substance abuse and mental illness); reducing homelessness and incarceration of people with substance abuse and/or mental disorders; and providing recommendations on improving current community-based care.

Harris, with Real MH Change, considers Alexander’s bill an imperfect improvement over the Murphy legislation.

“Both of [the bills] have far too much emphasis on rolling back the clock, promoting institutionalization, and not enough of a preventive approach or a trauma-informed approach,” Harris said. “What they share in common is this trope of ‘comprehensive mental health reform.’ Of course the system is completely messed up. Comprehensive reform is needed, but for those of us who have lived through it, it’s not just ‘any change is good.'”

Harris and Rodríguez-Roldán both acknowledged that many of the HR 2646 co-sponsors and supporters in Congress have good intentions; those legislators are trusting Murphy’s professional background and are eager to make some kind of change. In doing so, the voices of those who are affected by the laws—those asking for more funding toward community-based and patient-centric care—are being sidelined.

“What is driving the change is going to influence what the change looks like. Right now, change is driven by fear and paternalism,” said Harris. “It’s not change at any cost.”