By Katie Kerwin McCrimmon
FORT COLLINS — An 18-year-old college student who grew up as a girl and now identifies as a young man has settled a landmark civil rights case against Kaiser Permanente of Colorado.
In the rare case, the Colorado Civil Rights Commission found in March that there was probable cause that Miki Alexander Manigault suffered discrimination and unequal access to health care specifically because he is transgender. (Click here to see the Determination of Probable Cause.)
On the same day, after pressure from advocates at One Colorado, Colorado’s Division of Insurance issued a bulletin and became the third state in the country to specifically bar health insurance companies from discriminating against people who are gay, lesbian, bisexual or transgender. (California and Oregon preceded Colorado. The District of Columbia also bans discrimination against LGBT patients and Vermont has since followed suit.)
Faced with charges of unequal treatment, Kaiser Permanente quietly settled Manigault’s case before it was slated to go to a hearing in June. Amy Whited, a spokeswoman for Kaiser Permanente, declined to discuss Manigault’s case. As a result of a settlement with the Civil Rights Commission, however, Kaiser, one of Colorado’s largest health insurance companies, has agreed to work with the commission to convene discussions among insurers regarding health care for transgender people. (Click here to see an announcement of the planned discussions.)
Manigault’s case has already prompted at least one other complaint to the Civil Rights Commission and may open the doors for equal health care for LGBT patients in Colorado and elsewhere in the U.S. (Related: Click here to read about Kelly Costello, another transgender patient who has fought for care: In abrupt reversal, Anthem covers transgender care)
Manigault grew up as Michaela, a girl with irresistible Shirley Temple dimples who nonetheless loathed girly dresses. She has now evolved into Alex, a young man embracing the gender that he believes he was born with. It just never matched his body. Until now.
Alex finally had the chest reconstruction surgery that doctors deemed medically necessary but Kaiser previously failed to cover, according to the formal complaint. (Click here to see the Notice of Hearing and Formal Complaint.)
Alex and his family cannot discuss any details of his settlement with Kaiser. But the Colorado State University art major agreed to share his story of struggle and transformation.
Alex recently traveled to San Francisco to have an experienced surgeon remove his female breast tissue and sculpt a male chest.
“They felt like tumors on my chest or phantom limbs,” Alex said of the female breasts, which he used to bind to try to flatten them.
He and his mom decided to bring the civil rights complaint and filed it in January of 2012, when Alex was just 17, because insurance companies provide all sorts of breast surgeries for other patients, including reconstruction for psychological well-being for cancer patients. It seemed fair to them that health insurance should also provide coverage that makes transgender people healthier.
“A lot of transgender people go through so much drama and so much heartache and waiting for years and sometimes decades to even talk about what it is they want and need,” said Alex. “When you can finally admit what you want and feel safe, then the insurance company tells you ‘No,’ and puts another obstacle in front of you, that’s wrong.
“I’m just as surprised as you that I’m transgender,” Alex says.
Alex credits his mom for being in his corner and pressing the case. Deborah Manigault is a civil rights law enforcement officer for the U.S. Department of Housing and Urban Development. So she knew how to file a civil rights complaint and felt it was clear that Alex deserved to win.
“These are not elective surgeries. They are medically necessary for their health, for their mental health and their medical well-being,” she said. “There are many insurance companies who are claiming to be LGBT-friendly, but they are denying coverage based on transgender status.”
Alex has not decided how to proceed with what transgender people call bottom surgery. Many transgender people evolving from female to male don’t bother seeking a surgically created penis since the options are poor. Results are much better for males becoming female because an experienced surgeon can essentially tuck the penis into the body and retain sensation.
Alex has been taking testosterone injections since his junior year of high school, so his voice is now deep and body hair has sprouted on his stomach and will fill his chest once it fully heals. Now a sophomore in college, he still thinks he looks somewhat feminine because of a long, graceful neck and fine cheekbones that any model would envy. But the testosterone he must inject every two weeks literally empowers him as it bulks up his muscles.
In contrast to the famous “It Gets Better” campaign, Alex says it doesn’t get better overnight. Still, he is no longer hiding from friends and the world, afraid to hear his own voice. At last, he is embracing his manhood. He is becoming Alex.
‘I didn’t want to be transgender’
Alex doesn’t remember a light bulb moment when he suddenly knew that he should have been a boy. Instead, growing up in Maryland and the conservative South, he remembers being a weird kid who could beat all the boys in running races, but never fit in.
“I went through a long process of feeling I was different in some way and not knowing what that difference was,” Alex says.
Way back, at age 2, Michaela was a flower girl in a relative’s wedding. An outgoing toddler, Michaela pitched a fit over wearing the poufy floral dress for the ceremony. At the time, Deborah Manigault attributed the tantrum to a 2-year-old’s fickle independence. Now Deborah wonders if it was an early sign that Michaela didn’t feel right in her body.
As a fifth-grader, Michaela remembers once being teased by a group of classmates for not fitting in. She sought solace in a large cubby where she curled up and hid.
For years, hiding provided comfort.
But that was hard to do when you had to go out in public and figure out what to wear or whether to present yourself as a boy or a girl.
Tall and skinny, Michaela hated dresses and skirts. Pants fit like high-waters on her long legs. Her favorite item of clothing one year was a comfy pair of blue boys’ swim trunks that she remembers wearing day after day. Like Michaela, they were male with a touch of female. Hibiscus flowers crawled up the sides of the boy shorts.
By middle school, Michaela was wondering if she might be gay and attracted to girls.
A girl whose nickname was Apple passed through Michaela’ s school for a time. She was a tomboy too. They briefly flirted. But Apple left town and Michaela still couldn’t figure out why she was different.
On top of experiencing two genders, Alex is also biracial with an African American dad and an Anglo mom. Alex could pass for either. But when it comes to race and gender, Alex has often felt like an outsider.
Michaela was the only black kid in a rural white Georgia community. Then she had the reverse experience when her family moved closer to Atlanta and she had mostly black friends who sometimes ribbed her about her perfect “white person hair.”
Sports provided an outlet. Michaela still holds records from middle school for the mile, two mile and several relays. In high school in Georgia, Michaela was the only freshman to make the varsity soccer team. While Michaela fell in love with soccer, she couldn’t figure out her own identity. She hated having to dress up and wear high heels as required by the coach on soccer game days. She remembers wearing wedge shoes just long enough to run into her coach, then quickly switching to flat red Converses.
Early in high school, Michaela stumbled across Japanese Manga comic books that showed men attracted to men. Somehow that resonated. Either on a radio show or the Internet — Alex can’t remember which — she heard about transgender people and found an unwelcome answer.
“I didn’t want to be transgender. I was a really lazy child and it was a lot of work. It’s a lot of work for the rest of your life,” Alex said. “It took a while to talk about it openly. It felt like this really secretive thing, like someone had hurt me and I hadn’t shared it. It felt like a really secret bad thing.”
Mom guessed, dad reluctant to allow testosterone
Despite the pain and fear, Michaela knew she had to talk to her parents.
One day, early in 10th grade, she became very upset and was crying and told her mom she had to tell her something, but couldn’t say it. Michaela made her mom guess.
“I was scared to death,” Deborah Manigault recalled. “I’m thinking bad stuff: drugs, alcohol or you failed every class this year. Eventually I got to gay, then I landed on ‘You think you’re a boy.’”
Relief washed over both mother and daughter. Michaela had been suffering from depression and sleep problems. Although Deborah said she had never had any clue before she uttered the words that Michaela might be transgender, her child’s challenges suddenly made sense.
“It was something to grasp onto. This is what’s been wrong. She had terrible bouts of depression and misery,” Deborah said. “Golly. My only wish is that he had told us even sooner. When you have a miserable child, you’ll do simply anything to have that happy child back.”
Deborah thinks the fact that she happens to be a civil rights officer who could advocate legally for her only child was a great coincidence.
“I filed our complaint out of desperation and was also thinking, ‘What the heck. Let’s give it a go.’ It felt right.
“Not only on a practical level, but also on a deep spiritual level, perhaps babies do pick their parents. I’m grateful that this particular child was born to us. There are a lot of children who don’t turn out exactly the way parents would have assumed they’d turn out. A lot of parents do reject children. To me, discarding a child is the deepest form of evil.
“I am very, very grateful for Alex and grateful he was born to us and not to someone who was bigoted and intolerant.”
When Deborah looks back at Michaela’s art and photos of her, it all makes sense. Yes, she always had been boyish. And she had a ‘take no prisoners’ attitude. Deborah had even borrowed the famous Clint Eastwood movie line as a caption for one of Michaela’s childhood photos: “Go ahead. Make my day.”
Once Michaela opened up, Deborah got busy trying to help her daughter adapt to becoming a son. She wanted Michaela to tell her dad right away. But Alex remembers locking the door of his room and refusing to come out.
Eventually the two talked. Slowly since then, Alex’s dad has come to terms with his daughter’s need for reinvention.
“It was like the death of a child. They know I’m going to be different. They have to bury the memory of that girl that they raised in order to have a new child come out,” Alex says.
“That was a really hard process for my dad.”
A logical computer expert and graduate of Georgia Tech, Manuel “Mani” Manigault wasn’t on board with a physical transformation at first, Alex says.
He objected to allowing his daughter to take testosterone.
“His personality almost wanted to prevent it from happening,” Alex says. “He’s more conservative on lifestyle stuff. He didn’t want me to get my lip piercings or to make my hair weird colors either.”
But for Alex, proceeding with the physical transformation was his only choice.
“Once my dad relented on the testosterone, he loosened his fist on the whole thing: ‘It looks like we’re doing the right thing.’ He saw how much less angry I was. I had better grades.”
Silent at high school: ‘I didn’t want to hear my own voice’
Alex said parents should trust their kids if they say they’re gay or transgender because the child or teen has already grappled with every possible doubt.
Despite invaluable support from his parents, Alex told no one else.
“I was very quiet. I didn’t talk to anyone. I was both depressed and scared to death to speak. My voice was very effeminate. I didn’t want to hear my own voice. I didn’t want to plant any seeds of doubt.”
That same year, Alex’s mom applied for a job in Colorado and transferred to HUD offices in Denver. The family then moved to Broomfield.
At first, Alex registered at Broomfield High School as a girl named Miki Manigault.
But he tried to wear men’s clothes so people would figure out he was really a boy.
“I was hoping I could simply imply something without having to explain it,” Alex said. “It was nerve-wracking. I felt like at any moment I could be caught in a lie. Do you really think you can bend the rules this way?”
Then in junior year, he decided to register as male and that turned out to be easy. The school district changed his name and gender in the system. He became Alexander and they simply checked the male box instead of female. Done.
School officials asked Alex to use a unisex bathroom for adults near the office; he found that a relief since he didn’t want any guys taunting him by the urinals in the boys’ bathroom.
By November of that year, having just turned 16, Alex started injecting himself with small doses of testosterone. But his gender was still ambiguous and being a transgender kid in a new school wasn’t easy. Alex still told no one. He heard anonymous voices whispering “dyke” and “fag” in the hallways. Teachers would sometimes stumble over his gender.
“I was asked every day if I was a boy or a girl.”
Therapy behind the scenes was supposed to lift his spirits, to help with self-acceptance. But his therapist gave him bad news: “Being a gay transgender male was going to be one of the hardest things to do.”
Alex distinguishes between gender identity and sexual attraction. He knows that he is male. That is his identity. He is young and while he suspects he is a male attracted to men, he’s not yet certain. Hormones could change his attractions. If he is a gay transgender man, he could be in for romantic challenges.
“There’s a possibility that I’m screwed and I’ll be alone forever,” he said. “Men in the gay community like penises.”
Speaking again: ‘I’m transgender’
While the bleak outlook sometimes overwhelms Alex, he has begun to open up.
At Broomfield High, he eventually summoned the courage to attend a Gay Student Alliance meeting and announced that he was transgender. School officials asked him to serve as a mentor to a freshman transgender student. Having adapted at a younger age, Alex said that student didn’t need his help.
College has been remarkably liberating. During freshmen orientation last year in a dorm full of art students, Alex simply told everyone he was transgender.
He hoped he could make a big announcement and be done, “like throwing out one big handful of confetti and hopefully we’d never talk about it again.”
Of course that didn’t happen and people do want to talk about it.
“Everyone overcompensated. They were so ready to be accepting that it was overwhelming,’’ he said.
Still it’s great to have friends like Alex’s two male housemates, who don’t see it as any big deal.
“I often go round and round in my head about this. The only time someone’s sexuality influences you is if you are having sex with them. It doesn’t impact me,” said Marcus Stevenson, 19, who grew up in a very religious family in a rural part of southern Colorado.
Marcus is perfectly happy having a transgender friend and housemate. The fact that his conservative family or other people might judge Alex makes him angry. But he’s philosophical about the tough times Alex experiences: “There is no light without the dark,” he says.
Among peers, Marcus says there’s a “rat race of individuality,” so many young people who are desperate to be hip think Alex is very, very hip.
Alex doesn’t always feel ultra-hip or extremely happy.
The surgery wasn’t a quick fix for the emotional problems that being transgender either exacerbated or created. Still he feels like his brain and body are beginning to match each other.
“It’s not like I want to do cartwheels and back flips now that I don’t have breasts,” he said. “This is normal. Before when I wore a binder, it was always hot and it made cleavage and now I can just do what normal people do, just wear a T-shirt or whatever I want.”
Alex dresses most of the time in the male clothes that he has long preferred. But there’s still a touch of hibiscus in his wardrobe. He sometimes picks lacy see-through tops that he can now wear without a camisole. And he enjoys wearing leggings beneath shorts or around the house.
While Alex is getting more comfortable in his body, he doesn’t have any desire to become an activist. He loves staying busy with his art and his job at the CSU library.
Case sends powerful signal
LGBT advocates, however, see his case as critical. At the Colorado Civil Rights Division, all cases remain confidential until they go to a hearing. So officials there cannot say if there have been other cases like Alex’s.
“It’s the first one I know of related to health insurance,” said Ashley Wheeland, health policy director and a staff attorney for One Colorado, the group that advocates for LGBT people here.
“It sends a powerful signal that anti-discrimination protections do protect transgender individuals and that systems — including health systems — need to look within their (organizations) for discrimination and change that.”
Being transgender in Colorado puts you in a protected class on civil rights matters, Wheeland said.
“We think it’s really important. It brings the issues that transgender people face daily to the forefront. These are changes that we need so people don’t live in fear and can stand up for their rights,” she said “It’s life-changing for many people. It was under the radar.”
Still, neither Wheeland nor Alex expects a burst of new cases. Wheeland estimates that transgender people make up just one-half of 1 percent of all Coloradans.
And Alex laughs at the idea that health insurance companies are suddenly going to be flooded with transgender patients.
“It’s not like someone is going to turn transgender just so they can get health care,” he said.
For now, Alex’s wish is that people would stop fighting and start focusing on helping unconventional people like him be healthy.
He’s experienced some hatred on Facebook from conservative relatives who disapprove of him and “are praying for him.”
“There’s no reason for me to be in your prayers. I’m fine,” said Alex. “Overall it’s been really easy for me. I never got beat up because I am transgender. I never had my parents disown me. It’s not going to be a skip through the roses. But anyone growing up today is going to deal with a lot of depressing issues.”
He thinks of a Richard Wilbur poem called “The Writer” that inspired a tattoo on his arm. The tattoo shows a fist bursting through a stained glass window. Alex didn’t intend to reference what it feels like to have his male self break free, but now it seems to do just that.
Instead Alex liked the idea of the iridescent bird stuck in a room, trying to find a way to escape.
First the bird can’t find the opening that the poet has created in the shiny glass. It “batters against the brilliance” and drops, bloodied and defeated.
Then, like Alex, the bird gathers its strength and tries again.
Wrote Wilbur: “How our spirits rose when, suddenly sure, it lifted off from a chair-back, beating a smooth course for the right window and clear(ed) the sill of the world.”