To be herself, she needs to change her body. But first, comes the battle with insurers

Allendale, Michigan (CNN)Jasmine Glenn’s friends remember late-night phone calls from her, sobbing and saying she was ready to kill herself, knife in hand.

“I was trying to drink myself to death to escape who I was,” she said. “I wasn’t allowed to be myself, so I didn’t want to be anyone else.”
Then, at 35, she realized what she needed to do to be herself: accept that she’s transgender and live openly as the woman she always knew she was.
To do that, she said, she had to “fix” her body. But after the battle with herself came the battle with insurers.
Not all transgender and gender-nonconforming individuals need medical care to transition. And not all identify as a man or woman. Some resent the pressure to conform their bodies to traditional ideas about what makes a man a man or a woman a woman — especially as a growing body of research questions the relationship between sex and gender.
But those who seek solace in a typically masculine or feminine form say they are caught in a painful cycle of constantly having to prove that they are who they say they are to meet criteria set by physicians, insurance companies and lawmakers. 
And they fear that it’s about to get harder.
    The Trump administration has signaled its intention in recent months to rewrite a federal rule that bars health care discrimination based on gender identity. In its current form, that rule is one of the precious few tools transgender patients have to fight insurance denials for various medical treatments and procedures that fall under the broad umbrella of gender-affirming or transition-related care. Even with the rule in place, Jasmine and four other patients in different states detailed protracted battles for coverage.
    Jasmine began taking hormones in 2012, before she had insurance, paying out of pocket. In 2014, she got on a Michigan Medicaid plan offered by Priority Health. For the past four years, she’s been fighting to get coverage for vaginoplasty and facial feminization. Her doctors say the surgeries are medically necessary to treat her gender dysphoria — the diagnostic term for the distress she feels over the conflict between her gender and the sex she was assigned at birth.
    After rounds of appeals, she won pre-authorization for vaginoplasty but not a prerequisite hair removal procedure. After she was approved for hair removal and started treatments, her pre-authorization for vaginoplasty expired. Priority declined to again pre-authorize the surgery in 2018 on the grounds that it was no longer a benefit. Now, she is appealing the denial for vaginoplasty while her battle continues for facial feminization surgery.
    “Apparently, I am getting hair removed for prep for a surgery I now can’t get,” she said. “This crap is why I wish I were dead.”
    Priority declined to comment on Jasmine’s case, citing privacy laws. “Please know that we have dedicated doctors, nurses and clinicians on staff who work closely with our members to ensure they have the access to the care and treatment they need,” the insurer said in a statement to CNN. “Our members’ health and safety is always our first priority.”

    A landmark protection for transgender patients

    Until recently, American health insurers routinely defined gender-affirming procedures like the ones Jasmine is seeking as ineligible for coverage, even though the consequences of untreated gender dysphoria — including depression, substance abuse and suicide — are well-documented.
    A series of protections enacted during the Obama years attempted to make it easier for patients to access coverage for such care. The most significant was a provision of the Affordable Care Act known as Section 1557, which banned discrimination based on race, color, national origin, sex, age or disability in federally funded health care facilities and insurance plans. A rule enacted in 2016 interpreted the ban on sex discrimination to include discrimination on the basis of gender identity. Meanwhile, 19 states and the District of Columbia have enacted laws or mandates against blanket exclusions for gender-affirming treatment in benefits packages.
    Further complicating matters is a lawsuit challenging Section 1557 from several religious health care providers, including Franciscan Alliance Inc. Two insurers, Oscar and HealthFirst, told CNN that a preliminary injunction meant that they did not have to cover transition-related treatment — an interpretation that LGBTQ patient advocates and legal experts say is incorrect.
    Ambetter and MercyCare did not answer repeated requests for comment. Dean Care and MedMutual declined to comment.
    The trade association America’s Health Insurance Plans (AHIP) said carriers comply with state and federal laws and work to ensure that members have access to services they need. If a patient encounters barriers, “we would encourage them to have conversations with their health care plans to help ease the path to access to care,” said Cathryn Donaldson, communications director for the association.
      Now, LGBTQ advocates fear that Section 1557’s gender-identity protections may be rolled back. “The Trump administration, in the last year-plus, has been sending signals that it wants to not only not enforce but change its interpretation of health care law to exclude protections for transgender people,” Tobin said.
      On February 13, government lawyers said in a court filing that the US Department of Health and Human Services had submitted a draft of a proposed rule to the White House, suggesting that it had come up with new regulations for Section 1557. The action was confirmed in a notice on the Office and Management and Budget’s website.
      “A federal court struck down the gender identity provisions of the rule as contrary to law and issued a nationwide injunction barring HHS enforcement. We are reconsidering the reasonableness, necessity, and efficacy of the rule in light of the injunction and will continue to vigorously enforce all prohibitions on discrimination in health care according to the law and court orders, before, during, and after any rulemaking,” Roger Severino, director of the Office for Civil Rights within HHS, said in a statement to CNN.

      Fighting to be herself

      Nearly seven years ago, Jasmine was trapped in a cycle of despair fueled by alcoholism. After long days working in restaurants, she would often drink with friends in bars or their homes to the point of blacking out.
      “I preferred to be in that Salvador Dali level of drunk, where everything’s melting off the walls,” she said. “I was hurting, and so I wanted to watch the world burn.”
      She began to rethink her life in 2011, while she was under supervised probation for her second drunken driving arrest. She was living in a trailer in her hometown of Allendale, Michigan — a semirural suburb of Grand Rapids, in the conservative part of the state, where hospitals and stadiums are named for the family of Education Secretary Betsy DeVos.
      Jasmine’s driver’s license had been revoked, and she was unable to leave home except for work and Alcoholics Anonymous. Sober for the first time in her adult life, she started looking online for the language to describe what she was experiencing. She heard success stories that defied the sensationalized portrayals of people who identify as transgender that she grew up watching on daytime talk shows. She connected with others who shared her anxieties and identified what she’d been trying to suppress with alcohol.
        After coming out to friends and family, she took the first step toward changing her body to match her gender, a process referred to as physically or medically transitioning. In 2014, she applied for insurance through a Michigan Medicaid plan offered by Priority Health.
        It took her months to find the right doctor and seek referrals, then months more of filing claims, receiving denials and appealing. Then came hearings in which, she says, Priority’s representatives misgendered her by calling her a man even though she had been referring to herself in paperwork as a woman. She says they questioned her need for surgery despite her doctor’s recommendations. She spent countless hours on the phone and researching court cases that she could cite as precedents in her favor.
        Although the battle consumed her waking hours and frustrated her, it was the only thing keeping her from taking her life, Jasmine said. “I was so angry, I didn’t understand why they were making it so hard,” she said. “There was only one other option, and I couldn’t do that, because that would mean letting them win.”

        Navigating a jurisdictional maze

        Jasmine is not alone. Other people who identify as transgender with different types of plans from states across the country also described running into red tape and denials when they tried to get coverage.
        Like Jasmine, Derrick Robinson turned to alcohol to forget who he was before he transitioned. Back then, he identified as a woman and a lesbian. His 20s are a blur of blackouts, clashes with family and run-ins with police, he said. Then, he started dating a woman he knew from high school. As they grew close, she came to see how Robinson struggled with his identity and encouraged him to transition.
        Robinson started taking testosterone in June 2016 as part of his transition. Two months later, he said, he started wearing a chest binder to minimize the appearance of his breasts and help him look more masculine. His chest was the first thing people would look at when they saw him, he said. Their confused looks made him paranoid and fearful for his safety.
        By the time the couple married in October 2016, he had a mustache above his lip, and his hairline was receding. A few months later, his voice took on a raspy edge. He was eager to undergo surgery.
        An exclusion for gender reassignment surgery was written into the group plan offered by his employer, even though his home state, Minnesota, forbids discrimination based on gender identity in group and individual plans. A spokesman for his insurer, Medica, told CNN that it follows whatever the employer chooses to include or exclude in self-insured group plans like Robinson’s, which are subject to some federal laws but not the ACA. Medica denied his request for gender reassignment surgery, citing the exclusion. But when his psychologist provided a letter recommending bilateral mastectomy to treat Robinson’s gender dysphoria, Medica granted the request. Robinson had surgery in October, and after he recovered, he and his wife burned his bras and chest binders. Now, for the first time, he’s not afraid to look at himself in the mirror.
        “I just feel like I see the person I should’ve been seeing the whole time,” he said. “I’m finally living the life I want to live.”
        Brynn Mahsman tried to challenge an exclusion for gender confirmation surgery in her employer’s group plan in January 2016, thinking Section 1557 and Nevada’s anti-discrimination insurance mandate would be on her side. A representative for her insurer told her the plan complied with the most recent requirements of the ACA but noted that Health and Human Services had not yet “issued guidance or regulations with respect to many aspects of these laws,” which was true at the time. She would later find out that others like her — with self-insured group plans that are not subject to the ACA — have filed complaints with the Equal Employment Opportunity Commission, which enforces workplace anti-discrimination laws. But she wasn’t aware of her rights. By the time she had invested the energy in educating herself on the jurisdictional maze of health plans, she had lost her job and her benefits. Now, the software engineer said she works for a new company with benefits for gender-affirming procedures, and she has hope.
        Autumn Trafficante says she spent most of her 20s “trying to do the guy thing” after puberty forced upon her a masculine visage. By her late 20s, it got to the point where she couldn’t stand to catch her reflection in a car window — let alone a mirror — and see someone she didn’t recognize. She tried to feminize her appearance with clothes and makeup, she said, only to have her identity undercut by a stranger calling her the wrong gender.
        “It really wears on you when your life is made up of moments like that,” she said. “I woke up more days than not thinking about killing myself.”
        Right before her 28th birthday, she decided she’d had enough and put together a timeline and a budget for transitioning, she said. Then, she hit a snag with her marketplace plan. Despite letters from her physicians attesting to the medical necessity of the surgery, her insurer said in a denial letter that it considered facial feminization procedures cosmetic. She picked up extra work as a software engineer, extended a line of credit and borrowed money from relatives to scrape together around $70,000 to pay out of pocket for facial feminization surgery in April 2016. Two years later, she is still trying to seek reimbursement — not just for her own wallet’s sake but to set a precedent so that paying out of pocket is no longer necessary.
        “Even though it left me with more debt than I ever thought I would have, in retrospect, it was the best decision I ever made for myself; imagining my life without facial feminization surgery is the stuff of nightmares for me, yet that is the reality for the vast majority of trans women,” she said.
        An Oregon graduate student who asked to remain anonymous said she chose her school in part because its health plan offered benefits for gender-affirming procedures. She still spent nearly a year going back and forth with her insurer to get pre-authorization for facial feminization surgery — even with her doctor’s endorsement of its medical necessity. Her provider finally agreed, but she said she still had to pay out of pocket because her surgeon required payment upfront. She sold her car and pulled money from retirement accounts to cover the $38,000 bill and then requested reimbursement — only to be denied again, documents show. Thanks to efforts of her student union, the plan changed in 2018 to explicitly cover the procedure, and she was able to obtain reimbursement from her insurer.

        Negotiating the insurance labyrinth

        Being transgender is not a mental illness. It’s a state of identifying with a gender that differs from the sex you were assigned at birth. But for a transgender person to get coverage for gender-affirming care, they must often be diagnosed with gender dysphoria, a mental disorder.
        Some contend that the diagnosis inappropriately pathologizes gender noncongruence and should be eliminated. Others argue that the diagnosis ensures access to care.
        Initially, Jasmine thought the diagnosis would help her obtain coverage. Four years later, she says it has created barriers to treatment by stigmatizing her with a mental health diagnosis.
        As soon as Jasmine found out that 12 months of hormone treatment was a prerequisite for genital surgery, she started therapy to confirm a diagnosis of gender dysphoria, she said, even though she didn’t have insurance at the time. Her therapist provided a letter for her physician, who prescribed her hormones. She started taking them in July 2012, paying for them out of pocket.
        Her breasts grew to a C-cup size, and hair growth slowed on her arms and legs. She used hair regrowth treatment and her wispy orange hair grew past her shoulders and filled in her bald spots.
        As her body started to change, she says, she experienced harassment over her appearance at work. She lost her job as a waitress in Grand Haven and could no longer afford to live on her own. In 2013, she moved into her parents’ home, also in Allendale.
        Her experience is common. A leading survey of the American transgender population found that 30% of respondents who had a job in the previous year reported being fired, were denied a promotion or experienced some other form of mistreatment related to their gender identity.
        The same survey by the National Center for Transgender Equality underscored the impact of stigma and discrimination on the health of people who identify as transgender. Thirty-nine percent of respondents said they experienced serious psychological distress in the month prior to completing the survey, and 40% had attempted suicide in their lifetime — nearly nine times the overall attempted suicide rate in the United States.
        Much of that stress could be related to difficulties accessing health care, the survey authors said. One in four respondents experienced a problem in the past year related to insurance, such as being denied coverage for routine care because they were transgender. More than half of respondents who sought coverage for gender-affirming treatment were denied, and 25% of those who pursued hormone coverage in the past year were unsuccessful.
        Insurance in the United States is a patchwork of policies that are regulated differently, depending on where and how they were purchased. Almost half of Americans get insurance through their employer, according to data analyzed by the Kaiser Family Foundation for 2016. The other half consists of those without insurance, those relying on Medicare, Medicaid, military plans or plans bought on the ACA market exchange.
        The breakdown among the US transgender population is similar: According to the 2015 US Transgender Survey, 53% of respondents were insured through an employer-sponsored plan, 14% had plans they purchased directly from insurers or from health insurance marketplaces, 13% were insured through Medicaid, and 14% reported that they were uninsured.
        Jasmine enrolled in a basic state-funded Medicaid plan through Priority Health in 2014. The first time she requested coverage for surgery, Priority sent her a denial letter.
        “Sex change or transformation” was excluded from coverage, it said. “This exclusion applies despite any diagnosis of gender role or psychosexual orientation problems.”
        She channeled her anger into researching laws and court rulings to fight the decision. By then, she had heard of Section 1557 and cited it in the appeal of her denial.
        She called her condition “a significant disability that interferes with employment,” mirroring language in the World Professional Association for Transgender Health’s standards and research on the effects of gender dysphoria.
        After two reviews, Priority upheld the denial, citing the same exclusion.

        Federal protection under 1557: A moving target

        In 2015, when Jasmine sought coverage for surgery, federal rules may have technically been on her side — but there was ambiguity and room for interpretation. By then, a growing number of court decisions had interpreted federal laws against sex discrimination to apply to people who identify as transgender. And HHS had announced the proposed rule barring discrimination based on gender identity. But such an interpretation had not been codified in the ACA’s regulations.
        Then, in May 2016, HHS’ Office of Civil Rights (OCR) issued a regulation explicitly stating that discrimination based on sex includes gender identity and sex stereotypes. The regulation applied to Medicaid, Medicare and private insurers offering plans on state marketplaces, forbidding them from excluding gender-affirming care from coverage.
        The regulation did not tell insurers which services to offer. But it prohibited them from denying transgender patients equal access to coverage for medically necessary services available to other patients, such as mastectomies or prostate exams.
        As of January 2017, all blanket exclusions were supposed to be removed from policies on the marketplace. But CNN found at least 19 policies offered in 2018 that still had blatant blanket exclusions.
        When asked about the policies with blanket exclusions, some of the insurers offering them acknowledged that they should not be on the marketplace. Others said Section 1557’s regulations no longer applied to the plans because of the Franciscan Alliance lawsuit, a claim that experts dispute, suggesting that there is inertia and confusion about the state of the law that creates bureaucratic hurdles for transgender patients.
        When CNN pointed out the exclusions to Health First, which offered eight of the 19 plans, it acknowledged that the plans on were outdated. The carrier provided documentation showing that it has offered benefits for medically necessary transition-related services since 2017.
        “We apologize for any confusion this administrative oversight has caused and we are committed to improving the health and well-being of all of our members and our community,” said Matthew Gerrell, senior vice president of consumer and retail services.
        However, Gerrell also noted that his understanding was that 1557 did not apply to Health First policies because of the injunction in the Franciscan Alliance lawsuit.
        Before 1557’s updated regulations could take effect for insurers in January 2017, a federal district court judge said the rule violated the federal religious freedom law. Texas District Judge Reed O’Connor issued a nationwide injunction preventing OCR from enforcing the gender identity provisions of the rule. On May 2, 2017, government lawyers won a stay to allow HHS to reconsider the rule’s “reasonableness, necessity, and efficacy” in light of the court’s injunction.
        But the impact of that injunction varies depending on whom you ask. Interviews with a dozen stakeholders — lawyers, policy experts, state insurance commissioners and insurance company representatives — yielded different responses.
        Gender identity discrimination is still impermissible under the statute, says former agency director Jocelyn Samuels, who oversaw 1557’s final implementation. She is now executive director of UCLA Law’s Williams Institute, a think tank dedicated to sexual orientation, gender identity law and public policy.
        The injunction only bars OCR Rights from proactively enforcing the regulation, said Samuels, who served as director of the office from 2014 to early 2017.
        But 1557 is still in place, she said. The statute builds on other longstanding federal civil rights laws, which interpreted sex to include gender identity. Even if the administration withdraws regulations protecting transgender and gender-nonconforming individuals — as the Departments of Education and Justice have done — they cannot undo years of case law and precedent, she said.
        The injunction applies only to HHS enforcement, not private citizens, who can sue under the statute, Samuels said. In September, for example, a district court in California ruled in favor of a family that sued a San Diego hospital over the staff’s treatment of their transgender son, based in part on 1557.
        While Section 1557 is in effect, insurers that receive any federal funding must ensure that all health plans comply with its anti-discrimination provisions, said Julie Mix McPeak, president of the National Association of Insurance Commissioners. The group has not taken a position on the injunction, leaving it to states to decide.
        Representatives from two insurance companies said they did not offer transition-related benefits in states that did not include such services in their Essential Health Benefits, a set of 10 categories that insurers must cover under the ACA. They said state laws and mandates guide their policies.
        For example, Oscar Health offers plans with exclusions for gender-affirming care in Texas and Ohio, states without anti-discrimination policies that cover gender identity. When CNN contacted the insurer, its general counsel pointed out that its plan in California covers gender-affirming care, in compliance with the state’s anti-discrimination law and its Essential Health Benefits.
        “Oscar believes that gender-affirming care, including gender reassignment services, should be considered an Essential Health Benefit and covered by all health insurers,” general counsel Bruce Gottlieb wrote in an email to CNN.
        “Unfortunately, this is precisely the kind of issue that requires federal or state regulators to ensure that all insurers cover these services — otherwise, insurance markets will suffer from adverse selection,” Gottlieb wrote. “Oscar is proud to cover gender-affirming care in states that consider gender-affirming care an Essential Health Benefit, like California. And we are in constant conversation with regulators in other states to encourage them to mandate that all insurers cover these benefits.”
        But a state’s Essential Health Benefits establish baseline requirements for benefits packages — not a ceiling, said Dick Cauchi, a health care policy analyst with the National Conference of State Legislatures. Even so, adding benefits can increase premiums, which can factor into negotiations with the state when developing benefits packages, he said.
        Still, advocates say that’s beside the point when it comes to federally-funded plans. The ACA provides that, except where Congress has made explicit exemptions, all “health programs and activities” receiving federal funds, including insurance credits or subsidies, are prohibited from discriminating on the basis of race, national origin, age, disability or sex.
        In other words, “a state cannot enable a provider or an insurer to opt out of nondiscrimination requirements that apply under federal law,” Samuel said.

        ‘Not medically necessary’

        Jasmine tried again to get coverage for surgery in 2016, twice. She was denied, first based on the same exclusion and then because the surgeon was in another state.
        The repeated crushing disappointments began to weigh on her. The stress exacerbated chronic pain in her muscles and turned her into a recluse, she said. She struggled to find a restaurant job despite her credentials: a culinary arts degree, a bachelor’s in hospitality and 15 years working in restaurants.
        “To put it bluntly, it’s hard to get a job when you dress like a woman but look like a man,” she said.
        After a friend helped her find work, she suffered regular panic attacks in the kitchen, a place she had once loved. She rambled on about her suicidal thoughts to her co-workers, unnerving them and eventually costing her the job, she said.
        After long days working against the stiffness in her muscles, she went straight home and cried herself to sleep, she said. She spent her days off in bed, wary of the outside world. Strangers would “clock” her as trans and ask her questions, she said. Cashiers misgendered her and made her feel worse. She’s reluctant to go anywhere alone, including her favorite neighborhood sports bar, after encountering a drunk high school classmate who shouted derogatory names at her.
        She missed her favorite holiday, Halloween, on the year she convinced her parents and sister to dress as superheroes for their annual group costume tradition. She would have gone as Harley Quinn, her favorite.
        “I couldn’t do it. I was super stressed out,” she said.
        Finally, in 2017, Priority agreed to cover her genital reconstruction. But she couldn’t get on the year-long wait list for surgery until she went through multiple rounds of hair removal.
        Priority refused to cover that, as well as her request for surgery to make her facial features more typically feminine, saying that both were “cosmetic in nature and not medically necessary.”
        Leading medical organizations in the United States agree that gender-affirming care is the most effective treatment for gender dysphoria. The American Medical Association and the American Psychiatric Association have issued position statements supporting coverage for medically necessary treatment as determined by a patient and their health care provider.
        But to evaluate a procedure’s medical necessity, many insurers use criteria outlined in what’s known as the Stanford definition, Kristine Grow, senior vice president of communications at America’s Health Insurance Plans, wrote in an email.
        Unlike the American Medical Association, the Stanford definition factors in “the cost-effective(ness) for this condition compared to alternative interventions, including no intervention.”
        After Priority upheld denials for hair removal and facial surgery twice, Jasmine brought the case to Michigan’s Department of Insurance and Financial Services for external review.
        In August 2017, a physician reviewer agreed that hair removal was medically necessary for her. But the reviewer upheld Priority’s denial for facial feminization surgery, citing insufficient literature to support a claim of medical necessity. Jasmine resubmitted her request for surgery and after Priority denied it, she appealed again. Earlier this month, a state administrative judge heard the case and sided with her. Priority has not yet responded to the decision, her lawyer said.
        “We don’t want insurance companies determining our medical care, our treatment. We want doctors and professionals to make those decisions,” said Jay Kaplan, a staff attorney for the ACLU of Michigan’s LGBT Project.
        “To be able to visually conform is part of her completing her transition. If not, she’s always regarded as ‘that trans person.’ And she’s encountered problems in her life because of that.”

        ‘A backdoor way of maintaining an exclusion’

        CNN looked at more than 150 policies on Most of them, rather than containing blatant exclusions, were limited or unclear on what gender-affirming care they might cover. Some policies offer “certain” transition-related services without specifying which. Other policies say they offer “gender reassignment surgery” and services related to gender dysphoria on one page, only to exclude services that authorities on transgender health recommend for treating gender dysphoria.
        “We think this language is very problematic. We know that the way these exclusions operate in practice, ‘certain’ means ‘all we can get away with,’ ” said Kellan Baker, a health services researcher at the Johns Hopkins Bloomberg School of Public Health.
        “This is a back-door way of maintaining an exclusion without having the kind of bald-faced exclusion that invites all but the laziest of regulators to intervene.”
        The ambiguity leaves claims to be decided on a case-by-case basis that can stretch out for months — or even years, in cases such as Jasmine’s.
        Dr. Tracy Kayan, who specializes in chest surgeries in Plymouth, Minnesota, said she tries to make the case for medical necessity by describing the impact of gender dysphoria on a patient’s daily life. A transgender man with extra breast tissue may experience anxiety when people call him a woman, discouraging him from interacting with others. Or people at the gym may stare at him as his breasts move around, causing him to avoid exercising.
        Often, she said she finds the review process to be subjective, no matter what she says.
        “If you asked two different physicians working for the same insurance company and doing peer-to-peer reviews for transgender pre-authorizations, I’m not sure if the approval would be the same,” she said.
        “I honestly think a lot of what insurance companies approve is inconsistent and based on the personal biases of a single person, who could be an older, semi-retired family physician living in Texas who’s making a decision for a 19-year-old transgender patient living in Minneapolis who wants a breast reduction,” she said.
        Dr. Joseph Silletti, chief of the urology division at Bronx-Lebanon Hospital Center in New York, said he has met transgender patients who went for decades without surgery until insurance made it financially feasible.
        “I’d see them in the recovery room crying, and they’d say, ‘You don’t know what this means to me,’ ” he said. “There is no faking that.”
        Silletti started performing orchiectomies on transgender patients in 2013. The surgical procedure to remove one or both testicles helps with hormonal control. He said he saw an influx of transgender patients after New York Gov. Andrew Cuomo announced in 2014 the first of a series of measures preventing all insurers, including Medicaid, from discriminating against transgender and gender-nonconforming individuals.
        “I couldn’t imagine living every day and waking up and wondering why I have the wrong organs,” Silletti said. “I just couldn’t. But these folks have been, and now I understand what a relief it must be to have the organs you believe you need, and I don’t see that as any way ‘cosmetic.’ “
        Because New York sets forth criteria for coverage of gender-affirming procedures, Silletti has found that getting surgery pre-authorization is typically easy, he said. The hard part is getting reimbursed due to an insurance coding issue, what he and other surgeons call the “gender mismatch denial” that occurs when an insurer will approve a certain procedure only for patients of one gender. That leads to denials when, say, a doctor seeks reimbursement for a transgender woman’s orchiectomy. This can cause problems for transgender or gender-nonconforming people who have not changed their gender marker on government-issued identification.

          Transgender identity, in their words

        “The best way I can think to describe it is, in the pre-transgender world, we had two buckets you could live in,” he said. “We still have that, effectively, in computer systems.”
        Kayan said she gets around gender mismatch denials through creative coding. She used to see frequent denials for transgender men seeking mastectomies, a surgery most commonly associated with breast cancer in women. Then, she began asking insurance companies to cover breast reductions — essentially, the same procedure — to treat gender dysphoria, and she saw fewer denials, she said.
        Getting insurers to pay can be so complicated that some doctors preferred not to accept insurance at all. CNN reached out to 363 doctors listed on as offering transgender services. Of the 112 active surgeons who responded fully, 49% did not accept Medicaid, 38% did not accept Medicare, and 26% did not accept any form of insurance.
        Dr. Beverly Fischer, a plastic surgeon in Baltimore, performed her first breast-reduction surgery for a transgender man in 1996. For years, her private practice was cash-pay only. As demand for gender-affirming procedures grew and more companies began to offer them in their health benefits, she started accepting insurance in 2012.
        She said she stopped in 2017 because of the hassle.
        “We spent so much time on the phone arguing, it became too much of a chore,” she said. “I got to point where I said, ‘I can’t run my business anymore.’ “

        To be treated like any other woman

        Jasmine is still waiting.
        Each hurdle has stood in the way of a stable life and a job that makes the most of her culinary training. She would have preferred to spend the past few years managing a restaurant or a bar, the goal she was working toward before she came out. For now, she’s working at a fast-casual restaurant.
        She wants to move on with her life. She wants to stop discussing her latest insurance grievance with friends. She wants to stop explaining her identity to customers looking for a “token trans friend,” she said.

        See the latest news and share your comments with CNN Health on Facebook and Twitter.

        She wants to date and have a meaningful romantic relationship. She doesn’t want to be alone. She doesn’t want to go to another party and sit off to the side, fearful of starting something, only to have it end when a potential mate finds out that she has the wrong anatomy. She wants to meet someone with whom she can share her passion for “Batman,” “Star Wars” and Legos.
        “Transness has monopolized my entire life, and that’s not OK. I just want to do the surgery and be treated like any other woman.”

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        Not unlike any given trip to IKEA, action movies are chock-full of fights, the difference being that someone has to choreograph all those epic punches and spin-kicks. And since most of us don’t sit through a film’s credits without the promise of, say, Captain America staggering in front of a green screen to advertise a movie that won’t be out for three years, we’d like to take a moment to highlight a few of the cinematic artists who crafted some of our favorite movie fight scenes. Such as …


        Thank Jonathan Eusebio For John Wick, Black Panther, The Avengers, And More

        Loosely based on the story of everyone who watched Marley & Me and then angrily punched a hole in their drywall, John Wick (aka Scruffy Matrix) finds Keanu Reeves hitting and shooting his way to get to the baddies who offed his puppy dog. The fantastic action scenes were choreographed by Filipino American martial artist Jonathan Eusebio, who also worked on the sequel (titled John Wick: Chapter 2, perhaps in an effort to make literature seem more action-filled and exciting).

        Summit EntertainmentThis time, he’s killing people for ruining all his shirts in the last movie.

        Eusebio has done lots of great work, even in movies hardly anyone saw. Like Hitman: Agent 47, an adaptation of the successful video game series in which Mr. Clean has a midlife crisis, becomes a contract killer, and ransacks Donald Trump’s suit closet. Take this scene, wherein the titular Mr. 47 gets knocked onto a subway train, then rolls onto the tracks …

        20th Century Fox“Aw, that was my tra-” “Don’t worry, I’ll help you catch it!”

        … leading to a deadly bout of hand-to-hand combat that also involves navigating speeding trains and puddles of urine.

        20th Century Fox

        20th Century FoxAt least, we hope that’s only urine …

        Eusebio has also worked extensively as either a stunt or fight coordinator in Marvel movies such as Deadpool 2, The Avengers, Doctor Strange, The Wolverine, and the cultural juggernaut that is Black Panther. The latter featured giant battles, an extended car chase, and the only casino brawl in history not caused by booze, money, or Celine Dion tickets.

        Marvel StudiosPlus the deadliest use of a wig in a non-Steven-Seagal fight scene.

        He also worked on the Expendables series, which is presumably the usual process, albeit with more Metamucil breaks. Perhaps most impressively, he was the uncredited fight coordinator in the obligatory “that escalated quickly” sequence in Anchorman 2. Give this dude his Lifetime Achievement Award already.


        The Guy Who Did They Live Also Turned Matt Damon Into A Badass In The Bourne Series

        They Live is John Carpenter’s classic 1988 film about a pair of shades that allow a drifter to see the secret skeleton-faced alien overlords controlling our planet, and until they make a biopic about Bono or David Caruso, no pair of sunglasses will be so damn important in a movie. Perhaps the most memorable part of They Live is an extended fight scene between star and professional wrestler Rowdy Roddy Piper and Keith David, in which they punch each other in a filthy alley for roughly the length of The Eagles’ “Hotel California.”

        Universal PicturesThis is your periodic reminder that Piper thought all of this happened for real.

        Carpenter delegated the choreography of the scene to his frequent collaborator Jeff Imada, with only the request that “three specific wrestling moves” be a part of it. He doesn’t say which ones, but they probably didn’t involve slamming your opponent into concrete littered with candy wrappers and used condoms.

        Universal PicturesIf you go frame by frame, you can see a full pack of bubble gum falling out of his pocket.

        But Imada didn’t dissolve into a puddle of water like the aliens at the end of that movie (we think, it’s been a while). His name is on a ton of classic films before and after They Live, including Lethal Weapon, Rambo, Blade Runner, and Charlie Sheen’s magnum opus Hot Shots! Part Deux. More recently, he was the fight choreographer on The Bourne Supremacy and The Bourne Ultimatum — two of the ones starring Matt Damon, not his understudy Jeremy Renner.

        Universal PicturesAlthough it’s hard to tell who it is with that camerawork.

        Imada even did stellar work on otherwise-forgettable movies, such as this epic fight in The Book Of Eli, in which a post-apocalyptic Denzel Washington battles a horde of chainsaw-wielding madmen …

        Warner Bros. Pictures

        … or the critically panned but occasionally kickass Green Hornet remake, featuring scenes seemingly meant to gaslight audiences into thinking their popcorn was laced with PCP.

        Columbia PicturesOr something else, considering Seth Rogen is in this movie.

        A way better fight coordinator than a script picker, Imada has also worked in Batman v Superman: Dawn Of Justice, After Earth, the Total Recall remake, a couple of Fast & Furious movies, and the Twilight franchise. So if you notice any especially skillful angst-filled werewolf-on-vampire punches, that’s probably due to his expertise.


        The Transporter‘s Corey Yuen Has Been Kicking Asses For Almost 50 Years

        The Transporter sounds like a Star Trek spinoff about the exciting lives of those poor saps who spend eight hours a day standing in a windowless room waiting for someone to decide to beam somewhere. But no, it’s a 2002 action movie starring Jason Statham, Qi Shu, and Jason Statham’s bare chest.

        20th Century FoxAnd bare head.

        Statham stars as Frank Martin, a guy who transports packages somehow even too shady for UPS. Of course, this allows for a multitude of scenes wherein he kicks the crap out of bad guys, and by metaphorical extension, male pattern baldness as a whole.

        20th Century FoxThe famous scene where he interrupts a breakdance competition.

        The Transporter was co-directed and choreographed by Corey Yuen, who has a laundry list of martial arts movie credits. Or rather, the laundry list of a hotel hosting a bedwetter’s convention, because this guy’s been making movies since the late ’60s, working with luminaries such as Jet Li, Jackie Chan, and Sammo Hung. Yuen’s American directorial debut was No Retreat, No Surrender, which was also the first movie starring Jean Claude Van Damme (unless you count his performance as “Gay Karate Man” a few years earlier).

        Behind the scenes, Van Damme was apparently straight up knocking the other actors unconscious. When Yuen chastised him for breaking character to check whether his scene partner was, you know, still alive, they shot a second take … whereupon Van Damme proceeded to knock him out yet again.

        Also in Yuen’s filmography are the ’70s kung-fu flick 7 Grandmasters, featuring glorious swordplay like this …

        Tokyo Shock

        … and the friggin’ nuts Badges Of Fury from 2013. Sadly, it isn’t about anthropomorphic badges (or badgers) that are super angry.

        Easternlight Films

        Easternlight FilmsThough that wouldn’t be any less believable than the other scientific laws that govern this movie’s universe.


        Yayan Ruhian And Iko Uwais From The Raid Also Popped Up In Star Wars: The Force Awakens

        Like the frustrated daydreams of your apartment building’s super, the Indonesian action hit The Raid (subtitled “Redemption” in the U.S. so audiences wouldn’t think it was about bug spray) found a cop ass-kicking his way through a filthy high-rise — like Die Hard, if John McClane wasn’t a middle-aged former sitcom star. The movie concluded in a monumental fight scene only made better by grabbing a Nintendo controller and hurriedly mashing the buttons.

        Sony Pictures Classics*play for full effect*

        Written and directed by Gareth Evans, the fight choreography was done by stars Iko Uwais and Yayan Ruhian — who were so unknown at the time that Uwais was working as a “delivery guy for a phone company” when he met Evans. Of course, after the movie’s success, they soon followed it up with The Raid 2 (Re-Redemption?). It too was full of one insane action scene …

        Sony Pictures Classics

        … after another …

        Sony Pictures ClassicsThose walls were originally white.

        The pair’s post-Raid careers haven’t been as plentiful as you might think. While both of them appeared in Star Wars: The Force Awakens, they disappointingly merely showed up to verbally threaten Han Solo, presumably because Harrison Ford is far too old to get kicked in the face.

        Lucasfilm“Hi, we’re here to deliver your space phone book.”

        But it turns out that wasn’t the only highly-anticipated sci-fi sequel the Raid guys worked on. They also showed up in Beyond Skyline! You know, the sequel to that alien invasion movie so low-budget that it was filmed in the director’s apartment. But with Uwais and Ruhian on board as actors as well as choreographers, Beyond Skyline has some surprisingly badass scenes …

        Vertical Entertainment

        … including one where Ruhian gets his arm ripped off by a damn alien and keeps fighting.

        Vertical Entertainment“What’s the sound of one hand hacking?”


        Road House Was Authentically Nuts Thanks To Benny “The Jet” Urquidez

        Road House is a bonkers ’80s action movie starring Patrick Swayze as a bouncer who works to clean up a corrupt town while also roundhouse-kicking anyone under 21. In one of the most memorable fight scenes in any movie, Swayze has a beachside brawl that ends with him ripping out the other guy’s throat with his bare hands. Warning: The following clip is NSFW, unless you work as a bouncer in Missouri, in which case we have to assume this is business as usual.


        Metro-Goldwyn-Mayer“Come again!”

        This cinematic gem was partly the work of fight coordinator Benny “The Jet” Urquidez, a champion kickboxer who somehow managed to forge a career as a tough guy even with an Elton-John-inspired nickname. Urquidez once claimed that he was challenged to a fight to the death in a Hong Kong warehouse. He also claims to have won the fight, but refused to kill, leading to an audience riot. Those deathmatch patrons can be real jerks.

        Urquidez did the choreography for many more Hollywood movies, even managing to make Lou Diamond Phillips and Marky Mark seem like martial arts masters in The Big Hit, which concludes — in the most ’90s of fashions — in a fight inside a giant video store.

        TriStar PicturesThe fight ends with Wahlberg using AOL disks as ninja stars.

        Urquidez also performed in some movies. Here he is tussling with Jackie Chan:

        Golden Harvest

        Golden HarvestHow many of you can say you’ve had your nipples twisted by Jackie Chan? No more than 20.

        And you might recognize him from Grosse Pointe Blank as rival hitman Felix La PuBelle, who tries to murder John Cusack at his high school reunion.

        Touchstone PicturesWhich, if you’ve ever been to one of those things, would frankly come as a sweet release.

        Urquidez landed that gig because he’s John Cusack’s kickboxing teacher, which is apparently a thing John Cusack does to say in shape so he can carry around all his boomboxes.

        You (yes, you) should follow JM on Twitter, or check out the podcast Rewatchability.

        Get to writing your own fight scenes with a beginner’s guide to Celtx.

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        For more unsung heroes in the entertainment industry, check out 5 Big-Time Players In Your Fav Movies (Who Got NO CREDIT) and 5 Unknown People Who Secretly Made All Your Favorite Music.

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        Scots are loving this kebab shop sign in ‘Avengers: Infinity War’

        Thanos could use a deep fried kebab.
        Image: marvel studios

        Kebabs are good, but it’s a deep fried version that has got people talking.

        If you haven’t seen the new Avengers: Infinity War, there happens to be a scene set in Edinburgh, Scotland where Elizabeth Olsen (who plays Wanda) and Paul Bettany (Vision) have a conversation front of a kebab shop.

        But it’s not the conversation people are obsessing over. It’s the damn sign that says “WE WILL DEEP FRY YOUR KEBAB,” complete with a Scottish Saltire flag under it.

        Yes, the sign actually says that.

        So yeah, people think it’s pretty damn awesome. And by people, we’re pretty sure they’re just Scots, or at least Scots at heart.

        OK, you’re probably wondering by now: Do people in Scotland actually deep fry kebabs? 

        Well, the Scots deep fry a lot of things (hello, pizza crunch and deep-fried Mars bars), but it seems to be more of a joke about Scottish cuisine. 

        But it wouldn’t be surprising if there was a chippy (a fish and chip shop) out there doing it. There was Glasgow’s Stonner Kebab from a few years back, which was a pork sausage wrapped in doner kebab meat, battered then fried. 

        It’s also worth noting that the kebab shop in the movie, Hüsnü, was unfortunately only a film set. In real life, it’s a vintage jewellry store called Miss Katie Cupcake.

        Being Scotland though, they’re probably hiding a deep fryer out back.

        [h/t Junkee]

        Read more:

        Something Poked Holes In The Arctic, And We Can’t Figure Out What

        Another week, another “strange sighting” in the Arctic ice. If it was one of those sites that constantly spot space mice, floating spoons, and Batman’s signal on Mars or pyramids in the Antarctic, then we’d obviously be raising a skeptical eyebrow right now. But it was NASA who spotted these unusual holes in the Arctic ice, so color us intrigued.

        Operation IceBridge, despite sounding like something Jon Snow is planning for GoT’s final season, is NASA’s airborne mission that has been running for nine years, flying over both the Arctic and the Antarctic, photographing, mapping, and documenting the regions’ changing sea levels, land, and sea ice. 

        On April 14, IceBridge mission scientist John Sonntag saw something he’d never seen before – and this is the guy who gave us the incredible photos of the cracks in the ice before the Larson C ice shelf broke off last summer – so he’s no stranger to the mysterious frozen landscape.

        While flying over the eastern Beaufort Sea, Sonntag and the team spotted the curious shapes – circles with what looked like holes in the middle. “We saw these sorta-circular features only for a few minutes today,” Sonntag said. “I don’t recall seeing this sort of thing elsewhere.”

        The image snapped was so curious it qualified as Earth Observatory’s April “puzzler”; each month they share curiosities with the public with the challenge to help identify or shed light on the subject and the chance to win NASA recognition, “credit and glory”.

        The project scientists themselves have a few theories for what could have made these circles as some aspects are recognizable, but in all honesty, they’re still a little stumped.

        John Sonntag/Operation IceBridge

        “It’s definitely an area of thin ice, as you can see finger rafting near the holes and the color is gray enough to indicate little snow cover,” said IceBridge member Nathan Kurtz. However, “I’m not sure what kind of dynamics could lead to the semi-circle shaped features surrounding the holes. I have never seen anything like that before.”

        One suggestion is the central holes are created by marine mammals like seals gnawing through the ice to create air holes as they appear similar to documented breathing holes created by ring and harp seals.

        “The encircling features may be due to waves of water washing out over the snow and ice when the seals surface,” offered Walt Meier, a scientist at the National Snow and Ice Data Center. “Or it could be a sort of drainage feature that results from when the hole is made in the ice.”

        Other suggestions include warm springs made from groundwater flowing from the mountains, or the warmer currents of the Beaufort Sea or the nearby Mackenzie River reaching the surface. The truth is, currently no one knows. We told you, intriguing!

        Read more:

        10 high schoolers who had cardboard cutout prom dates

        Happy prom season to people everywhere and inanimate objects that look like people! 

        Taking a date to prom isn’t for everyone. Sometimes, your date bails last minute. Sometimes, over the top promposals just aren’t for you. And sometimes, your celebrity crush/unrequited love stays unrequited. 

        But no worries! If you’re stressing about not having a (human) date for prom this year, here are 10 people who found love in the form of a cardboard cutout.

        1. The girl determined to meet Killmonger

        Twitter user @uhdeevuh brought a cardboard cutout of Michael B. Jordan to prom this year after she couldn’t get a date. 

        “Now I need to MEET my man,” she tweeted, with photos of a friend crouched behind the cutout to hold it up. 

        We hope she finds him!

        2. The junior who coordinated outfits with Justin Bieber 

        Poor @lowhangingfruit couldn’t find a date to prom, but she was determined to not attend the dance alone.

        She decided to bring a cardboard cutout of young Justin Bieber — bowl cut and everything — and even coordinated her dress with her date’s bright red pants. 

        3. The kid who took his pre-prom photos with Michelle Obama

        Shafe Selvidge loves the former first lady. He has a cardboard cutout of Mrs. Obama and he’s even taken Christmas photos with it. In January, Selvidge wished Michelle Obama happy birthday with a prom photo.

        “I would love to get a picture with the real you someday,” he tweeted. 

        4. The high schooler whose date ditched her for golfing

        When @carrrieplain’s prom date ditched her to go golfing, she decided that taking photos alone just wasn’t for her. Instead of photos with her date, she took her prom photos with a cardboard cutout of Cody Simpson. 

        5. The student who thinks her (lack of) romantic life was because of Nick Jonas

        Twitter user @shannon__fields posted two photos from her high school prom, captioning it, “Do you think me going to prom with a cardboard cutout of @nickjonas had anything to do with why boys never liked me?” She even had the classic foot-popping kiss with her paper date.

        6. The girl who brought Danny DeVito to prom

        Good thing there’s no troll toll for high school. Hannah Gladwell brought a cardboard cutout of Danny DeVito — who was at least wearing a blazer — to her prom. 

        7. The senior who went to prom with Batman

        “Incase you’re having a bad day,” @Asivrs tweeted, “Remember that I went to prom with a cardboard cutout.” She even matched her superhero date, accessorizing her dress with a Batman belt, fingerless gloves, and a bat mask. It’s a lot.

        8. The girl whose date got hit by a car

        When Avinnash was hit by a car, he couldn’t make it to his senior prom. Instead of going to prom with him, Amanda brought a cardboard cutout of his face and had someone stand in as Avinnash for her prom photos. 

        According to their friend Zahra, Avinnash was OK, even if he was left for a cardboard version of himself. 

        9. The high schooler who brought tech daddy Elon Musk

        Elon Musk: billionaire, innovator, and most recently, prom date. @thesmelloftea brought a cutout of the Tesla CEO as her date.

        “I’m sorry Elon I just really look up to you and watching the falcon heavy launch in person made me tear up,” she tweeted, “Honestly I only think it’s fair that Elon gets a cardboard cutout of ME.”

        10. The young voter who felt the Bern at prom

        On the cusp of graduation, @chloxraynaud took a political stance at prom and brought a cardboard cutout of then-presidential candidate Bernie Sanders. She captioned her prom photos with #Bernie2016 and #FeelTheBern, posing with her democratic socialist date. Even if Bernie didn’t win the primary, @chloxraynaud definitely won prom. 

        If you’re dateless for prom this year, just know that there are a lot of options out there.

        WATCH: Here are 5 more truly original movies

        Read more:

        5 Stupid Things We Need To Stop Clicking On

        We are living through the final gasps of the Information Age. Experts estimate that 62 percent of all information we now receive is deliberately false, and that includes the percentage and experts I made up at the start of this sentence. The sad truth is, most of you will never have the critical thinking or research skills to know what’s real, and that will only make you more sure about the wrong things your stupid ass believes. The good news is that this article isn’t about that shit. The fake news fight is over, and stupid won. No, this article is about the dumb things we all keep falling for — even you, the genius who chose the right political side and religion.


        Pointlessly Insane Products Are Not That At All

        Last year, Tiffany & Co. started selling the Sterling Silver Tin Can, an empty can that costs $1,000. You’ll notice that this is far more than you’d normally pay for soupless garbage. To be clear, this wasn’t some tin can that once held Prince’s final green beans. It’s only a can. As an artistic statement, it was 50 years stale, and as a money-making scheme, it was somewhere between a portable diarrhea box and that same product without a lid. It’s the kind of idea that would make the other Saved By The Bell writers say, “Look, if you’re not ready to come back to work, take more time off to deal with the death of your son.” The point I’m making is that it’s hard not to comment on Tiffany’s silly can, and that’s more appealing to Tiffany & Co. than when we comment on how the people who mined their products all died of slavery.

        “Darling, I was part of many souls transcending penetration to transform a utilitarian men’s room into an installment of signature Tiffany oeuvre.” — this Tiffany copywriter explaining to his wife why there are seven colors of pubic hair in his underpants

        And it’s not only tin cans and Wu-Tang albums that are marketed in intentionally strange ways. Food advertisers have figured out that they can get more attention by being ridiculous than by being delicious. Remember when KFC used fried chicken as sandwich bread in the Double Down? Or when Chick-Fil-A announced that their fried chicken hated gay people with the Cajun Titty Jiggler? We all made fun of them, but they absolutely did not care. These are people turning pigeon meat and “deported” foreign nationals into nugget shapes. They’ll take any press they can get.

        We need to stop doing this. It’s very possible the only conversation any of us had or will ever have about Dr. Pepper came when they released a special version of their soda for men only. We all went on Twitter to say things like, “Forbidding women from tasting Dr. Pepper Ten will only delay the discovery that it’s made from semen, not stop it completely.” We asked questions like, “Why would you make a soda for men only? Are you trying to find the perfect drink to pair with losing custody of your kids?” Or maybe you simply speculated, “Dr. Pepper Ten sounds like the refreshing treat you reach for when defending an accused rapist you haven’t met.”


        Products should make the customer happy, not be so deliberately dumb that the customer hears about them during a Jimmy Kimmel monologue. You shouldn’t make every tenth new Oreo out of cat suppository in the desperate hope that cookie influencers tweet about it. And pizza, you especially need to get your shit together.

        In 2012, a Pizza Hut employee happened upon the idea of a hot-dog-stuffed crust, quite by accident, when his manager caught him fucking a pizza and demanded an explanation. This marked the last time there would ever be a non-insane pizza invention. Today, pizza marketing is a series of deranged innovations, like a serial killer’s journey toward becoming the Minotaur. For instance, Pizza Hut created “smart” shoes that place an order for you. Aside from getting the elderly to wonder what they’re going to come up with next, what the fuck good do pizza shoes do anyone? If you have a use for ordering Pizza Hut via shoe, your foot is going to fall off from diabetes long before you get to do it a second time.

        And did you know that Domino’s spent millions of dollars promoting something called “carryout insurance?” It’s what it sounds like — a financial guarantee that when your sloppy ass drops a pizza, they give you another one. Aside from getting us to mention how dumb that is, what’s the point? Was there a community of fat idiots eating pizza off the ground and demanding their representatives do something? Let’s say it’s just to set your mind at ease. Let’s pretend you’re thinking about ordering Domino’s, but decide against it because you’re always dropping pizza. Will this convince you? Of course not. You’re not even here. You were taken in the night by mad scientists, and now you’re a lump of brain tissue labelled “HISTORY’S SADDEST FUCK.”

        “CARRYOUT INSURANCE!? Hey, boss? Yeah, I just found a loophole that gives me unlimited floor pizza. So what I’m saying is you can kiss my ass.


        All Things “Of The Year” Are Arbitrary Decisions Made By Small Teams Of Random Assholes

        We are living in the darkest of times. Our current sexiest man alive looks like a rectangle who makes its living hustling milk-drinking contests.

        “I’m digesting four gallons of Half & Half. Hi, I’m Blake Shelton, your sexiest man alive.”

        When People magazine announced hoedown music standout Blake Shelton as the sexiest man alive while Casper Van Dien was still not dead, it hit like a bomb. Every Twitter account and Safeway express lane had a hot take on it. It wasn’t merely controversial; it was a direct challenge to what vaginal lubrication even meant. What will it do to society if passably handsome NASCAR dads are the new standard of sexy? Do we need to stop doing sit-ups? Will there be enough denim?

        What will Casper Van Dien do with this boner?

        You know what we should have been doing that whole time? Not giving a shit about how handsome Blake Shelton is. Don’t get me wrong, Blake Shelton is alright. His condoms probably don’t expire, and if he was arrested for sodomizing a dairy cow, you’d think “Him?” But let’s not play games. He’s not the sexiest man alive. At best, he’s “Oklahoma’s Hottest Mostly Ham DNA.” But we should remember that this isn’t some great honor decided by measuring the gonad stimulation of test subjects. “Sexiest Man Alive” is picked by four or five editors desperately trying to hang onto print media jobs, and every now and then one of them is smart enough to say, “What if we trolled everyone?” With all respect to Blake Shelton’s fuckability, if you died trying to teach a prosthetic arm how to give a handjob, the People staff would write your name up on the “Sexiest Man Alive MAYBES” board.

        It’s important to keep in mind how meaningless these titles are before we get outraged. Before Donald Trump, Time gave its 2006 “Person of the Year” title to You, as in the second-person pronoun. And in 1938 they gave it to Hitler, the Donald Trump of 1938. These are meaningless choices meant to inspire terrible conversations between uninteresting people. Did you think LaTonya from Fayetteville was chosen as Jet ‘s “Beauty of the Week” because of her winning tits and smile? Wake up. It’s because her face tattoo says “Abortion is Bae.” Please, all of us, we have to stop getting outsmarted by the Jet magazines of the world.


        It’s Not An Event When Fictional Characters Die

        In 1992, DC Comics killed Superman — an invincible ventriloquist with laser eyes, frost breath, and chronosphere-bending flight speed — with a rock monster who was pretty good at punching. Despite it being the third time he had died, the country went into mourning and the story was picked up by the actual news. Which was weird, because if the media wanted to cover upsetting Superman stories, where were they when his girlfriend got turned into a pony and fucked his horse?

        I think about this every day. Every day.

        Why are we so obsessed with fictional deaths? Most of the time, they’re not even real in the make-believe universe in which they happen. Captain America and Batman die around 20 times a year, each in different combinations of fake-outs, resurrections, and universe reboots. If a dead guy’s best friends own a time machine and the Eye of Agamotto, you can probably hold off on making funeral plans. And if your favorite character dies on The Walking Dead, maybe don’t waste an hour watching Chris Hardwick cry until you see the body.

        It should help you relax knowing that most fictional deaths are only abusive pranks, but the “real” ones are about as meaningless.

        I mean, you knew there wasn’t going to be any more Firefly. This death cost us maybe two wisecracks.

        Remember when Han Solo died? He was a 73-year-old laser gun fighter scheduled to get his own movie in three years. His death was both long overdue and completely inconsequential to the amount of Han Solo you will continue to see on your TV. His father-in-law, Darth Vader, was on screen for about 36 minutes before he died in 1983, and since his death, there have been more Anakin Skywalker stories than anyone could ever want. Anakin Skywalker is the Nicolas Cage of outer space. He stopped making good movies three decades ago, yet he’s still everywhere and radiating inexplicable cosmic energy.

        If George R. R. Martin went on TV to announce that a meteor hit Westeros between books and everyone in A Song Of Ice And Fire is gone, how is that different from the world you’re living in now? The guy has clearly wanted to focus more on snacks for about four books. You know what’s sadder than seeing Ned Stark get his head chopped off? Watching some fragile-hearted slob go through the stages of grief in a YouTube video afterwards. Parents, if your child is filming themselves weep over a make-believe death, that’s a bigger failure than if your child is filming themselves pee into a tube sock for Patreon supporters. I mean, you can do whatever you want, but when you cry over fake people whom you can still see every day for as long as you want, you’re only sending a message to the people around you that you’re a dramatic piece of shit. But I know something that will cheer you up!


        Being Special Is Free

        That’s right, I said it.

        You’re welcome.

        It’s pretty easy to sell someone nothing more than the idea that they’re special or important for actual money. For example, somewhere right now, a Todd is looking through a rack of keychains to see if they have one with his name on it. “I hope they have a Todd,” he might announce as he thumbs through dusty garbage. “They do! And it’s spelled right!” So Todd will buy it, a cute reminder of the worst store in the least interesting part of a city he once visited, and it will never occur to him that an Indonesian factory gambled and won that a completely shitty Todd would one day pay money to remind himself of his own name. This next part is way off-topic, but not even the Indonesians could have foreseen that this keychain would one day be used to frame Todd …

        … for Toddslaughter.

        Back to the point I was trying to make: We are all susceptible to this crap. Coke had its first sales increase in more than a decade when it introduced the idea of adding the customers’ stupid fucking names to their cans and bottles. And the internet has been haunted by ego-stroking personality quizzes and IQ tests since before we used it to pay girls peeing into tube socks. We are so desperate to be told we’re special that we will suspend all disbelief and critical thinking to hear it. You should know that answering a few simple personality questions does not make you the coolest ninja turtle, and you shouldn’t trust the scores of an IQ test that you watched yourself cheat on which also advertises free Slavic women and four new pounds of dick girth.

        One of my favorite examples of this, and favorite things in general, is an online community called Intertel — “An International Society of the Intellectually Gifted.” It’s very difficult to get in. You can only join if you score in the top 1 percent of any self-administered intelligence test and mail in a $10 application fee. You may have considered that this in fact checks to see whether you’re stupid enough to mail in a test with a 98 percent score or less and nothing else. If you get accepted, you then pay a $39 annual fee to be a part of a genius club for people who are very specifically not. What do you get? I’m so glad you asked. For the annual fee, you get unlimited pity and the right to post a photo and bio about your unusually gullible self. It has created an avalanche of unearned ego that looks like a late ’90s Casper Van Dien fan page whose webmaster went mysteriously missing.

        Image courtesy of the estate of the Casper Van Dien Fan Page & Genius Community webmaster.

        OK, no, but seriously, this next image is a real screenshot from the Inertel (An International Society of the Intellectually Gifted) website. This is a real person who really thinks he’s in the 1 percent of intellectual elites, and this is his real profile.

        I didn’t doctor this. This is what an actual genius named BigJim369 pays $39 a year to display. Fuck! This world is magic and you get to live in it!

        Another business that exploits your love of yourself on a massive, sprawling scale is the pop-up museum industry. The name implies that there are things to do or learn inside them, but they’re more like oversized photo booths than art galleries. For instance, if you take a trip to the zany, world-famous Museum of Ice Cream, you will learn zero to one things about ice cream and eat ice cream worth $45 less than the entry ticket. What you will do is wait in line to take photos of yourself next to what you’d describe in any other context as “nothing of interest.” So to be clear, we are so self-obsessed that it’s now an effective business model to charge us money to take pictures of ourselves so we can promote you online.

        You didn’t fool ME, Museum of Ice Cream. But my family loved it. Five stars.


        Stop Making It Seem Like There Are Nazis

        OK, so the world has enough idiot racists to elect Donald Trump president, but not all of those voters were full white supremacists. Some of them were simply too religious to know when someone is lying or too old to change their mind about politics. And yes, a troubling number of them were Nazis. But in a lot of ways, most things are fine and the world isn’t as awful as you think.

        You’re welcome again.

        Impossibly shitty people, like the Trump supporters who took that Garfield mug personally, seem like they’re everywhere. A lot of that is our fault — the decent people making fun of them. They use us to amplify their voices, like Han Solo (R.I.P.) convincing a hallway of Stormtroopers that he’s way more people than he actually is. Every few minutes, a website publishes a variation on the article “These Miserable Fucks Said Something Racist About A Thing And Got Annihilated By Twitter.” They’re fun and vaguely heroic, but if you read more than one, you’ll start to see that they all share the same content. It’s the same three or four racist tweets quoted in every article, tweeted by the same three or four racists who “attacked” the Star Wars with the Asian girl and “staged boycotts” of the all-lady Ghostbusters. We need to stop treating these three or four people like they’re a threat to anything other than skewing PornHub’s algorithm to favor mother-son incest.

        BREAKING NEWS: Local high school’s least-likable prick still making quite a spectacle out his irrelevant awfulness.

        Here’s a reassuring fact: A study of Reddit found that 1 percent of communities were responsible for 74 percent of all conflict. We are taking the intentionally ignorant comments of a Kia’s worth of debate club hobbyists and pretending they’re a tidal wave of hate we must stand together against. The “alt-right” movement is 30 boys too cranky to date and too slow to learn Dungeons & Dragons. Their supporters are a toxic group of gamers who will disappear once they turn 17, and their media outlet is a cable network whose entire audience will be dead in two more flu seasons. All these people want is for the other side to get upset, so if we stop writing thinkpieces about the rise of dapper white nationalism and focus more on how liberals hate suicide cults, we can be rid of them almost immediately.

        BREAKING NEWS: C-word who only tweets C-wordy antisemitic things DOES!

        Ann Coulter is a good example. She’s the skeletal remains of antique intolerance, and she has about as much cultural influence as Corey Feldman’s band, Oral Thrush and the Yeast 2000s. Has she ever done anything other than hiss wrong things at impatient TV personalities or pretend that clinical antisemitism is antisemitic comedy? She only seems like she is a thing because 10,000 of us dunk on the bitch every time she blames her oral thrush on the Jews. Without all of us explaining to each other how wrong she is, Coulter would just be wandering through Home Depot to see if there are any white employees she can ask about the toilet safety rails. And soon she would be hatching spider eggs in her mouth while her parakeet watched her body rot. “Rawk! The Jews are at it again!” it would repeat to her undiscovered corpse. “The Jews are at it again!”

        We all seem to get how dumb it is when the news says “teens” are doing a comically apeshit thing like human centipede parties or detergent eating. Why can’t we use those same giant brains to figure out how one Nazi nerd looking for attention isn’t “the Right”? I know it’s tough to resist trolls, but Kim Kardashian owning all the world’s money should have taught you that there is virtue in shutting the fuck up about some things. We need to stay strong not in the battle against the “alt-right,” but in the battle to ignore them. The next time you see another column about how women won’t date conservative men, leave it alone. Let those dickless Nazis keep writing versions of that article into the empty void until they learn evil causes women to dry up. And the next time someone on your Facebook thread defends their Second Amendment rights after a school shooting, don’t validate their child murder fandom with attention. Move your cursor to the left and click on their mother’s profile. Pose as Blake Shelton, win her moist trust, and quietly destroy that child-murderer’s family. Every one of us can shut up and make a difference.

        Seanbaby invented being funny on the Internet. You can follow him on Twitter, or play his hit mobile game Calculords.

        Did you realize Casper van Dien was in a Tarzan movie in the 90s?

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