August 01, 2022

Addressing the existing barriers to care and health disparities for transgender population involves understanding regulations and policies in place to protect transgender individuals, as well as being sensitive to their unique life experiences, their needs in the workplace and challenges encountered while interacting with the health care system. A recent poll reveals that when asked, more than a third of U.S. adults believe transgender men and women face a great deal of discrimination in America today.⁴

An important aspect to consider is the impact of discrimination in health care settings. One study found that 29% of transgender respondents said that their provider has refused to see them because of their actual or perceived gender identity.⁵ Similarly, employers need to consider the implications (and important nuances) surrounding discrimination in the workplace. Research from McKinsey & Company found that transgender job applicants are more likely than cisgender applicants to face challenges in the job-hiring process, and once hired, transgender employees are more likely to report a sense of alienation from their colleagues and managers. The nuance/complexity surrounding these issues reaffirms the need for employers to first delve deep and seek to wholly understand the unique challenges of this population and then provide support accordingly.

As employers redesign their policies and benefits for transgender individuals they need to allow for personalization and flexibility, as each transgender person may be at a different point in their transition journey. Likewise, transitioning is a unique experience that will likely look different and require different accommodations/considerations for each individual. While some transgender people may be open to sharing, others may prefer to keep details quiet. Nonetheless, they are employees first; therefore, Human Resources' (HR) approach should be tailored and personalized to meet their distinct needs.

 

Using appropriate and sensitive terminology is the first step in the journey of inclusive benefits and culture. To assist with that and to explain terms used throughout the document, a glossary of terms has been included in the appendix.

Key Transgender Health Concerns

Although the data continues to be limited in this area, transgender people appear to be at a greater risk for certain medical conditions, and are more likely to engage in risky health behaviors:

• Depression and anxiety: Transgender individuals may experience comparatively higher levels of depression and anxiety due to a variety of external (e.g., stigma, lack of social support and discrimination) and internal influences (e.g., hormone use, psychological resilience, transition status and self-esteem). One study found that levels of anxiety among transgender participants are three times higher than those among the general population.⁷ In a geographically diverse sampling of transgender Americans, researchers found that 44% had clinical depression and 33% suffered from anxiety.⁸ Depression and anxiety are often precipitated by social stigma. Supportive social relationships help ease the problem.⁸ Another study suggests that the risk of depression is nearly four times greater in transgender individuals who are not using hormone treatments than those who are.⁹
• Substance abuse: While more research is needed to identify factors contributing to substance abuse in the transgender population, one cross-sectional analysis found that the prevalence of alcohol, nicotine and drug substance use disorder diagnoses (SUDDs) among transgender adults is significantly higher than it is among their cisgender peers.¹⁰
• Violence: Transgender individuals commonly face harassment: 50% of transgender respondents surveyed reported harassment from coworkers, 7% report experiencing physical violence and 6% report sexual harassment.¹¹ Transgender women of color make up a majority of reported violence that caused fatalities.¹²
• Sexually transmitted infections (STIs): The transgender population is at a higher risk for STIs. For example, Black transgender women have the highest rate of new HIV diagnoses and transgender men who have sex with men may also be at a higher risk of exposure to the monkeypox virus.^13,14
• Pregnancy and childbirth: Despite the heightened focus on inclusivity and transgender health care issues, considerate knowledge gaps persist, especially about pregnancy and birth experiences among transgender individuals. Such gaps in understanding may proliferate in part due to how medical systems traditionally track sex/gender as male or female. Though more research is needed in this area, one literature review found that transgender men face significant discrimination and obstacles throughout pregnancy and through childbirth.¹⁵
• Hormone use-related conditions: There are some health risks that may be associated with hormone use among transgender individuals.
• Skin health: Transgender men may experience acne, muscle problems or weight gain when taking testosterone.¹⁶
• Vein health: Estrogen treatment used by transgender women is a risk factor for venous thromboembolism (VTE), or a blood clot that forms in the veins.¹⁷
• Cancer: It is possible, though rare, to develop cancer due to hormone treatment (e.g., breast cancer).¹⁸
• Heart health: Recent research indicates that transgender individuals who use hormones may have a greater risk for heart attack and stroke, this is especially evident among transgender women on estrogen.¹⁹ Transgender women may have concerns that they will have to stop their hormone treatments if they develop heart issues—which might then prevent them from reporting symptoms (e.g., chest pains or breathing trouble) to their doctor. It is important to note that the scientific understanding of this issue is still evolving, and thus, probably does not yet warrant stopping hormone therapy.
• Illegal silicone injections: Transgender individuals who may be unable to access or afford professional reconstructive procedures or gender-affirming care may turn to illegal silicone injections. These silicone injectables are often not medical grade quality and contain toxic ingredients that can lead to severe disfigurement, scarring and even death.²⁰

Evolution of Standards of Care

As medical carriers and employers alike continue to review progressing guidelines and assess current benefits to meet the needs of transgender people, various sources are available to shape their approach to transgender coverage. The Standards of Care (SOC) for the health of transsexual, transgender and gender nonconforming people, developed by the World Professional Association for Transgender Health (WPATH), an interdisciplinary professional and educational organization, is one source that carriers and employers utilize.

"The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment."²¹

The first WPATH SOC guidelines were published in 1979 and the most recent edition (SOC7) was published in 2012. SOC7 is more comprehensive than the prior versions and contains numerous updates that address changes in both the transgender community and in the practices of physicians who care for them.²² As needs for transgender people continue to evolve, additional guidance will be required, which is a priority for WPATH. The organization is in the process of releasing SOC8 that includes new guidelines and additional chapters.²³ Most surveyed employers offering transgender-inclusive benefits (71%) follow WPATH’s Standards of Care coverage guidelines, which is considered the standard for transgender services; an additional 16% follow their health plan’s guidelines.²⁴

Although the SOC7 is comprehensive and includes evidence-based treatment options, certain topics, such as lack of data on successful outcomes of treatment, treatment regimens (e.g., hormone dosing) are not part of the guidelines.²⁵

For most medical carriers and employers that want to take a comprehensive approach in developing their transgender benefits, they often utilize additional sources besides WPATH SOC to develop their coverage standards. These include:

• Independent panels and reviews;
• Medical societies; and
• Internal teams and medical directors.

In 2016, University of California, San Francisco, released the second edition of its Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, a peer-reviewed, evidence-based list of recommendations that complements the current WPATH SOC7 guidelines and the Endocrine Society Guidelines, which was updated and released in 2017. The most recent publication on transgender care, released in 2019, is by the American College of Physicians, called Care of the Transgender Patient. It is designed to assist clinicians in understanding the specific medical issues relevant to transgender people.

Value of Telehealth in Providing Care and Support

Many transgender patients face barriers when accessing care and have had negative experiences when trying to navigate the health care system.²⁶ A study found that 70% of transgender patients experience discrimination when they seek care, which resulted in them postponing medical care out of fear of being mistreated due to their identity.^27,28 This lack of care may increase health care costs over time. While the transgender community continues to grow, better access to care will continue to be a need.

The rise in telehealth utilization has highlighted the potential of virtual care to expand access to services, especially for those who have difficulty accessing and within brick-and-mortar settings. Telehealth can help transgender people access culturally competent, affirming providers that have the knowledge and experience to treat transgender people and are able to meet their unique needs. In addition to having access to trans-competent providers, patients can receive transition-related care virtually, particularly for hormone replacement therapy (HRT). Rock Health data suggests that telehealth adoption is already higher among the lesbian, gay, bisexual, transgender and queer (LGBTQ+) population as it provides a more comfortable setting and better access to care.²⁹ While telehealth utilization increased for both LGBTQ+ people and non-LGBTQ+ people during the pandemic, utilization was higher among LGBTQ+ people (49% vs. 34%, respectively).³⁰ In addition, 61% of LGBTQ+ respondents who used live-video telehealth reported being more satisfied with the experience compared to in-person interactions vs. 52% of non-LGBTQ+-identifying adults who used live-video telemedicine.²⁹

With transgender people living across the country, telehealth may not be available for every transgender person who needs to receive affirming care, and patients may not be able to seek care from an out-of-state provider. As virtual health continues to expand, there will be opportunities, barriers and risks that need to be considered and addressed. Click here for more insights on how virtual health can shape the future and enhance the patient experience.

Quick Survey Results: The Scope of Benefits that Could Be Offered to Support Transgender Employees

Transgender health care is continuing to evolve, and more transgender people are seeking support for gender-affirming medical treatment. Transgender-inclusive health benefits may include non-surgical and surgical gender-affirming procedures. When evaluating the current coverage and assessing coverage gaps, employers that offer or plan to offer transgender benefits should consider the following standard benefits which are critical in a transgender person’s transition:

• Non-surgical: Mental health counseling, HRT, lab work, doctor visits, speech/voice therapy and reproductive benefits (i.e., embryo freezing and sperm preservation).
• Surgical: Genital surgery, breast/chest surgery, facial feminization/masculinization, thyroid chondroplasty, laser hair removal, voice surgery, hair reconstruction, liposuction/lipofilling.

Employers can enhance their transgender-inclusive health benefits by covering additional reconstructive surgeries, including rhinoplasty, genioplasty and facial prosthesis. These additional reconstructive procedures—typically not referred to as cosmetic—are important in that they can further improve the social functioning of a transgender person, not their appearance. Employers can refer to clinical guidelines to determine whether procedures like these should be covered. A detailed listing of other procedures that employers cover can be found in the Transgender Benefits in 2022 Quick Survey.

Below is a summary of findings from the Transgender Benefits in 2022 Quick Survey conducted by Business Group on Health in March/April of 2022. Sixty-five employers responded to the survey, which examined benefits offered to transgender employees; specifically, medical coverages and benefits, as well as limitations and offered the following insights:

• Employer coverage for both non-surgical and surgical gender-affirming procedures continues to increase. As of today, a majority of employers surveyed cover both non-surgical and surgical procedures.
• Fifty-six percent of employers cover non-surgical procedures, including reproductive benefits (i.e., embryo freezing and sperm preservation), and 48% cover speech/voice therapy. Among employers that cover non-surgical gender-affirming procedures, most also cover mental health counseling, HRT, doctor visits and lab work.
• Employers cover a variety of surgical procedures, with the majority covering genital (98%), and breast/chest (85%) surgeries.
• Three in four employers do not have a lifetime dollar limit for gender-affirming procedures.
• Only 25% of employers cover reversal surgeries under their plan.
• More than half (56%) of employers surveyed consider reconstructive procedures to be medically necessary for transgender employees covered under their health plans.
• For other transition supporting services the majority of employers offer second opinion service (55%), high-touch health concierge services (39%) and centers of excellence or high-performance networks for gender-affirming procedures (18%).
• Ninety percent of employers surveyed provide short-term disability coverage to employees after a gender-affirming procedure and 51% provide long-term disability coverage.

Considerations to Enable More Inclusive Benefits and Workplace Policies

A company’s organizational culture plays a big role when it comes to the design and implementation of transgender-inclusive benefits and policies. For many, evolving their transgender benefits approach may be borne out of external and/or internal [e.g., employee resource groups (ERGs)] encouragement to make the workplace more inclusive and offer a greater sense of belonging for transgender people and their dependents. Eighty-three percent of large employers surveyed in 2021 have already made such program changes to increase the inclusion of transgender health care benefits and create more equity in their offerings.³¹

The following list covers some key steps in the areas of health benefits, workplace policies and employee communications that may be considered by employers.

Health Benefits

• Verify that transgender individuals receive appropriate preventive care: Be mindful that transgender individuals may still have preventive care needs related to their sex assigned at birth. For example, a transgender man may still need to receive a mammogram. In this instance, the individual’s record may reflect the identified gender (M), which may lead insurance companies to reject any claims associated with care required for the former gender (F). In 2015, HHS gave the directive to health insurance companies that they cannot use gender to determine eligibility for preventive services—but these protections were later rolled back in 2020.³² Implementation of the amended directive is unclear given the 2020 Supreme Court of the United States (SCOTUS) ruling that sex-based discrimination at the workplace includes discrimination based on gender identity.³³ Enforcement of the rolled-back rule is further challenged by the second version of the U.S. Core Data for Interoperability (USCDI v2) that references gender identity within the patient demographic data class.³⁴ Information and data system designs may lag in adopting a transgender-inclusive model within a standard electronic health record so that patients can receive the most comprehensive care possible.³⁵ There is also concern that some transgender patients still avoid sharing information about their gender identity out of fear of discrimination from providers.³⁵ Thus, to help ensure employees can access the preventive care they need, it is important for employers to routinely consider how their health plan partners/vendors are classifying data related to gender identity.
• Compare WPATH SOC with health plan’s guidelines: WPATH’s SOC guidelines generally line up with those of national carriers. However, there may be some procedures that aren’t covered if they are deemed reconstructive. Employers should evaluate the two to determine if there are variations in coverage. If there is a procedure that WPATH recommends that the health plan doesn’t cover, the employer may need to evaluate if the procedure should be covered based on a number of factors, including benefit philosophy and cost of the procedure.
• If covering genital reconstruction surgery, consider contracting with high-quality gender-affirming centers: Genital reconstruction surgery isn’t a common procedure; therefore, it should be performed only at a facility that has high volume and expertise in the area. Work with carrier(s) to identify high-quality providers/hospitals that are in-network and/or accessible and can perform the surgeries or be more flexible by adding travel and lodging benefits to ensure that employees can access medically necessary care. Some reconstructive procedures (breast augmentation) may be more straightforward and can typically be done in the community setting.
• Ensure access to transgender-competent providers: It is imperative that transgender and gender-nonconforming people can locate and access providers that not only understand their specialized health needs as a transgender person but also render services in a compassionate and caring manner. When asked, only 29% of respondents said that their health plan has easily identifiable providers in their network who are experienced and/or specialize in transgender health care.²⁴ When vetting medical vendors, ask bidding vendors how individuals can search and/or access transgender-competent providers and what support they receive within the services and provider search tools managed by the health plan.
• Offer care navigator/concierge: Forty-five percent of LGBTQ+ individuals report having difficulty finding a primary care provider and 60% have difficulty accessing a mental health provider.³⁶ Offering targeted navigation/concierge support is one way that employers can connect transgender individuals to culturally competent/congruent providers and ensure access to gender-affirming care. On average, three out of four employers surveyed offer navigation support to transgender employees.²⁴
• Modernize reproductive/family-forming benefit offering: It is important to consider that some transgender individuals may plan on having children or becoming parents one day. Such aspirations, along with all reproductive options (e.g., egg retrieval, sperm banking) should be discussed with providers before patients undergo any surgical or medical procedures that might limit their future reproductive options. Consider steering members toward high-quality providers who follow evidence-based protocols and deliver superior clinical outcomes that also offer counseling on reproductive planning for transgender individuals. For context, one-third of employer respondents offer family-forming support tailored to the transgender community.²⁴ For additional information on how employers can modernize their reproductive benefit offering through evidence-based treatments, click here.
• Reevaluate domestic partner coverage eligibility: Most large employers surveyed indicated that domestic partners and children of domestic partners are eligible for health benefits in 2022 and 2023. When asked about their company’s top reasons as to why they offer domestic partner coverage, almost all (94%) said it is part of their diversity, equity and inclusion (DEI) efforts, 73% indicated it is in keeping with their company’s culture and 70% shared it is to improve employee retention/attraction.³⁷ In addition, 41% shared it was to meet HRC criteria for the CEI.³⁷ For those offering transgender-inclusive benefits, this becomes important for employees who transition legally yet remain in their partnership. By covering both spouses and domestic partners, employers ensure that the transition has no effect on coverage for the employee’s spouse/partner.
• Consider the needs of transgender children/dependents: Gender-affirming care can be lifesaving for transgender and nonbinary youth.³⁸ Though provision of this care is associated with improved mental health outcomes and is considered a powerful suicide prevention tool, legal challenges arising at the state level leave its clinical future somewhat uncertain.^39,40 In light of these considerations, it is understandable that according to Business Group’s Transgender Benefits in 2022 Quick Survey, employers are assessing coverage for dependents under 18 years of age.²⁴
• Review all exclusions and restrictions: To ensure that there are no barriers to care for individuals trying to transition, consider eliminating separate dollar maximums for gender affirmation surgeries or other related procedures, restrictions on out-of-network coverage, limitations on care or surgery, or reversal surgery. If changes are made, communicate the change to employees in a positive and sensitive manner using inclusive language.

Workplace Policy

• Review and update company policies: Complete a broad analysis of HR/workplace policies (e.g., non-discrimination/equal opportunity and anti-harassment policies) to determine if any run counter to new transgender policies or are mutually exclusive. Some sick leave and/or short-term disability policies exclude certain procedures or recovery from procedures. In addition, policies should be updated to include terms such as sexual orientation and gender identity.
• Offer adequate access to single-occupancy or gender-neutral restrooms and/or allow transgender employees to use the restroom that coincides to their gender identity/gender expression: There is no law or requirement stating that employers must create separate restrooms for transgender employees. Some employers suggest to transgender individuals that they use the restroom that aligns with their gender identity and/or gender expression; some transgender individuals may be more comfortable using a single-occupancy restroom. In addition, employers that make sanitary napkins/tampons/pads available, should ensure that these products are available in all on-site restroom(s) to support the menstruation needs of transgender men.
• Remember the little things: While making small modifications do not result in sweeping policy changes, addressing the following issues related to gender can make a big difference in a transgender employee’s life in the workplace.
• Name badges: When the time is right, allow transgender employees to change their names on name badges. Employers are not required to wait until the name is legally changed to make this change in the workplace.
• New ID picture: Give transgender employees the opportunity to take a new company identification picture throughout their transition.
• Cubicle/office signage: As with name badges, allow employees to change the name listed on their office door or cubicle entrance. In addition, signs in communal office areas should use inclusive/gender-neutral language where applicable (e.g., instead of calling it a “breastfeeding room” or “mothers’ room,” employers may want to call it a “nursing room” or “parents’ room”).
• Dress code/uniforms: While dressing as one’s identified gender should be welcomed and not stigmatized; employers should clarify that attire must conform to the overall code set forth by the company. Additionally, consider a gender-neutral approach to company-provided uniforms. Some individuals (transgender or not) may opt for a male cut of a polo shirt, while others may gravitate to the female version of a uniform.
• Pronouns: Encourage all employees to list their pronouns (i.e., him/he/his, she/her/hers, they/them/theirs) on their name badges and email signatures. Doing so can help employers prevent instances of misgendering in the workplace—which can also lend a hand to improving their well-being.⁴¹

Communication

• Listen to employees: Many corporations with diversity initiatives have a business resource group, ERG and/or an LGBTQ+ advocacy group that promotes diversity and understanding within the company. These groups can play an important role in delivering feedback to diversity leaders and those in HR. Often, HR leaders and ERGs drive policy and benefit changes related to transgender individuals. According to the Transgender Benefits in 2022 Quick Survey, the majority of survey respondents work or partner with their ERG on a quarterly (20%), monthly (16%) or annual (20%) basis to promote and develop programs for their transgender employees.²⁴
• Highlight all policies: Be mindful of where your workplace and benefits policies are housed on the company’s website to ensure it is visible for employees looking for details. All policies should be easy to access on the HR website. Consider pushing out communications to showcase the company’s policies and/or displaying them in a central/high-traffic area (whether online or on-site).
• Educate all external stakeholders: Ensure that all health vendor partners, especially concierge teams, are well-versed in company policies and support benefits offered to transgender individuals.
• Create a resource guide for managers and employees to build understanding of the needs of transgender individuals and the challenges involved with the transition: A resource guide can be a helpful tool for managers, employees and co-workers to refer to during an employee’s transition. Importantly, a member of the LGBTQ+ affinity group (transgender employee preferred if one is on staff) should review all communications to ensure that the terminology and recommendations are appropriate. The resource guide could address topics for both employees and managers, including:

Conclusion

Transgender-inclusive benefits and policies are one of the fastest-changing areas of health benefits. While recent trends have been for employers and states to remove coverage exclusions, increased legal and regulatory uncertainty over state authority following the SCOTUS decision in Dobbs v. Jackson Women’s Health Organization may impact employer assessment and implementation of a variety of plan offerings, including transgender-related programs. For employers that adopt, continue, or evolve transgender-inclusive programs, an imperative will be to maintain provider access while ensuring transgender individuals get cost-effective, high-quality care as they, and other participants and beneficiaries, would for other covered services.

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Culture and Strategy Health Equity Benefits Communication Plan Design & Administration