June 20, 2024

Legal and cultural issues vary around the world. Some countries have made significant progress, while others still don’t provide needed protections. Below is a list of policies found in some countries organized by positive changes in policy and negative policies still in place:^5-13

Positive Changes

• Third gender being legally recognized in Southeast Asia
• Increase in countries legally recognizing same-sex marriage

Negative Policies

• Bans on access to care for transgender youth for their transition
• Sterilization requirements when individuals transition
• Bans on egg donations and surrogacy
• Identifying as LGBTQ+ punishable by death or prison

For a more detailed look at anti-LGBTQ+ laws, the Human Rights Watch outlines specific laws by state and country. This information provides context as companies work toward having inclusive workplaces globally.

Acceptance

LGBTQ+ equality progress is due in part to society being more accepting of LGBTQ+ people. Figure 2 showcases how attitudes toward LGBTQ+ are becoming more being welcoming in several countries.

The Impact of Discrimination and Social Determinants of Health

Understanding LGBTQ+ health starts with understanding the history of oppression and discrimination that these communities have faced. For example, in part because bars and clubs were often the only safe places for LGBTQ+ individuals to gather, alcohol abuse has been an ongoing problem. Social determinants of health (SDOH) affecting LGBTQ+ individuals largely relate to oppression and discrimination.

Examples include:^3,4,14-16

• Legal discrimination in access to health insurance, employment, housing, marriage, adoption and retirement benefits;
• Lack of laws protecting against bullying in schools;
• Lack of social programs targeted to and/or appropriate for LGBTQ+ youth, adults and elders; and
• Shortage of health care providers who are knowledgeable and culturally competent in LGBTQ+ health.

Source: Source: Gallup World Poll. McCarthy J. Is the world better for gay people than it was 10 years ago? Gallup. June 13, 2022. https://news.gallup.com/poll/393602/world-better-gay-people-years-ago.aspx. Accessed May 30, 2024.

LGBTQ+ people are impacted by a number of disparities, including:¹⁴

• Being criminalized or finding that their relationships are not legally recognized in some countries;
• Higher rates of suicide attempts among LGBTQ+ youth (two to three times higher) than among the heterosexual population;
• Higher levels of homelessness among LGBTQ+ youth;
• Fewer lesbians receiving preventive services for cancer; and
• A higher risk of HIV and other sexually transmitted diseases (STDs) among gay men especially in communities of color.

LGBTQ+ people with multiple identities (e.g., part of a racial minority or neurodiverse) have more risk factors related to their health and often experience disparities when trying to access care, as shown by the following examples:

• Minority racial and ethnic LGBTQ+ people have substantial increases in health and societal disparities compared to their White counterparts.
• Lesbians and bisexual females are more likely to be overweight or obese.
• Transgender individuals can be labeled as sexual predators by media and/or politicians even though they are usually the victim.
• Transgender individuals have a high prevalence of HIV/STDs, victimization, mental health issues and suicide and are less likely to have health insurance than heterosexual or LGB individuals.
• Elderly LGBTQ+ individuals face additional barriers to health because of isolation and a lack of social services and culturally competent providers.
• LGBTQ+ populations have the highest rates of tobacco, alcohol and other drug use.
• There is reported higher prevalence of neurodiversity in the LGBTQ+ community.^24,25,27,28
• The impact of menopause on gender diverse individuals varies substantially depending on where they are on their transition journey and use of hormone therapy. This community can struggle with isolation and body dysphoria in addition to other menopause-related symptoms.³⁰

For more information on how employers can address social determinants of health, please see our Social Determinants: Acting to Achieve Well-being for All guide. The following links provide relevant resources on how employers can address issues disproportionately impacting LBGTQ+ communities:

• Suicide
• Substance Abuse
• Overweight and Obesity
• Cancer

Employer Considerations for Developing LGBTQ+ Friendly Benefits

To have more inclusive benefits, employers are updating and incorporating eligibility criteria, gender affirmation health services, HIV/AIDS coverage, family-friendly benefits and leave.

LGBTQ+ Voluntary Self-Identification

According to the Human Rights Campaign, 60% of employers indicated that they currently have a self-ID process in place that allows their LGBTQ+ employees to voluntarily disclose their sexual orientation and gender identity in confidential Human Resource records.⁴¹ To prevent issues with health plan enrollment, a best practice is to include two gender-related questions: gender identity and sex assigned at birth. Please note, however, that some markets that are welcoming to LGBTQ+ people it is legally not viable to incorporate self-ID process (e.g., France).⁴²

Same-Sex Partner/Spouse and Dependents’ Coverage

For years, employers have sought to offer same-sex partner coverage globally, often by working with their health plans to find creative solutions for coverage. If a local health plan is unable to provide coverage, captives and other financing mechanisms (e.g., global underwriting, multinational pooling) might be able to do so. Since there are concerns in some countries about whether extending coverage to same-sex partners/spouses might put the employee and their family at risk (in countries where being LGBTQ+ is criminalized), employers will want to work with their legal teams to find the right balance in providing equity while limiting risk.

Gender Affirmation Health Services

Employers who have been able to provide coverage for gender affirmation health services have not experienced a huge increase in health care spending.¹⁸ The uptake of these benefits is small, as transgender people make up less than 1% of the population, and every transgender person’s transition journey is different. Most transitions take many years resulting in costs being spread out over a long period of time.

Covering transgender care outside the U.S. can be challenging. Employers may have to work with actuaries when negotiating coverage with local health plans.¹⁸ A health plan might cover transgender care but require a high premium because it is unclear what the actual cost of coverage is. If an employer is having issues with health plans covering these services, the company may want to look into captives and other purchasing alternatives to cover those services.

Even if an employer provides coverage, employees may not be able to find appropriate care. World Professional Association of Transgender Health (WPATH) has a global provider search tool that can be helpful for identifying medical providers with knowledge of transgender health needs.

Evidence-based Care

For guidance on providing evidence-based care, here are a few relevant resources:

• WPATH’s transgender care guidelines cover the spectrum of gender affirmation services, including mental and reproductive health and preventive care.
• University of California San Francisco’s Transgender Care Guidelines outline care for transgender individuals across a spectrum, from gender affirmation surgery to HIV to non-communicable diseases (e.g., cancer, cardiovascular health).

Recent changes in the evidence-based care space include upcoming global guidelines and information about transition regret. World Health Organization (WHO) is currently developing transgender care guidelines. Of those who have undergone transition surgery, only a small minority (1%) express regret about transitioning.²³ Reasons for regret include body dysphoria, societal acceptance, appearance not reflecting self-image, surgery complications and detransition.²³ The latter reason was a small portion of those with regrets.²³

Care Navigation

The National Center for Transgender Equality created a health care coverage navigation guide for transgender people. A solution that some large employers are implementing is having a point of contact on their care navigation team be the lead on LGBTQ+ care and assistance.¹⁸ In Japan, one employer offers an artificial intelligence (AI) chatbot to help LGBTQ+ people access the benefits they need without risk of stigma.¹⁸

Travel Benefit

Some employers provide travel benefits for employees seeking care (including gender-affirming health services or cancer). To protect privacy, the companies do not ask what care is being utilized. The benefit has a monetary cap. Employees use it for a range of health services, and it is considered a component of meeting health equity needs across an employer’s diverse workforce.

Centers of Excellence

Given the limited LGBTQ+ health knowledge in the medical community, Centers of Excellence (COEs) can provide safe, evidence-based care for gender-affirmation health services. COEs have the advantage of reducing complications from treatment and increasing LGBTQ+ trust in the medical community.

• University of California, San Francisco’s Transgender Care
• University of North Carolina Charlotte’s Center of Excellence for Transgender Health
• Mount Sinai’s Center for Transgender Medicine and Surgery
• U.K.’s National Health System’s Gender Dysphoria Clinic Search Tool
• U.K.’s Nottingham Centre for Transgender Health
• U.K.’s Nottingham Centre for Transgender Health

For a more in-depth look at issues related to transgender health, please see the Business Group’s A Closer Look at the Evolution of Inclusive and Equitable Transgender Benefits and Policies .

HIV/AIDS Coverage

In several markets, HIV/AIDS coverage is excluded by health plans and risk benefits (e.g., disability and life insurance).^19,20 Beyond that, in some countries, an HIV+ person would not be eligible to receive health plan coverage at all.¹⁹ For example, in Mexico, HIV+ people have to wait 5 years after starting a job to get health plan coverage. Employers will want to work with actuaries, brokers/finance and/or captive consultants when negotiating with health plans and risk benefit insurers. Vendors may cover HIV/AIDS but at a very high premium if they don’t know how much the care will actually cost. If the local plan is not willing to negotiate, employers may consider captive or other purchasing alternatives to provide coverage.

Pre-Exposure Prophylaxis (PrEP)

Pre-Exposure Prophylaxis (PrEP) is a once-a-day pill that significantly reduces the possibility of contracting HIV in concert with other safer sex practices (e.g., condoms). In 2019, the U.S. Preventive Services Taskforce gave PrEP an A rating, and Affordable Care Act (ACA)-compliant plans cover the preventive treatment.²¹ In 2018, the European Centre for Disease Control and Prevention released guidelines for coverage and minimum standards. In 2020, a generic version of PrEP launched, which substantially reduced the cost of the drug.

To get a better understanding of PrEP utilization around the world, PrEPWatch has a global tracker. For more information on employer considerations for PrEP, please see the Business Group’s Optimizing Your HIV/AIDS Prevention Strategies: Despite Much Progress, More Work Remains .

Family-Friendly Benefits

To ensure that family-friendly benefits are inclusive, many employers are removing medical reasoning for access to fertility treatment as it will not apply to same-sex couples. Offering cryopreservation of eggs and sperm for employees who are transitioning is another central element to an inclusive family planning approach.²⁰ However, employers need to be aware of legal barriers. For example, in Japan, the government requires transgender individuals to be sterilized.

LGBTQ+ fertility benefits are more prevalent in Western markets. Leading global companies have LGBTQ+ inclusion in their global family planning benefits as a global consistency strategy.²⁰

For more information on family-friendly benefits, please see the Business Group’s Fertility and Family-forming Benefits: a Guide for Employers.

Leave

Large employers are expanding leave benefits to provide a globally consistent approach for their employees. As part of this approach, some companies are considering changing their parental leave terminology to be more gender neutral, such as using the terms birth parents and non-birth parents vs. moms and dads, or parental leave vs. maternity and paternity leave, where appropriate.¹⁸ Also, it is often overlooked that transgender men, depending on where they are on their transition journey, may become pregnant.¹⁸ Similar to other marginalized communities, when transgender men are pregnant, they face significant obstacles and discrimination from pregnancy through childbirth. To learn more about this specific experience and what employers can do to address these disparities, review the Business Group's Ending Disparities in Maternal (or Carrier) Mortality article.

Employers should also review other leave benefits, such as caregiver and bereavement leaves, to ensure parity between employees’ spouses and same-sex partners, as well as same-sex partner’s dependents.

For more information about leave, please see the Business Group’s An Inclusive Look at Leave article.

Employer Considerations

Members have shared various ways to address the barriers and challenges encountered when developing a global LGBTQ+-inclusive benefit strategy:

• Research and understand what you are required to report to the local health authority in certain locations. For example: Does the company have to report that the spouse is the same sex? What risk does this pose to the employee? To the employer? Then, become transparent about why you are or are not moving forward with a policy.²²
• Consider a captive for more flexibility in local coverage. Also, consider a global insurer to determine whether you can provide a “top up” benefit globally. Explore opportunities to have a large multinational insurer underwrite certain policies on a global basis.¹⁸
• Create a chart of what LGBTQ+-inclusive benefits you have in each geography to help you identify gaps and plan how to address those gaps.¹⁸
• Be aware of local and regional values and their impact on sustainability.²²
• Engage and partner with the DEIB department of your company. Establish an DEIB executive group to work through benefits parity across the world.²²
• As companies build new benefit offerings (e.g., menopause and neurodiversity support), viewing them from a DEIB lens will help ensure that these benefits are more inclusive from the beginning and meet LGBTQ+-specific needs.
• Consider bringing in an external consultant.²²

Working with Employee Resource Groups

Employee resource groups (ERG) can be a great source for identifying benefit gaps and challenges and providing recommendations, as well as promoting benefits and well-being initiatives to targeted groups (e.g., LGBTQ+). Several employers have worked with their LGBTQ+ ERG to ensure that their gender affirmation health service coverage was adequate and that LGBTQ+ employees were covered under family-friendly benefits.

External Resources

Here are resources from external organizations:

• Human Rights Campaign
• Trans Toolkit for Employers
• Corporate Equality Index
• Out & Equal
• Toolkits
• Country Programs (Brazil, China and India)
• Pride at Work’s Union Guide to Discussing LGBTQ People and Issues
• National Center for Transgender Equality’s Health Care Coverage Navigation Guide for Transgender People
• Human Rights Watch’s Anti-LGBTQ+ laws by country and state
• OECD Society at a Glance 2019: Spotlight on LGBT

More Topics

Resource Culture and Strategy Diversity, Equity, Inclusion & Belonging (DEIB) Health Equity