May 25, 2021
Equity, diversity and inclusion (EDI) is a top priority for large employers. Ensuring a company’s health and benefit programs account for diversity and inclusion is of increasing importance. While most companies share a desire to be inclusive, effective implementation can be a struggle due to the legal and stigma barriers that LGBTQ+ employees face around the world.1 Therefore, benefit teams should align with various partners to ensure that they can develop and deploy meaningful benefit offerings for their employees, including EDI colleagues to understand needs/expectations of employees; local legal teams to ensure compliance and risk mitigation; and local health insurer/broker to encourage/enable support for LGBTQ+ benefits in the marketplace.
Although progress in legal protection is being made, with more countries decriminalizing people who identify as LGBTQ+, there is still a spectrum of LGBTQ+ equality and intolerance around the world, leading to challenges for the LGBTQ+ population.1-4 Figure 1 shows the spectrum of sexual orientation laws around the world, followed by a few regional examples.
Source: ILGA World 2020
While several Latin American countries (Argentina, Brazil, Colombia, Costa Rica, Ecuador and Uruguay) have legally recognized same-sex marriage, during the COVID-19 pandemic, Colombia, Panama and Peru had a gender curfew, where men and women alternated the days when they could leave their home impacting transgender citizens, whose gender on legal documents does not match their outward expression.5 Several states in the U.S. have implemented anti-LGBTQ+ laws including, Arkansas, whose law prevents transgender youth from accessing medical care for their transition.6 The Trump administration removed LGBTQ+ questions from the 2020 Census, eliminating data collection of LGBTQ+ people in the population and impacting their access to services and resources.7,8 The Biden Administration rolled back Trump’s limitations on health protections for LGBTQ+ people seeking health care services.9
LGBTQ+ rights are still in their early stages in many parts of the world. In several countries, same-sex relations are either illegal (e.g., Singapore, Malaysia) or frowned upon (e.g., China, Indonesia).4,10 Many countries do not allow same-sex marriage (e.g., South Korea, India), and some require transgender individuals to be sterilized when they transition (e.g., Japan) or make transition illegal (e.g., Vietnam).10,11 Philippines and Taiwan are more progressive toward LGBTQ+ rights than other countries in the region.10 Filipinos are the most accepting of gay people in the region, and the Taiwan Constitutional Court ruled in favor of same-sex marriage.11 India’s Supreme Court struck down its law that criminalized gay people, enabling several employers to be more open about their EDI policies.7,11 Transgender people have legal recognition in India, Nepal, Bangladesh and Pakistan as hijra, a legally recognized third gender.12 While legal breakthroughs have occurred, Indian LGBTQ+ folks face social discrimination and stigma (access to education and work).12
Europe, Middle East and Africa
The European Union has LGBTQ+ rights in their treaties related to workplace discrimination. However in Poland, about a third of the country have issued ordinances citing “LGBTQ+ Ideology Free” Zones, an effort to reduce the LGBTQ+ equality efforts touted by the European Union.13 Several Middle Eastern and African nations make being LGBTQ+ punishable by prison or death.3,4
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.
LGBTQ+ equality progress is due in part to society being more accepting of LGBTQ+ people. Figure 2 provides a country- level overview of acceptance of lesbian, gay and bisexual (LGB) people.
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 affecting the health of LGBTQ+ individuals largely relate to oppression and discrimination.
- 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.
LGBTQ+ people are impacted by a number of disparities, including:14
- LGBTQ+ people are criminalized or their relationships are not legally recognized in some countries.3,4
- LGBTQ+ youth are two to three times more likely to attempt suicide.
- LGBTQ+ youth are more likely to be homeless.
- Lesbians are less likely to get preventive services for cancer.
- Gay men are at higher risk of HIV and other sexually transmitted diseases (STDs), especially among communities of color.
Intersection of Race, Sexual Orientation and Gender Identity
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.
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:
Employer Considerations for Developing LGBTQ+ Friendly Benefits
Inclusive benefits require employers to update and incorporate eligibility criteria, gender affirmation health services, HIV/AIDS coverage, family-friendly benefits and leave.
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.17 If a local health plan is unable to provide coverage, captives and other purchasing alternatives (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 partner/spouse 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 large 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 seek 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.
For guidance on providing evidence-based care, here are two relevant resources:
- WPATH’s transgender care guidelines covers 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).
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 (A.I.) chatbot to help LGBTQ+ access the benefits they need without risk of stigma.18
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 to reduce complications and increase LGBTQ+ trust in the medical community. Here are a handful of COEs that focus on transgender care:
- 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
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 .
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 at 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.
For more information on working with health plans to cover HIV/AIDS, please see the Business Group’s Negotiation Tips for Mainstreamed HIV/AIDS 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 .
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 minimum benefit.20 Two fertility vendors who have LGBTQ+ inclusive offerings are ORM Fertility and Carrot Fertility. Please note that the Business Group does not endorse vendors, and this is provided for informational purposes only.
For more information on family-friendly benefits, please see the Business Group’s Parent Package: A Case for Supporting Working Parents and Global Trends in Family-Friendly and Work/Life Benefits.
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 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 on leave, please see the Business Group’s Leave and Family-Friendly Benefits country deep dive article.
Members have shared various ways to address the barriers and challenges encountered when developing a global LGBTQ+-inclusive benefit strategy, including:
- 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 so that you may be able to 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 be better able to 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 EDI department of your company. Establish an EDI executive group to work through benefits parity across the world.22
- Consider 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 (Figure 3).
For more information on how employers address equity, diversity and inclusion in their benefits, please see our Quick Survey Findings: Equity, Diversity and Inclusion in Employer-Sponsored Health and Well-being Initiatives.
Here are resources from external organizations:
- Human Rights Campaign
- Out & Equal
- 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
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