Employers’ Role in Moving Transgender Healthcare Forward

Many companies want more inclusive policies but struggle with navigating new territory. Here are some tips

Each year, the Human Rights Campaign creates a Corporate Equality Index (CEI), rating American workplaces on LGBT equality. One of the criteria used in the CEI rating system is employment benefits – providing equivalent benefits for transgender individuals.

From 2002 to 2015, the percentage of major corporations with policies and benefits for transgender employees expanded from a mere 5 percent to almost all employers – 93 percent – according to an NBGH Issues Brief from January 2016. Employers are now beginning to spend healthcare dollars to ensure their transgender employees receive the same level of benefits as their cisgender employees (people whose self-identity conforms with the gender that corresponds to their biological sex).

Trans-Affirmative Healthcare Today

While transgender advocacy has become more apparent in society today, the reality is that transgender healthcare has a long way to go. Based on the National Center for Transgender Equality’s 2011 study, 48 percent of transgender individuals cannot afford healthcare and 28 percent postpone medical care due to discrimination. However, we’ve seen over the last few years that many states and localities have passed human rights/anti-discrimination laws aimed at inclusion for the LGBTQ community, and many insurers have broadened their policies recently to include more access for transgender-related healthcare. For example:

  • The Affordable Care Act (ACA) of 2010 banned sex discrimination in healthcare settings that have a connection to federal funds, and this law has been interpreted by the federal government to protect transgender people from discrimination.
  • In 2014, Medicare removed a national exclusion on transition-related surgeries.
  • In September 2015, after pressure from LGBTQ advocacy groups, the U.S. Department of Health and Human Services (HHS) proposed a new policy, clarifying the ACA’s nondiscrimination clause (Section 1557), which will enable transgender Americans to file claims of civil rights violations against physicians, insurers, and hospitals who fail to provide trans-affirmative healthcare. This includes hormone replacement therapy, counseling, and surgical procedures that have previously been considered aesthetic.
  • The New York State Division of Human Rights’ regulation, which went into effect January 20, 2016, states that discrimination on the basis of gender identity is sex discrimination under the New York State Human Right’s Law.
  • In March 2016, the EEOC filed its first two sex discrimination cases based on sexual orientation (which includes transgender individuals) and the federal government filed a suit to challenge House Bill 2, signed by the governor of North Carolina.

Taking a Closer Look

Transgender healthcare is about much more than transition-related surgery, and specific healthcare issues beyond gender reassignment needs should be kept in mind when reviewing plan design. Here are some considerations:

  • Qualified mental healthcare—Researchers from the University of Minnesota found 44 percent of transgender individuals had clinical depression and 33 percent suffered from anxiety. Depression and anxiety were often precipitated by social stigma[1], and lead to self-harm or suicide. In fact, the National Transgender Discrimination Survey (NTDS) reported that the prevalence of suicide attempts among respondents is 41 percent, which vastly exceeds the 4.6 percent of the overall U.S. population who report a lifetime suicide attemptqualified therapists are few and far between, and typically out-of-network.
  • Aesthetic procedures—Surgeries and procedures currently considered “cosmetic” in nature – such as laser hair removal, voice surgery, facial feminization and hair reconstruction – are vital to the overall well-being of many who wish to physically transition. Gender dysphoria, experienced by many transgender individuals, is, as defined by the National LBGT Health Education Center, clinically significant distress or impairment due to noncongruence of a person’s gender role and gender identity.
  • Access to healthcare for children—As reported in the New York Times in May 2016, national numbers for transgender youth are still elusive; however, surveys show that “a higher proportion of teenagers than adults tend to identify themselves as transgender[3].”Data for children and adolescents is even more difficult to come by — the first project to even track large numbers of children, the TransYouth Project at the University of Washington, only began its work in 2013. However, as information and advocacy becomes more readily available to parents and youth, healthcare will need to meet an ever-growing demand for medical coverage. Benefits would need to include access to qualified mental health providers and hormone blockers, which are an important part of a transgender youth’s transition.

Helping Transgender Employees and/or their Transgender Dependents

Many companies want more inclusive policies that reflect their commitment to diversity, but struggle with navigating new and foreign territory. Here are some tips:

  1. Start with Plan Design—A majority of employers offering transgender-inclusive benefits (62 percent) follow the World Professional Association for Transgender Health (WPATH) Standards of Care coverage guidelines[4]. The WPATH emphasizes that medical procedures attendant to sex reassignment are not “cosmetic” or “elective.” When communicating benefits, be careful to avoid such derogatory classifications. Trans-inclusive benefits include non-surgical (counseling, speech therapy, hormone therapy), surgical, and “aesthetic” procedures (reduction of thyroid chondroplasty – or Adam’s Apple, facial feminization, hair reconstruction, hair removal, lipofilling/liposuction).
  2. Encourage routine care—Encourage transgender individuals to utilize preventive care benefits. A transgender man may need a mammogram and insurance companies cannot deny this benefit because his record reflects the identified gender male. Be prepared to support your employee if he or she faces discrimination by the insurance carrier.
  3. Utilize Centers of Excellence—If covering genital reconstruction surgery, establish a Centers of Excellence network. Genital reconstruction isn’t a common procedure and should be performed only at a hospital that has high volume and expertise in the area.
  4. Remember families—Transgender healthcare can apply to dependents, including covered children, who choose hormone blockers (which can require out-patient surgery), counseling, bone density scans, and other early-intervention-related care. Not all care is covered, and costs can be prohibitive for most. For instance, while ongoing hormone replacement therapy runs $300 – $2,400 per year, the hormone blocker implant typically recommended at the onset of puberty can run as high as $25,000.

The Road Ahead

There are an estimated 1.4 million transgender adults living in the U.S. today[6]. While transgender advocacy is more apparent in society today, the reality is transgender healthcare isn’t yet where it needs to be. Over the next year, though, we’ll see more protections put in place to cover transgender employees. In the meantime, it is the employer’s job to create a supportive and inclusive workplace environment for transgender colleagues, and create a culture that encourages dialogue and values diversity. Times are changing and laws are moving forward, and as employers we need to move forward, too.

About the Author

Margaret Botney is a senior consultant in Xerox HR Services’ Engagement Practice. With more than 10 years’ experience in communication and engagement, Margaret has conceived and implemented a wide range of communication campaigns, with particular focus on health and welfare programs and wellness initiatives, as well as compliance communications and retirement planning. Margaret originally joined Xerox HR Services in 1999 and returned in 2012 after a period in academia, during which time she was an English professor, serving as chair to an academic advisory council and senior editor of the CCHA (Community College Humanities Association) journal, and developing curricula related to diversity and inclusion. Margaret earned her MA degree in English Literature from McGill University in Montreal in 1994, and her BA degree in English Literature from the University of British Columbia in Vancouver in 1991.


[1] Bockting WO, Minder HM, Swinburne Romine RE, Hamilton A, Coleman E. 2013. Stigma, mental health, resilience in an online sample of the US transgender population. American Journal of Public Health; 103(5): 943-951.

[2] Haas, Ann P., Rodgers, Philip L., Herman, Jody L. January 2014. Suicide Attempts among Transgender and Gender Non-Conforming Adults: Findings of the National Transgender Discrimination Survey.

[3] Hoffman, Jan. May 2016. New York Times. As Attention Grow, Transgender Numbers are Elusive.

[4] Lykens C. 2014. Gender reassignment benefits in 2014. Survey Report. National Business Group on Health.

[6] Flores, Andrew R. Jody L. Herman, Gary J. Gates, and Taylor N. T. Brown. June 2016. How Many Adults Identify As Transgender in the United States? The Williams Institute.

About The Author

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