Care in Transition

Alex Hanna explains how access to the various pieces of necessary health care can be extremely limited or nonexistent for many transgender people seeking transition care.

Charles, a transgender man, and his spouse have been trying to have a baby using his eggs. He’s been on testosterone for six years but has been off hormones at the suggestion of his insurance company. They won’t cover the procedure to harvest his eggs but suggested he even begin taking estrogen to have a better chance of doing so.

“I have to do what they want me to do,” Charles (not his real name) says, otherwise his chances of getting the procedure covered will become slimmer. Being off testosterone for so long has had adverse consequences for him.

Charles also suffers from endometriosis, which causes him constant pain. His primary care doctor is friendly to transgender patients like himself, but couldn’t care for him in her facility. He was referred to a women’s clinic, where he felt very uncomfortable and had to explain his body to the providers.

This kind of experience is all too common for most transgender people. Getting proper health care as a transgender person is difficult in Wisconsin, as it is in most of the U.S. Most employer health insurance plans don’t cover transition care. In addition, when insurance does cover care, there is a paucity of providers who know how to provide adequately for transgender patients. Even something as simple as allowing for preferred names and pronouns is not a standard feature of health software.

Differences and Similarities in Needs

By transition care, we mean many different things: The World Professional Association for Transgender Health’s (WPATH) Standards of Care prescribe a range of procedures. There are procedures that cisgender people receive which aren’t accessible to transgender patients. For instance, the estrogen easily accessible to a cisgender woman going through menopause is necessary for transgender women to maintain sufficiently high levels of estrogen. However, there are also procedures which may be considered elective or cosmetic, such as breast augmentation, bi-lateral mastectomy, and facial hair removal. This does not include procedures which do not have an equivalent for cisgender people, such as phalloplasty and vaginoplasty. In addition, transition care includes mental health, counseling, therapy, and medication.

All elements of transition care—including those which are considered elective or have no equivalent within the cisgender population—are considered medically necessary, not only by WPATH but the American Medical Association and American Psychological Association.

The cost to employers for providing these benefits has been shown to be minimal. One reason is that utilization of these benefits is so low that they cost very little compared to total premiums collected. A 2013 study, published by the Williams Institute at UCLA, found that most employers who provided this benefit reported no cost to adding them. They actually argued the reverse, that the benefit of providing necessary care increased employer health and happiness. Although insurers typically add modest charges to cover projected additional expenses, the experience to date has been that actual incurred costs are far lower than these projections and are essentially negligible when averaged across large insured populations. San Francisco insurers initially imposed a modest surcharge when for transgender care; insurance company surcharges took in $5.3 million in additional revenue 2001–2006 while the actual costs incurred were $386,417 or only 7% of the revenue collected on the basis of initial actuarial estimates. Based on this experience, San Francisco insurers stopped charging separately for transgender care.

Unfair Barriers

However, most states have explicit exclusions written into their insurance guidelines prohibiting coverage for transition care. Wisconsin’s state insurance board has this exclusion written into its guidelines, which means that Wisconsin state employees cannot access these benefits. To date, insurance commissioners in eight states (California, Colorado, Connecticut, Illinois, Massachusetts, Oregon, Vermont and Washington) and the District of Columbia have, by regulations or guidance, interpreted state laws prohibiting gender identity discrimination to prohibit transgender exclusions. Four states (Illinois, Massachusetts, Vermont and Washington) have also cited state and federal bans on sex discrimination in adopting these rules. Federal courts have also agreed, in the context of tax deductions and prison healthcare, that categorical trans exclusions are arbitrary and unlawful.

Transition-related exclusions are discriminatory because 100% of the people affected are members of the same group: transgender people. The U.S. Department of Health and Human Services Departmental Appeals Board recently invalidated Medicare’s long-standing transgender exclusion, concluding that sex reassignment surgery is effective, safe, and medically necessary in appropriate cases and that there is no medical basis for such an exclusion. Recently, the Department of Health and Human Services has issued rules under the Affordable Care Act (ACA), which would ban discrimination based on gender identity. The proposed rules would apply to any insurer working with Medicare, Medicaid, or the ACA Health Insurance Marketplace. While this could be a huge victory, these rules could be interpreted very narrowly by insurers and providers, meaning it may exclude medically necessary services which are considered elective or do not have a cisgender equivalent.

Dane County, which recently passed an ordinance designating gender identity as a protected class, also has an exclusion written into coverage guidelines for county employees. Even though Madison and Dane County like to pride themselves on being a place where LGBTQ people can exercise freedom of expression and from discrimination, this exclusion amounts to explicit de jure piece of discrimination.

Allies for Inclusive Care

Two groups have been working toward removing these exclusions in Wisconsin and Dane County. The Wisconsin Transgender Health Coalition (witranshealth.wordpress.com) is a network of organizations dedicated to collecting data, sharing resources, creating educational materials and opportunities, and advocating for policy change for transgender folks across the state.

A second group, the Dane County Trans Health Group, has been advocating for removing the restriction from Dane County policy and building support for full coverage of transition care for county employees. You can join these groups to move this work forward by helping them work for policy changes that provide more inclusive healthcare for transgender people, and your first action to support transgender inclusive health care is right here—add your name to this petition stating that you support inclusive coverage in Dane County: tinyurl.com/dane-trans-health.

Three counties in the U.S.—San Francisco, Multnomah (Portland), and Macomb (Detroit)—provide these benefits to their employees. Dane County has another chance to lead in equality and justice by providing this benefit to their employees.

Charles manages his endometriosis pain rather than be treated like a second-class citizen at the women’s clinic. He laments that he knows more about negotiating health insurance than any non-insurance professional should. And all that so that he has the privilege of buying a $130 vial of testosterone. He asks himself, “Do you want groceries, or do you want T?”

Dane County and Wisconsin need to do better. That chance is opening up, and our lawmakers need to seize this opportunity to make the lives of transgender people in the U.S. that much better.

Additional members of the Wisconsin Trans Health Coalition who helped contribute to this piece: Alex Hanna, Z! Haukeness, Gabe Javier, Owen Karcher, shor salkas, and Anders Zanichkowsky


Alex Hanna is a PhD candidate at UW-Madison, with an interest in social movements, political sociology, media, and the Middle East. She has taught workshops on computer programming and data analysis.