Disparity in Health Care: Transgender Americans

13 Dec

While I could go on for page after page after page on the disparity in health care for different populations, such as the quality of care for people of color, people without financial resources, women, and all of the intersections of oppression, I would like to spend some time focusing on the disparity of health care for our transgender brothers and sisters.

Disparity in Health Care for Transgender Americans–how does the government define this population and collect data: At least 0.25% of the population in the United States identifies as transgender.  One should note this statistic is innately flawed due to under-reporting.  Most of the information gathered is based on post-operative people who have transitioned, the most straightforward data to collect.  If one looks at the chart below (Conway, 2002), one notices the dramatic increase in Male-to-Female (MtF) transitions, indicating the difficulty of tracking historical trends.  These numbers do not include Female to Male (FtM), nor do they include a population who identify as transgender independent of surgery.

TABLE 1: Estimates of MtF SRS operations among U. S. residents:




1990’s – 2002





I am defining transgender as:  an individual who identifies with a different gender than what the doctor assigned at birth.  Conversely, cisgender is defined as the gender assignment at birth that matches the perceived or innately internalized gender of an individual.  I need to underscore that one need not have any type of surgery to identify as transgender.

People who identify as transgender in Oregon (and across the United States) face the significant challenge of the denial of health insurance.  Cisgender people are provided insurance coverage for things such as breast cancer, prostate cancer, and ovarian cancer.  Unfortunately, the same is not true for the transgender community, nor will most health insurance providers help to cover the cost of transitioning or hormone therapies, the very same hormone therapies that are covered for cisgender people.

Alec Esquivel (FtM) is a prime example of someone who requires care but is denied coverage. Esquivel has a medical need for a “hysterectomy to prevent ovarian and uterine cancers and to offset the hormones he takes for gender change” (Banim, 2011).  Unfortunately, his surgery is being denied by Providence, his health insurance carrier, because Alec is transgender. This is not a case of elective surgery, but rather a surgery recommended by Alec’s doctors to ensure his continued health.  Alec’s case, which is currently in litigation in the state of Oregon, is representative of a much larger problem.

This issue is exacerbated by the fact that people have limited choices for health care providers.  For example, if one works for the State of Oregon, one must choose coverage through the Public Employees Benefits Board (PEBB), which offers only Kaiser Permanente or Providence Health. Neither of these carriers insure care related to health care needs for transgender people, people with a diagnosis of “Gender Identity Disorder”.  Since health insurance is typically tied to employment, this problem exists for most transgender people.

When one looks at the values held by society as reflected in health insurance practices locally and nationally, one can identify the value of keeping cisgender people healthy and providing health insurance for preventive care as well as diagnostic care.  The contrasting value is the failure to provide health insurance for transgender people.

This contrasting value stems from fear, lack of visibility of the transgender community, and lack of education about transgender and gender identity issues.  Fortunately, the city of Portland joins a tiny host of pioneering local governments that now have made it mandatory for transgender city employees to have health care parity with their cisgender peers.  Portland’s transgender-inclusive healthcare policy helps to increase visibility and helps to promote change on a state and national level (Banim, 2011). Another value identified is the value of work or employment, as evidenced by linking health insurance to employment.

The policy of most health insurance providers, as exemplified by Providence Health, is to exclude all health insurance coverage for the transgender population in Oregon and nationwide if such treatment is tied to the diagnosis of gender identity disorder (American Psychiatric Association [DSM-IV-TR], p. 536-537).   Providence outlines the exclusion in their Handbook: “All Services related to sexual disorders or dysfunctions regardless of gender, including all Services related to a sex-change operation, including evaluation, surgery and follow-up Services” (Providence p. 44).  Unfortunately, this means that transgender women (MtF) who require treatment for prostate cancer are denied coverage.  Transgender men (FtM) who require treatment for breast cancer or a hysterectomy are denied coverage.  In fact, the insurance companies have such a broad impact that anyone one with “Gender Identity Disorder” may be denied coverage for a wide variety of services.  Of course, other obstacles such as race and class only compound the issue of being transgender.

Only 4% of Fortune 1000 companies provided inclusive health coverage for transgender people in 2011, up from 0% in 2004 (Human Rights Campaign, 2011).

Oregon does provide for some protection for the transgender community.  In 2007, the Oregon Legislature passed the Oregon Equality Act, which added sexual orientation and gender identity to most protections (Lambda Legal).  Fortunately, the Equality Act provides policy around use of public bathrooms for transgender people.  People in Oregon have the legal right to use a public bathroom matching their gender identity. The Equality Act does not refer to anything specific about insurance, so it will take case law to get there; thus the very relevant implications of the Esquivel case.

On June 8, 2011 the City Council of Portland, OR unanimously passed transgender-inclusive healthcare for City of Portland employees.  Portland and San Francisco are now the only two cities in the United States that provide transgender-inclusive health insurance to city employees.  Mayor Adams said, “This action is about keeping and attracting the best and the brightest, in addition to being about basic fairness” (Brooks, 2011).  While this policy for city employees of Portland is a step in the right direction, it does not yet translate into the private sector; it does however set an impressive precedent.

The city of Portland, OR does now have policy addressing health care for transgender people.  In fact, Portland’s policy for transgender-inclusive health care should be used as a model of what health care looks like for the United States.  A.J. Pearlman of the U.S. Health and Human Services Department stated at the LGBT Health Conference in Portland:

 All eyes are on Portland and the state of Oregon for the future direction of health care. The Affordable Health Care Act could potentially contain a non-discrimination clause.  We also need to look toward 2014 when the pre-existing condition clause kicks in and we hope that transgender health care will be included—being transgender would then be considered a pre-existing condition and would be covered by insurance (Pearlman, personal communication, November 15, 2011).

Unfortunately, she did concede that, “should the US Supreme Court strike down The Affordable Health Care Act in June of 2012, we are looking at a very different and difficult option” (Pearlman).  The current Supreme Court has demonstrated its lack of ethics and its biases against women and sexual minorities.

My recommendations are: first, we need better tools with which to identify the transgender population without the fear of recrimination or “outing.”  A new tool would have to accept a more inclusive definition of transgender.  The definition would have to include FtM and would have to be independent of any type of surgery.

An additional tool might be to change how the US Census form looks.  The current binary format does not work and does not accurately reflect what the population of the United States looks like.  Having four categories regarding gender would be more accurate and useful: Male, Female, Transgender, and Intersex.  The new format could also be used to help provide better and more inclusive health care for the national population.

Regardless of personal opinions and personal values around gender identity, gender conformity, and transgender people, the issue of civil rights should prevail.  A policy that actively discriminates against a population, such as the Providence Health policy, is a violation of civil rights.  If a value of the American people is to be healthy and to secure adequate health insurance, that insurance should apply categorically, regardless of gender identity.

*If there are TSM readers that would be interested in my citations, I’m happy to provide a reference page.


2 Responses to “Disparity in Health Care: Transgender Americans”

  1. Jennifer Lockett December 13, 2011 at 11:21 am #

    A very interesting and eye-opening article Michael. Thank you for sharing. I hope you got that interesting article I sent you about the identical twins – genetically identically and differing in that one identified as male and the other as female. Very interesting indeed.

    • Michael Hulshof-Schmidt December 13, 2011 at 5:52 pm #

      Jen, thanks for your continued support of all of the LGBT community. Yes, I got your article and you have again inspired me to compose another post that I hope you will be pleased with.

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