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Transgender Health Coverage: Is Now The Time?

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In recent years, substantial efforts have been made to promote social policies that support health, education, respect, dignity, and equality for transsexual, transgender, and gender-nonconforming people in all cultural settings.

 
Research and studies are providing evidence-based best practices for transgender healthcare and its impact on transgender people’s lives. 

Insurance companies should keep up to date and consider how they can support the transgender community’s healthcare needs. This article focuses on Mexico, but also discusses relevant information from other regions.

There continues to be a dearth of information about the transgender community, not just in Mexico but globally as well. Social stigma, lack of gender identification tools in general surveys, and non-disclosure of gender preferences, among other impediments, have caused this demographic to remain underidentified and understudied. Despite this, sufficient data does exist highlighting the unique biological, behavioral, social, and structural contextual factors surrounding the transgender community.

Considerations

For a comprehensive understanding of the morbidity and mortality risks associated with gender diversity, it is imperative to understand the concept of gender dysphoria as it is the primary reason transgender people seek treatment. According to the U.K.’s National Health Service (NHS), gender dysphoria refers to a sense of unease resulting from a mismatch between one’s sex assigned at birth and one’s perceived gender identity.1 

Gender dysphoria’s causes are still unclear. But it is clear that finding affordable resources such as counseling, hormone therapy, medical procedures, and social support is necessary for transgender people to freely express their gender identity and minimize discrimination. And the lack of these resources appears to contribute to the development of this condition.

Classification

The International Classification of Diseases 11th Revision (ICD-11) includes new changes to reflect modern understanding of sexual health and gender identity. ICD-11 has redefined gender identity-related diagnoses, replacing the former diagnostic categories of “transsexualism” and “gender identity disorder of children” with the newer “gender incongruence of adolescence and adulthood” and “gender incongruence of childhood,” respectively. The gender incongruence diagnosis has also been moved out of “mental and behavioral disorders” and into a section named “conditions related to sexual health.” These changes reflect updated knowledge and point out that gender-diverse identities are not mental health conditions. Classifying them as such can lead to sizable challenges and stigma.2

As many transgender people do not suffer from gender dysphoria and do not experience their gender incongruence as distressing or disabling, this diagnosis is not considered to be a mental health issue by itself. However, gender dysphoria may lead to depression and anxiety for affected individuals, and thus may have a harmful impact on their lives and mental health.

History, Interventions, and Outcomes

Since the mid-19th century, medical literature has consistently discussed gender dysphoria. The first successful sex reassignment surgery was completed in 1952, and in 1954, endocrinologist and sexologist Dr. Harry Benjamin used the term “transsexualism” for the first time to describe what we now term “transgender.” Awareness of treatments for gender dysphoria became more prominent in the second half of the 20th century when more healthcare professionals started supporting gender role transitioning through changes in physical characteristics by using therapy, hormones, and surgery. 

Today, a variety of therapeutic options exist for gender dysphoria. Treatment frameworks, however, will vary from person to person. While some may need more than one therapeutic intervention in order to alleviate their gender dysphoria, others may not need any at all. 

Treatment options include therapies to facilitate a patient’s desired changes in their gender expression and role in daily life, such as hormone therapy to feminize or masculinize the body, surgery to alter primary or secondary sex characteristics (e.g., breast/chest, external and/or internal genitalia, facial features, body contouring), and psychotherapy. 

Satisfaction levels experienced by transgender individuals after treatment interventions is about 87% for male-to-female patients (MtF) and 97% for female-to-male patients (FtM). Regrets, on the other hand, are few, totaling about 1.15% for those who had MtF surgery and less than 1% for those who had one or more FtM procedures.3, 4 

For statistical purposes, most of the data reported in the literature is based on the segment of the gender-diverse population (which includes transgender and non-binary individuals) who choose to receive treatments aimed at physical transition, either through hormone therapy or sex reassignment surgery, or sometimes both. 

Though methodological shortcomings exist in the evaluation of long-term outcomes of transition therapies, systematic reviews and meta-analyses have shown that approximately 80% of long-term studies have reported subjective improvement post-transition in terms of gender dysphoria, quality of life, and mental symptoms.5 Generally speaking, transgender individuals report a lower quality of life in relation to the general population6, 7 prior to treatment, and improvement after gender transition treatment is provided.7

In a study conducted in Denmark that investigated psychiatric morbidity before and after sex reassignment surgery (SRS) from 1978 to 2010, 27.9% of the sample analyzed presented psychiatric morbidity before SRS in comparison with 22.1% after SRS.8 Studies conducted by Lundstrom and by Kuiper and Chen-Kettenis estimated that suicidality dropped from 20% to 1% after treatment.9

A 2005 article in the journal Psychological Medicine showed that, at an emotional level, FtM individuals considered breast removal (top surgery) to be the most important surgery while MtF transitioning individuals identified vaginoplasty as the most important surgical intervention.4 One of the aims of this study was to research which areas of functioning improve as a consequence of SRS. The study found that among this population, gender dysphoria, as the main reason for treatment, fundamentally disappeared after SRS. The conclusion was that transgender people improved in several important functional areas, such as psychological, social, and sexual, and that one to four years after surgery, SRS continued to be therapeutic and beneficial.4 Results improved when strict eligibility criteria was applied for SRS and when individuals were provided adequate social support and psychological therapy follow-up.4 

Insurance Perspectives

With pressure increasing to expand health insurance coverage for transgender-related services, including primary and preventive care as well as transitional therapy, a cost-effectiveness analysis of insurance coverage for medically necessary related services has been done and regulatory policies have been put in place in some jurisdictions to support transgender population coverage and avoid unfair discrimination. 

In 2014, the U.S. Department of Health and Human Services lifted a 33-year ban on coverage for gender transitioning care for the Centers for Medicare and Medicaid Services. This was supported by existing literature that demonstrated the efficacy, safety, and effectiveness of sex reassignment treatments. 

A 2016 study funded by the Commonwealth of Massachusetts Group Insurance Commission (GIC) showed that the prevalence of sex reassignment treatments is 1:100,000 in the U.S.9 Using quality-adjusted life years (QALYs), researchers compared QALYS between no health benefits and a willingness-to-pay threshold of $100,000/QALY at five- and 10-year time horizons (Table 1).9 


Table 1: Expected results of the base case cost-effectiveness analysis

Source: Padula WV, et al. Societal Implications of Health Insurance Coverage for Medically Necessary Services in the U.S. Transgender Population: A Cost-Effectiveness Analysis9 

Providing insurance coverage had a positive impact on long-term survival rates for this cohort and appears to be highly cost-effective. With the cost to transition ranging from $10,000 to $22,000 and the cost of coverage calculated at $2,175/year, these expenses provided significant value by reducing the risk of negative outcomes such as HIV, depression, suicide, and drug addiction.9

Over a 10-year time horizon, coverage for medically necessary services produced greater cost ($31,816) but with greater effectiveness (7.37 QALYs). This resulted in an incremental cost-effectiveness ratio (ICER) of $9,314/QALY, which compares favorably on a per-patient basis to the $100,000/QALY willingness-to-pay threshold.

A 2016 article about the Human Rights Campaign Foundation (HRCF), a 40+ year old organization focused on lesbian, gay, bisexual, transgender, and queer (LGBTQ+) rights worldwide, indicated that 57 of the approximately 200 biggest employers offered at least one transgender-inclusive healthcare benefit.9 In addition, about 17 major insurance carriers already administered or provided coverage for at least one employer or student group health plan that offered transgender benefits.

The HRCF’s Corporate Equality Index (CEI) is the U.S national benchmarking tool on corporate policies, practices, and benefits pertinent to LGBTQ+ employees. The promotion of non-discriminatory policies, equality benefits for LGBTQ+ workers and their families, and support for an inclusive culture and corporate social responsibility, have driven efforts to ensure healthcare coverage for the transgender community.

Many companies in the U.S and the U.K. have removed the gender dysphoria exclusion from their group health insurance policies, and now offer health insurance cover as a benefit for their transgender employees. Treatments included in such cover vary from one company to another. They can range from psychological and hormone therapy only to more extensive benefits such as speech therapy, depilatory (hair removal) treatments, and MtF and FtM surgery. Coverage is subject to a requirement of criteria for medically necessary support, and benefit limits and exclusions are established by each insurance company. 

According to the CEI, the number of companies that offer transgender-inclusive health insurance coverage has increased 22 times since 2009.10 In the 20-year history of the CEI, survey data has explicitly shown that having a transgender-inclusive workplace deepens employee engagement and is beneficial to a company’s success.

Focus on Mexico

In 2016, the HRCF partnered with Mexico’s Alianza por la Diversidad e Inclusión Laboral (ADIL) to officially launch the HRC Equidad MX: Workplace Equality Program. Transgender-inclusive practices in Mexico were initially promoted by U.S.-based multinational companies eager to provide inclusive practices across their global operations. In 2022, more than 242 employers in Mexico earned high ratings and the HRCF’s designation of “Best Places to Work for LGBTQ+ Equality” or “Mejores Lugares para Trabajar LGBTQ+”.10 Nevertheless, there are still opportunities to improve health-related benefits, non-discrimination policies, and support services for Mexico’s transgender community.

Clinics that specialize in LGBTQ+ healthcare needs and non-governmental organizations (NGOs) such as Clinica Condesa and Letra S estimate that between 0.3% to 1% of the Mexican population is transgender. Private insurers in Mexico do not currently cover sex reassignment treatments. There is also no single coverage solution for transgender health needs. Devising affordable and cost-effective solutions is imperative for the development of better and more inclusive health insurance plans. The individual evaluation of products, conditions, and needs by insurance companies serving Mexico would help not only to guarantee more healthcare aid but also to create statistical experience that would allow them to deliver better services for all types of health insurance customers. 

Conclusion

Gender dysphoria is the primary reason transgender people seek gender-affirmative treatment. The lack of appropriate healthcare for this community contributes to negative outcomes that include depression, anxiety, and suicide. This leads to increased morbidity and mortality as well as an associated financial impact. 

Health insurance services are major aids in the delivery of healthcare. Existing literature demonstrates the safety, efficacy, and effectiveness of sex reassignment treatments and the positive impact of these treatments on quality of life and long-term survival rates, showing this approach can be highly cost-effective in the long run. The CEI has also demonstrated the benefits to corporate group health insurance programs of providing access to gender transitioning treatments.

Currently, there is no single health insurance solution for transgender needs in the Mexican market, but it is vital to follow coverage trends and determine the best way to deliver practical answers for more inclusive health insurance coverage. Doing so will improve supplied services and yield a positive and very profound social impact. 


References

1. https://www.nhs.uk/conditions/gender-dysphoria/
2. https://www.who.int/standards/classifications/frequently-asked-questions/gender-incongruence-and-transgender-health-in-the-icd
3. https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English.pdf
4. https://www.cambridge.org/core/services/aop-cambridge-core/content/view/D000472406C5F6E1BD4E6A37BC7550A4/S0033291704002776a.pdf/sex-reassignment-outcomes-and-predictors-of-treatment-for-adolescent-and-adult-transsexuals.pdf
5. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0016885#pone.0016885-Johansson1
6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5440516/#CR13
7. https://link.springer.com/article/10.1007/s11136-006-0002-3
8. https://pubmed.ncbi.nlm.nih.gov/26479779/
9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4803686/
10. https://reports.hrc.org/corporate-equality-index-2022?_ga=2.34817121.130785883.1655887924-48410943.1655887924
11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7035595/
12. https://www.nature.com/articles/s41598-021-81411-4
13. https://williamsinstitute.law.ucla.edu/wp-content/uploads/Public-Opinion-Trans-Mexico-English-Dec-2020.pdf

The Author

  • RGA Global Medical Team

Summary

In this article, RGA explores how insurance companies can support the transgender community's healthcare needs.