by Assemblyman Mark Leno
November 16, 2004

IMAGINE CONSISTENTLY PAYING for health insurance – only to find that when you need care, your insurance carrier won't pay for it, leaving you with thousands of dollars of medical bills. Imagine being denied health coverage over and over by insurance carriers, even though you're healthy and active and haven't been sick a day in your life. Imagine the frustration with a medical community that doesn't even recognize your gender and sometimes treats you disrespectfully because it doesn't understand you.

For transgender people, these are the harsh realities faced every day in accessing the basic health care all of us need.

Transgender people, like everyone, share anxiety about national health care issues such as the increasing cost of prescription drugs and insurance. But they're also concerned about issues that are transgender-specific. An independent business owner, for instance, could consistently be denied a health policy simply because he has transitioned from female to male. A full-time employee could be forced to pay out of pocket for medical care because her employer's policy won't cover procedures related to her transition – regardless of whether they're necessary for her health. Transgender people also receive substandard care because of bias or lack of information on the part of health care professionals.

The term transgender describes people whose gender identity is different from the gender they were assigned at birth. Gender identity, a characteristic we all possess, is our internal understanding of our own gender. For many transgender people, the difference between their gender identity and their birth-assigned gender creates considerable stress and anxiety that can lead to depression, suicidal feelings, and even increased risk of alcohol and drug dependency. When this is the case, access to appropriate and affordable health care is central to being able to live a full life.

The term transition is used to describe the process some transgender people undergo to bring their outward gender expression into alignment with their gender identity. Insurers in California rarely cover transition. They'll cover breast reconstructive surgery for a woman who has breast cancer, but they won't cover transition when a doctor recommends it for the psychological well-being of the patient.

Costs are often cited as a reason for not covering transition, but evidence shows the costs to be minimal. In 2001, as a San Francisco supervisor, I passed an ordinance that required the city to provide expanded health care coverage to transgender employees. After three years of the new plan, it's estimated that the revenues to pay for care exceeded costs by a factor of 25, demonstrating that concerns about spiraling costs were misplaced.

Even if a transgender person pays the full cost of transitioning, insurance providers will often refuse to accept the individual because he or she has already transitioned. When a person's application for an insurance policy is rejected because that person has transitioned, the only reason given is that the person has a "high risk" for health care complications. However, this reason has never been backed up with verifiable data.

Of course, discrimination occurs not only in the provision of insurance coverage but also in the provision of direct health care services. While few justifications exist for insurance discrimination, none exist for discrimination in services. Fortunately, motivated by community activists and allies, the health care profession is slowly addressing the need for training on these issues. While few medical- or nursing-school programs include substantive information on transgender health care, more and more institutions are doing in-service trainings to begin the long process of transforming themselves into discrimination-free environments.

If transgender people are going to be able to fully access medically necessary services, some action will have to be taken on a larger scale to root out and eliminate these clearly discriminatory policies and practices. Such action will have to be clear and comprehensive in order to overcome the bias that currently exists against transgender people in the health care industry.

Assemblymember Mark Leno holds a California Assembly Select Committee hearing on health care and coverage for transgender people Tues/16, 6-8 p.m., San Francisco LGBT Community Center, Andrew Spencer Ceremonial Room, 1800 Market, S.F. (415) 865-5555.