What support should PMI offer transgender employees?

transgender-inclusive

Need to know:

Insurers currently offer gender affirmation treatments and surgeries within private medical insurance (PMI) schemes on an on-demand basis.
Many employers are starting to include transgender-specific healthcare by incorporating mental health support services as part of their PMI offering, tailored for trans employees.
PMI can prove useful for managing transgender employees’ general healthcare requirements, for example, sensitively providing gender-specific health screenings.

The Yogyakarta Principles are a universal guide to human rights, providing international legal standards around sexual orientation, gender identity, gender expression and sex characteristics. Originally published in 2006 and then revised in 2017, the Principles state that gender affirming healthcare should provided by public health systems, or that the costs should be covered or reimbursable under private and public health insurance schemes.

This brings the conversation firmly to private medical insurance (PMI) schemes, which act as a support to the services already provided under the UK’s strained NHS system. How can employers approach transgender-inclusive healthcare within their PMI schemes?

The story so far

PMI is well-established, and tackles short-term, acute medical conditions. Previously, transgender-specific healthcare has not been a natural fit, says Dr Doug Wright, medical director at Aviva.

“The whole history of [PMI] is [it is] set up around short-term treatments for conditions that completely resolve [after] treatment," he explains. "With gender identity issues, that’s not a short-term problem, and the treatments that are required as well as the support required go on for many years in most cases.”

Therefore, most insurers only include transgender healthcare as and when requested. This has led to a lack of clarity over what insurance providers will or will not cover in this area, says Tony Woods, partner and UK leader at Mercer Marsh Benefits.

Some employers, however, have swerved the traditional PMI offered by insurers to instead provide gender affirmation treatment options as part of a self-insured healthcare trust arrangement. This enables employers to have more direct control over what treatments are included. Other employers have opted to supply a lump-sum type of benefit to cover transgender surgery, though employees are then left to source the surgery themselves.

Complexities and cost

One of the main complexities employers have to consider is the sheer range of available treatments, and the fact that every transitioning employee will have vastly different requirements.

Gender affirmation treatment journeys will typically start with behavioural counselling and non-surgical procedures, such as hormone treatment and puberty suppressants, before surgical options, like genital surgery or reconstructive work, are broached. There may also be additional surgeries, for example around fertility.

This spectrum of services creates a grey area around cost implications. Michelle Rae, UK head of propositions at Cigna Europe, says: “It does make it challenging to design a benefit for the surgical piece; it’s complex, there’s all different specialists that can be involved and the costs will vary. Where do [employers] set a benefit level and ensure that it’s not discriminatory? [It] might be fair for a female to male [transition] but it might not be fair for a male to female [journey].”

There are also considerations around including surgeries that may be viewed as cosmetic treatments, such as Adam’s apple reductions, hair transplants or facial feminisation surgery; cosmetic surgeries would not typically be covered for a non-transgender employee under a PMI scheme. Employers need to be wary, therefore, not to discriminate against non-transgender employees.

Cigna and Mercer Marsh Benefits concur that transgender surgery costs start at £20,000, while Mercer’s Transgender healthcare guidance, published in December 2017, states that costs can rise to up to £80,000. This may make employers nervous, but pricing options are emerging. "We’re starting to see hospital groups create package pricing, so they’re designing package pricing options that reflect the different types of choices they are seeing patients choose,” explains Rae.

Some employers may consider implementing a financial cap for gender affirmation treatment coverage. However, this could drastically impact transitioning employees.

“If somebody thinks they’re going down a private path and they hit a cap and they [are] told they have to go back to the NHS, they could be facing a two-year wait time in some cases," warns Woods. "If that happens, from a mental health point of view, it would be a devastating impact. Caps [do not] provide the employee with certainty."

Practical considerations

“There’s only two consultants that do the female to male surgery, and there’s [about] 10 who perform male to female surgeries, that’s across the whole UK,” warns Rae. A lack of gender affirmation surgery resources could therefore lead to employees needing to travel and book accommodation when undergoing treatment. Typically, though, these additional costs would not be covered by a PMI policy.

This could also have a knock-on effect on the amount of time an employee will need off work, especially as total treatment time can amount to up to three years. “The legal requirement is to have lived in the gender for 12 to 24 months [prior to treatment] so it all comes into play even in the private system,” adds Woods.

Employers should think about whether employees’ dependents over the age of 16 should be included in PMI coverage around this, and whether they can support a transgender-inclusive PMI policy with facilities such as gender-neutral toilets.

Investigating employee demand for gender affirmation treatments is also a consideration, in terms of measuring potential return on investment.

Part of wider health and wellbeing

Employers can use PMI to sensitively address the general healthcare needs of transgender employees. Simon Croft, professional services lead at transgender inclusion consultancy and training organisation Gendered Intelligence, who uses the pronouns he and him, explains: “One of the most challenging barriers for trans people is that assumptions tend to be made about physical characteristics and hence [their] health needs based on a person’s gender identity. For example, a trans woman would identify herself as female and [use] female pronouns, but she might need prostate screenings. A trans man might need cervical [screenings].”

With this in mind, a PMI policy that facilitates private waiting areas and quicker treatment pathways may help transgender employees feel more confident and comfortable tackling their healthcare queries.

Supporting mental wellbeing

The majority of PMI schemes will already include broader counselling services; although this can help transgender or transitioning employees, specific transgender mental health services are a popular starting point for employers and insurers.

In 2017, Cigna introduced a specific pre-operative counselling benefit to their PMI coverage, designed for employees aged over 18 who have been diagnosed with gender dysphoria. This benefit has a lifetime limit of up to £10,000 and is still provided even if an employer opts out of funding other mental health services.

“The biggest value for individuals and for corporates is making that [early access into psychological support] process easy and without a long wait period,” says Wright.

What does the future hold?

Employers are now asking questions of their PMI providers, typically around funding mental health support services, non-surgical gender affirmation treatment routes and, on occasion, reconstructive surgery.

“What we’re trying to say is: start somewhere, because the demand is there," Woods says. "Providing healthcare provision for transgender employees is such a great signpost to say that this is an inclusive workplace, we’re trying to do something here to support our [employees] in that community, and that’s one of the reasons a lot of employers want to do something. They feel it’s a real, tangible thing they can do to demonstrate that they really are genuine in wanting to create an inclusive workplace.”

“We seem to be at a stage where PMI is evolving from that thing that has always existed that pays for elective surgical treatments on a short-term basis into something that becomes much more integral to the overall health and wellbeing strategy of a business,” Wright concludes.

Darren Towers: How can employers make health and wellbeing strategies inclusive for trans employees?