University of Iowa graduate student stef shuster’s health insurance covers many needs, but not the $10,000 they spent on chest surgery. shuster is transgender, and as a result their healthcare policy—purchased through the university—does not cover what is considered by healthcare professionals to be a medical necessity.
“I can only dream about what else that money could have been spent on,” shuster wrote in an e-mail. “I honestly don’t know how I pulled it together in order to pay for that. It is an exorbitant amount of money—almost what I make in one year on my graduate student salary, to put it in perspective.”
shuster is one of thousands of transgender students nationwide whose health insurance does not cover their fundamental needs. In fact, basic health insurance policies, including those used at most universities and colleges, are explicitly exclusive: While they cover chest reduction surgeries for non-transgender men and hormonal treatments for non-transgender people, they will not cover surgical or hormonal interventions for trans-identified people, leaving them to bear the brunt of these expenses.
The World Professional Association for Transgender Health Standards of Care [PDF], the most consulted standards for treatment of transgender patients, take a very clear stance on the importance of access to medical services as one component of treating gender dysphoria, “discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth.” And the American Medical Association has issued a resolution supporting “public and private health insurance coverage for treatment of gender identity disorder as recommended by the patient’s physician.”
Medical treatment options include, for example, feminization or masculinization of the body through hormone therapy and/or surgery, which are effective in alleviating gender dysphoria and are medically necessary for many people.
The full cost of transition, depending on what procedures are performed, can be incredibly expensive.
One trans woman estimated that her transition cost her $49,550—none of it covered by insurance. A transition-support web site estimates that full transition for trans women costs from $40,000 to $50,000. To put these figures in context, the American Psychological Association web site notes that up to 64 percent of transgender people report earning less than $25,000 per year.
And that doesn’t focus specifically on students, who are frequently saddled with massive debt and low-income part-time jobs. Even with a demonstrated need for inclusive coverage, most schools have not amended their policies to fill the existing gaps.
The University of Iowa is a good example: Neither the student health insurance plan, the faculty and staff insurance plan, nor the graduate student health plan cover transgender medical care.
“I know of a couple of cases [of transgender identification] on campus and people have covered it themselves,” said Richard Saunders, the director of benefits at the University of Iowa, who said there hadn’t been interest in including transgender students and staff in insurance plans. “Employers generally don’t add coverages unless there is a need from their community.”
Belying Saunders’s assertion, the Campaign to Organize Graduate Students UE Local 896—at the University of Iowa—brought a proposal for transgender health coverage to the bargaining table last year.
“COGS argued that this coverage should be extended as a matter of civil rights in order to provide equal health care coverage for all graduate employees,” Field Organizer Jennifer Marsh wrote in an e-mail.
Despite Iowa’s inclusion of gender identity in the state’s nondiscrimination policy, the Iowa Board of Regents, which oversees the University of Iowa, rejected the proposal.
In what shuster said was a possible fluke, their hormones are covered by GradCare, the University of Iowa’s graduate student health insurance plan. Another transgender student told Campus Progress that the Student Health Insurance Plan reimbursed them for hormones, as well, but does not cover the more costly surgical procedures that can alleviate gender dysphoria and related depression.
The number of colleges with inclusive plans is hard to determine. The Human Rights Campaign lists eighteen institutions that cover at least some transition-related medical expenses in student health insurance plans; for the most part, these institutions are either large public universities or elite private ones.
Harvard’s new plan was negotiated directly between members of the transgender community and members of a staff working group, who then discussed changes with Blue Cross Blue Shield of Massachusetts.
“There's a lot of communication that goes back and forth, and there are many advocates within the staff and faculty at the university who have weighed in on the process,” Harvard Trans Task Force co-chair Jia Hui Lee said.
While it includes hormonal treatment and chest surgery, Harvard’s plan does not include genital surgery. Lee said the reason for the exception was an insurance issue: Providers of gender confirmation surgery are scattered across the country, and Blue Cross Blue Shield does not recognize a particular protocol. In many states, documentation of genital surgery is required to change the gender marker on one’s birth certificate.
The University of Pennsylvania plan does cover genital surgery, but relies on a health insurance rider from provider Aetna that has what many transgender students consider a very inconvenient wording.
The policy states, in part, that Aetna considers surgery medically necessary when patients show:
- A sense of estrangement from one’s own body, so that any evidence of one’s own biological sex is regarded as repugnant
- Stable transsexual orientation evidenced by a desire to be rid of one’s genitals and to live in society as a member of the other sex for at least 2 years, that is, not limited to periods of stress
- Life-long sense of belonging to the opposite sex and of having been born into the wrong sex, often since childhood
- Wishes to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment
UPenn senior Josh Tweedy wrote his BA thesis on the transgender health rider, which he used in June to pay for a laparoscopic hysterectomy.
“You’re not really transgender enough according to Aetna unless you want to make your body look like the ‘opposite sex’,” he said. “I think that shows a flawed and fundamental misunderstanding of identity.”
Transgender people choose a variety of ways to transition. Though he was grateful for the coverage, Tweedy expressed dissatisfaction at Aetna’s assumption that all trans men transition the same way: Hormones, chest surgery, hysterectomy, then genital surgery.
“In order to have my hysterectomy covered, I had to lie and pretend that I was [trying to get] one step closer to fitting the binary,” Tweedy said, adding that he had to fight to get his surgery covered, even with the policy right in front of him.
And many transgender people do not identify as part of the gender binary at all. Under UPenn’s policy, shuster would have a hard time getting coverage at all.
“If a policy plan even covers transgender-identified people, usually we are conceptualized as going from one gender to ‘the’ other, rather than ‘another’ gender,” shuster wrote. “The fact that non-binary people exist is way off the radar of insurance companies.”
The World Professional Organization for Transgender Health’s newly updated Standards of Care stress the importance of a personal transition and of acknowledging non-binary identities. When contacted by Campus Progress, an Aetna media liaison was unable to find someone capable of commenting on the rationale behind Aetna’s policy, or someone who could talk about potential changes in light of the new standards.
Like shuster, most transgender students receive no coverage at all through their university health insurance policy, and those who do face insurance policy headaches and drawn-out battles for basic healthcare. But more and more universities are covering transgender services in what Tweedy said was a calculated move.
“All the colleges and universities do this diversity rating thing,” he said. “If your institution is accepting of sexual diversity, it boosts your overall rating. By boosting the rating you get more applicants, students, and money. It’s a numbers game.”
This may signal a shift in the prevailing wind. Until that happens, students like shuster struggle with an added financial burden as they work their way through school—a burden that goes against the advice of medical professionals and transgender advocates.