3
Executive Summary
THANKS TO ADVOCATES; COMMUNITY MEMBERS; organizations; New York elected ocials including Governor
Andrew Cuomo, Senators Tom Duane and Brad Hoylman, Assemblyman Richard Gottfried, and the New York City Council
LGBT Caucus; as well as media and celebrity attention, acceptance and visibility for members of the transgender community
continues to increase in New York and across the country.
In New York, an estimated 25,000 transgender individuals face discrimination at every turn: from family members, at school,
in the workforce, at the hands of the police, in the housing system, and in health care.
Breaking Barriers to Transgender Health Care
3
SYSTEMIC AND WIDESPREAD DISCRIMINATION IS DEVASTATING
According to surveys and data:
• 18% of people of transgender experience in New York were unemployed in 2015
• People of transgender experience are 2.4 times more likely to be living in poverty than the
general population
• An estimated 40% of people of transgender experience were forced to leave school
• 61% of people of transgender experience in New York report being mistreated by the police
• 27% of people of transgender experience experienced homelessness in New York
3
DISCRIMINATION LEADS TO POOR HEALTH
A lack of housing, jobs, education, and high rates of violence —all considered social determinants of health—
coupled with discrimination contribute to starkly worse health outcomes for the transgender community:
• Transgender women are 49 times more likely to be living with HIV
• 39% percent of transgender individuals report experiencing serious psychological distress in the past
month, and, overall, 40% report having tried to commit suicide
• Nearly a third of transgender individuals report using illegal and non-medical prescription drugs
3
BARRIERS TO HEALTH CARE
Too often, transgender patients have to educate their doctors and medical providers about transgender health
issues, including awareness about after-care and post-operative care. Private health insurance companies
routinely deny coverage for procedures for transgender individuals. Furthermore, transgender individuals are
often refused treatment due to their gender identity, and many individuals have been harassed in a doctor’s
oce. Few states have adopted laws that protect individuals from discrimination, and even fewer provide
Medicaid plans to transgender individuals.
3
SUMMARY OF RECOMMENDATIONS
In this report, we identify the contributors to poor health among members
of the transgender community and the barriers to health care. We also make recommendations, including:
• Training all health providers
• Mandating coverage of comprehensive gender-arming care services in all health insurance plans
• Implementing anti-discrimination employment policies and housing policies
• Passing the federal Equality Act
2
3
Breaking Barriers to Transgender Health Care
Coverage of Gender-Arming Health
Services in the United States
AS ACCEPTANCE AND VISIBILITY
continue to increase for transgender communities
in the United States (U.S.), health care insurance
coverage for services related to gender armation
also grows. This growth in insurance coverage
can partially be attributed to an increase in the
following:
• Body of literature on transgender health
• Agreement among experts on the benets
and eectiveness of gender-arming
health care for transition as a means for
transgender people to live authentically as
themselves
• Patient and ally advocacy focused on
improving the health, equality, and overall
well-being of transgender people
• New policy interpretations that clarify
non-discrimination on the basis of gender
identity and/or expression
• Growing evidence about the cost-
eectiveness of gender-arming health
insurance coverage
An increasing number of organizations such as
the American Medical Association, the American
Psychiatric Association, the World Professional
Association for Transgender Health (WPATH), and
the World Health Organization have stated their
support of gender-arming services. Despite
this support, and increase in gender-arming
health insurance coverage, disparities across states
continue. Figure 1 shows states with and without
gender-arming health insurance coverage.
1
Insurance coverage of transition-related care
and legal protections vary from state to state.
2
Since 2012:
• New York and 19 other states, in addition
to D.C., have adopted laws that prohibit
transgender exclusions in health
insurance coverage;
• New York and 11 other states, in addition
to D.C., have prohibited private insurance
plans from discriminating based on gender
identity and/or expression; and
• New York and 16 other states, in addition to
D.C., have updated their Medicaid policies
to cover gender-arming transition-related
services and care.
FIGURE 1: DISPARITIES IN INSURANCE COVERAGE OF GENDERAFFIRMING
HEALTH CARE FOR TRANSGENDER PEOPLE, BY STATE
Source: The Movement Advancement Project (MAP)
MEDICAID
State Medicaid policy
explicitly covers health care
related to gender transition
for transgender people
(17 states + D.C.)
PRIVATE INSURANCE
State Medicaid policy
explicitly excludes
transgender health
coverage and care
(11 states)
State Medicaid has no
explicit policy regarding
transgender health
coverage and care
(22 states)
Transgender exclusions
in health insurance
service coverage
prohibited
(20 states + D.C.)
No law providing
LGBT-inclusive
insurance protections
(36 states)
Law prohibits health
insurance discrimination
based only on gender
identity only
(2 states)
Law prohibits health
insurance discrimination
based on sexual orientation
and gender identity
(12 states + D.C.)
Law prohibits health
insurance discrimination
based only on sexual
orientation only
(0 states)
4
Breaking Barriers to Transgender Health Care
As of October 2018, there are 36 U.S.
states where it is legal for health insurance
plans to exclude coverage of gender-
arming services.
1-3
In late 2016, the Trump
administration proposed regulations to roll
back key provisions of the Aordable Care Act
(ACA), which has serious consequences for
health insurance coverage specic to gender-
arming health services throughout the U.S.
and would subject transgender individuals to
unfair discrimination in health care settings.
Gender-Arming Health
Insurance Coverage
in New York State
IN 2014, THE ACA EXPANDED gender-
arming health insurance coverage for trans-
gender people throughout the U.S., including
New York State. New York has adopted laws
to protect against discrimination based on
gender identity and expression (Table 1).
1,2
In New York State, health insurance plans—
including Medicaid, Medicare, and many
private employer-endorsed plans—cannot
discriminate and refuse covering gender-
arming care based on gender identity.
Barriers to Gender-
Arming Health Care
TRANSGENDER PEOPLE FACE A MUL
TITUDE OF BARRIERS
when seeking and
obtaining health insurance and health care
services. These barriers are multifaceted. Dr. Asa
Radix, Senior Director of Research and Educa-
tion and the Clinical Director of the Transgen-
der Health Program at Callen-Lorde Community
Health Center, notes that “the pressing issues
among transgender people include access to
hormones and surgery, housing, legal issues
(e.g., name change to reect gender identity),
and employment. Unless these [barriers] are
addressed, any medical conditions may not be
well controlled.” It is vital for insurers, policy-
makers, providers, and community members to
work together to address these barriers.
TABLE 1: NEW YORK STATE HEALTH INSURANCE PROTECTIONS
FOR GENDERAFFIRMING HEALTH CARE SERVICES
Non-discrimination laws prohibiting health insurance
discrimination based on sexual orientation and gender identity
Insurance providers banned from excluding coverage
for gender-arming care services
New York State Medicaid began covering transition-related
care, including gender-arming surgeries in 2015
“Transgender
people shouldn’t
have to educate
their providers.
Providers need
to work on
developing
their capacity
to serve
transgender,
gender non-
conforming,
and non-binary
clients and adhere
to the WPATH
Standards of Care.”
– Alicia Rubenstein,
Transgender
Program
Coordinator,
Amida Care
“The proposed
rollback of ACA
regulations
could have an
eect on “the
lack of qualied
surgeons who
accept Medicaid,
leading to longer
wait times for
procedures.”
– Kevin Steens, RN,
MBA, Vice President
of Clinical Services
and Programs,
Amida Care
5
Breaking Barriers to Transgender Health Care
Health Care
Environment
EXCLUSIONARY INSURANCE
COVERAGE FOR GENDER
AFFIRMING SERVICES
THERE ARE 36 U.S. STATES where health
insurance plans can exclude coverage of gender-
arming services.
1-3
Many health insurers
are allowed to discriminate on the basis of
gender identity and/or expression, creating
obstacles for transgender people to acquire
necessary health care. Additionally, some health
insurance plans invoke what they deem a lack
of “medical necessity” to deny coverage, based
on a false argument that such care is cosmetic
or experimental.
4
This often results in a delay
in or avoidance of receiving care, which places
transgender people at greater risk for other
illnesses, including depression and mental health
issues that can lead to suicide.
LACK OF INSTITUTIONAL SUPPORT
FOR TRANSGENDER CULTURAL
COMPETENCY AMONG HEALTH
CARE PROFESSIONALS
TO CREATE A PATIENTCENTERED
ENVIRONMENT
that is welcoming and
understanding of transgender patients’ health
needs, institutional policies need to be adopted
to ensure that health care professionals have
cultural and clinical competencies and education
in transgender health care.
3,5-6
Owing to a lack of cultural competency, providers
may rely too heavily on transgender patients to
educate them about their own care.
In Lambda Legal’s 2009 Health Care Survey, 65% of
transgender respondents reported encountering
health care professionals and medical providers
who were unaware of the specic health needs of
transgender people.
7
In the 2015 U.S. Transgender
Survey (USTS) of over 25,000 transgender
respondents, about 1 in 4 respondents reported
having to teach health care professionals,
including medical providers, about transgender
care.
8
In New York State, in the same survey,
32% of trans respondents who saw a health care
provider in the past year reported having at
least one negative health care experience due to
being transgender, including having to teach the
provider about transgender care.
In a study of health care providers who have
interacted with transgender patients, it was
revealed that some don’t have knowledge of
available resources and care strategies to refer
patients for gender-arming health care and
transgender specialty care.
9
LACK OF EDUCATION, TRAINING,
AND AWARENESS AROUND AFTER
CARE OR POSTOPERATIVE CARE
RESEARCHERS HAVE FOUND THAT
the number of gender-arming surgeries are
increasing and are being utilized by people from a
range of demographics, particularly because some
of the surgeries are now covered by Medicaid or
Medicare plans.
10
However, there is a high rate of
post-surgical complications in gender-arming
surgery, highlighting the need for greater
education, training, and awareness around after-
care or post-operative care.
11,12
Before coverage of gender-arming surgeries by
Medicaid, gender-arming surgery was generally
only available to those with nancial means. Many
of these early patients had private resources to
ensure their after-care maintenance, travel to
appointments, and home health service needs
were met.
13
With gender-arming surgeries
“Transgender,
gender-
nonconforming,
and non-binary
(TGNCNB) people
face signicant
barriers that
impact the
ability to access
transition-related
care. Widespread
discrimination
against
transgender
people has caused
many TGNCNB
people to distrust
the health care
industry and
avoid seeking
out care. This is
compounded
by a long history
of health insurance
companies
denying coverage
for transition-
related care, acting
as gatekeepers
and preventing
access to medically
necessary
treatment.”
– Alicia Rubenstein,
Transgender
Program
Coordinator,
Amida Care
6
Breaking Barriers to Transgender Health Care
becoming more accessible, providers must ensure
that all patients have supports in place to help
with recovery. These supports should include
assistance for home care and next-day visits after
discharge from the hospital. Social supports such
as safe, stable housing and transportation to and
from medical appointments are essential. Health
plans that specialize in care coordination and case
management have proven to be successful models
of care by surrounding each patient with a team
of providers, health navigators, behavioral health
specialists, and social workers.
Eective after-care must be comprehensive, to
include services that address co-occurring medical
conditions and/or mental health issues, supportive
services such as caregivers and home health aides,
and assistance with continued/regular follow-up
doctors’ visits and physical therapy. There should
be open communication between mental health,
medical, and surgical team members to ensure
that co-occurring conditions and health issues
are addressed. For example, if the patient has
a past history of substance use or depression,
those issues must be discussed with the full
care team prior to prescribing medication for
pain management. It is also critical for care to
be patient-centered, and the patient must be
educated around issues including dilation in
male-to-female surgery, catheter care, wound
care, medication/pain management, and phallus
management, and home visits are an important
component to ensure better health outcomes
in relation to these issues. After-care should be
viewed holistically as part of the full continuum of
transgender health care and services.
Social Determinants
of Health
HOUSING INSTABILITY
HOUSING IS A MAJOR SOCIAL
DETERMINANT
of health among transgender
communities. In the USTS survey, about 1 in 4
respondents experienced housing discrimination
in the past year, such as being evicted from or
being denied housing, due to being transgender.
8
About 1 in 3 respondents reported having been
homeless.
Twenty-seven percent of respondents from the
same survey experienced homelessness.
8
About
1 in 8 experienced homelessness in the past year
because of being transgender, and about one-
quarter (26%) of respondents avoided staying in a
shelter because they feared being mistreated as a
result of being transgender.
VIOLENCE AND TRAUMA
TRANSGENDER PEOPLE EXPERIENCE
high levels of trauma, mistreatment, harassment,
and violence. In the USTS survey, 1 in 2
respondents experienced verbal harassment,
nearly 1 in 10 respondents were physically
attacked, and nearly 1 in 2 respondents were
sexually assaulted due to being transgender.
8
Violence often leads to worse health outcomes
and fatalities. Transgender people, particularly
black and Latina transgender women and
immigrants, are disproportionately impacted
by hate crimes. The past three years have been
the deadliest years on record for transgender
communities in the U.S., with reports of high levels
of hate crimes, including homicide.
14,15
Between
2008 and June 2016, at least 146 transgender
people were murdered. In 2017 alone, there were
28 transgender people on record who were fatally
shot or killed by other violent means. Rates of
violence-related incidences continue to rise in
transgender communities.
Many transgender people are reluctant to seek
protection from police ocers after an assault
because of discrimination and mistreatment.
“One of the most
pressing issues…
is the lack of stable
housing for our
community…
This [lack of
housing] becomes
a barrier when
trying to access
trans-arming
surgeries and not
having a stable
place to heal
properly.”
– Octavia Lewis,
MPA, Community
Ambassador,
Amida Care
7
Breaking Barriers to Transgender Health Care
This includes being verbally harassed, being
repeatedly addressed with incorrect gender
pronouns (misgendering), and/or being sexually
and physical assaulted. Additionally, transgender
respondents who interact with police ocers
and/or other law enforcement authorities are
often mistaken for doing sex work, leading
to many transgender people being abused
or coerced into sexual activities initiated
by police ocers to avoid arrest. In the USTS
survey, nearly 9 out of 10 respondents said
they have been harassed, attacked, sexually
assaulted, or mistreated by police and other
law enforcement authorities.
8
In New York State, among transgender people
who interacted with police ocers and/or
other law enforcement authorities who thought
or knew they were transgender, 61% said they
were mistreated. The majority (57%) of
transgender respondents are uncomfortable
asking police for help.
8
EMPLOYMENT DISCRIMINATION
EMPLOYMENT IS A KEY DETERMINANT
of health. However, employment discrimination
is prevalent for many transgender people.
In the 2015 USTS survey, transgender
respondents were 2.4 times more likely to be
living in poverty compared with the U.S.
population (29% vs. 12% respectively).
8
The rate
of unemployment among transgender people
is three times that of the general population,
and the rate of unemployment is up to four
times higher for transgender people of color.
In New York State, 34% of transgender
respondents from the same survey reported
living in poverty, and 18% were unemployed.
Additionally, 30% of transgender respondents
who had jobs experienced mistreatment,
including being red and denied promotion
due to being transgender.
8
In January 2019, The Gender Expression Non-
Discrimination Act of 2018 (GENDA) (A.3358
Gottfried)/(S.07010 Hoylman), which legally
codies protections for TGNC people against
discrimination in employment and health care,
was passed in New York State. TGNC individuals
are now guaranteed protections against
discrimination in employment under
New York State law.
EDUCATION ACCESS
BULLYING, VIOLENCE, AND
MISTREATMENT
in schools disrupt the
educational quality and opportunity for
transgender people. In the USTS survey,
3 out of 4 transgender students in elementary
and secondary schools reported being
mistreated, disciplined for defending
themselves, and required to dress according
to their sex assigned at birth, not their gender
identities.
8
As many as 2 out of 5 transgender
people were forced to leave school or were
expelled because of gender-based mistreatment.
Among transgender people who made it to
college and other higher education institutions,
1 in 4 experienced assault and 2 in 4 had to leave
college because of mistreatment.
In New York State, 74% of transgender students
in elementary, middle, and high schools (i.e.,
kindergarten to grade 12) reported being
mistreated specically due to being transgender.
8
Stigma and
Discrimination
HEALTH CARE
A HUMAN RIGHTS CAMPAIGN
REPORT
shows that among transgender
people living with HIV in the U.S., 19% reported
being refused treatment due to their gender
identity, and 28% reported they have been
harassed in a doctor’s oce. This creates a
signicant barrier to care and leads to care
avoidance by transgender people.
FAMILY, COMMUNITY,
AND PEERS
TRANSGENDER PEOPLE OFTEN
EXPERIENCE
lack of support from family,
community, and peers, which places them
at greater risk for violence, homelessness,
and unemployment. These consequences
are long term and can have an impact on
transgender people’s health.
“Employment
discrimination is
a huge issue in
the transgender
community.
Subsidized
education,
employment
training, and
incentive programs
are needed to hire
transgender people
who may need
more mentoring
and preparation
for the workplace
given the amount
of discrimination
they experience.
As such,
[employment]
is an important
determinant
of transgender
health.”
– Zil Goldstein,
NP, Program
Director,
Center for
Transgender
Medicine
and Surgery,
Mount Sinai
8
Breaking Barriers to Transgender Health Care
In the USTS survey, 10% of transgender
respondents reported that their family members
were violent toward them once they disclosed
their transgender identity, and 8% were kicked
out of the house by their immediate family
because they were transgender.
8
NAME AND
GENDER MARKERS
TRANSGENDER INDIVIDUALS OFTEN
experience diculties and road blocks in
updating their name and gender markers on
identication cards and other ocial records
to accurately reect their gender identity. In
the USTS survey, only 11% of transgender
respondents have had their name and gender
marker updated on all identications (IDs) and
records, 49% did not have an ID or record with
the name they preferred, and 67% did not have
an ID or record with the gender they identied.
8
In some cases, transgender patients may be
hesitant and/or embarrassed to show their IDs
in settings such as a health facility or a doctor’s
oce for fear of being interrogated by security
or sta. This often results in a delay in care
or complete avoidance of care. Respondents
identied cost as another barrier to updating
IDs and records.
Among those who have shown their ID
and do not have updated markers that
match their gender or name, 25% reported
being verbally harassed, 16% were denied
benets or service, 9% were asked to leave,
and 2% were assaulted.
8
In New York State, 34% of transgender
respondents who have shown an ID with a
name or gender that did not match their gender
identity were mistreated, including being
verbally harassed, denied benets or service,
asked to leave, or assaulted.
8
Only 12% of
transgender respondents in New York State
reported having the name and gender marker
that match their name and gender identities on
all of their IDs.
To address this issue in New York City, the
New York City Council recently passed (as of
September 2018) legislation that allows people
to select “X” as an option on their birth certicate.
This legislation is expected to be signed into law
in the near future.
16
Behavioral Health
SOCIAL FACTORS INCLUDING higher rates
of poverty, racism, transphobia, sexism, and early
life trauma for transgender individuals contribute
to higher rates of behavioral health issues.
DEPRESSION AND SERIOUS
PSYCHOLOGICAL DISTRESS
THE PREVALENCE OF SERIOUS
PSYCHOLOGICAL DISTRESS
among
transgender people is four times higher compared
with the general U.S. population. In the USTS
survey, 39% of transgender respondents reported
experiencing serious psychological distress
in the past month, compared with only 5% of
the U.S. population.8 In New York State, 40% of
transgender respondents experienced serious
psychological distress in the past month.
In the same survey, 40% of transgender
respondents reported having attempted suicide
in their lifetime.
This is nearly nine times the
prevalence of the attempted suicide rate when
compared with the general U.S. population
attempted suicide rate of 4.6%.
SUBSTANCE USE
IN THE USTS SURVEY, about one-third of the re-
spondents (29%) reported using illicit drugs and/or
non-medical prescription drugs in the past month.
This is almost three times the rate of similar use of
substances among the general U.S. population.
8
However, while substance use is a prevalent
health issue in the transgender community,
health care facilities are not consistently equipped
with transgender-competent providers to treat
substance-use disorders.
“There is a great
need for increased
community re-
sources for trans-
gender people,
particularly for
those who do not
have a strong net-
work of supportive
family and friends.”
– Kevin Steens, RN,
MBA, Vice President
of Clinical Services
and Programs,
Amida Care
“There are not
enough sub-
stance-abuse
facilities that are
competent enough
to provide the level
of care that the
transgender com-
munity requires
without further
traumatizing
them. All facilities
that are licensed
through the State
of New York should
be required to
complete manda-
tory training on
how to provide
care and services
to the transgender
community.”
– Octavia Lewis,
MPA, Community
Ambassador,
Amida Care
9
Breaking Barriers to Transgender Health Care
Integrating HIV Prevention
and Treatment Services
in Gender-Arming Health Care
HIV CONTINUES TO BE a major health issue
in transgender communities in New York, the U.S.,
and throughout the world. In a recent nding,
transgender women are 49 times more likely to be
living with HIV compared with the global general
population. Transgender men are also at higher
risk for HIV. The Centers for Disease Control and
Prevention reports that between 2009 to 2014,
2,351 transgender people were diagnosed with
HIV in the U.S.: 84% were transgender women,
15% were transgender men, and 1% another
gender identity.
17
A 2013 analysis showed that
an estimated 22% to 28% of transgender women
are living with HIV in the U.S., of whom 56% were
black/African American.
18
The barriers to health care, social determinants
of health, economic marginalization, stigma
and discrimination, and other factors described
previously leave the transgender community
highly vulnerable to HIV acquisition. Taken
together, these ndings highlight the need for
solutions that holistically address the health needs
of transgender individuals, including integration
of HIV prevention and treatment services with
gender-arming health care.
To date, there is a lack of integration of HIV
programs and gender-arming health care
programs specically designed for transgender
people. Research has shown that transgender
people prioritize gender-arming services such
as hormone therapy over other kinds of medical
care, particularly if there is a perception that the
treatment may potentially interfere with their
gender-arming treatment or when faced with
limited resources and the choice of paying for
gender armation vs. paying for HIV services.
In particular, HIV prevention tools such as pre- and
post-exposure prophylaxes (PrEP and PEP) are es-
sential to ending the epidemic. Preventing one HIV
infection can save as much as $500,000 in lifetime
medical costs. Ensuring reach and coverage of HIV
prevention methods to transgender populations is
critical to help people of transgender experience
take control of their sexual health.
Additional steps can be taken to expand access
around sexual health services to people of
transgender experience, including:
1. Increased outreach that educates transgender
people about PrEP and PEP, using people of
transgender experience in campaign material;
2. Better linkage of those interested in PrEP
to treatment: most insurance plans cover PrEP,
and New York also oers free or
low-cost programs;
3. Promoting greater awareness around studies
that have shown that PrEP is safe, no serious
side eects have been reported, and PrEP
does not interfere with hormones
19,20
; and
4. Taking a patient-centric approach to PrEP,
with health care providers prepared to
prompt thoughtful conversations with
each individual around whether PrEP is
right for them.
It is important for health insurers and public
health professionals to promote integration of
gender-arming services and HIV prevention and
treatment tools for transgender people. With this
approach, PrEP is a promising strategy to prevent
HIV acquisition among transgender people and
end the HIV/AIDS epidemic.
“There have been several
studies that demonstrate
that many transgender
women often prioritize
their feminizing care over
everything else, including
HIV/sexually transmitted
infections prevention. As such,
it is vital that these services
complement each other.”
– Asa Radix, MD, Callen-Lorde
Community Health Center
IN THE UNITED STATES,
it is estimated that there
are more than 1.4 million
transgender adults. Some
22-28% of transgender
women are living with HIV.
IN NEW YORK STATE,
there are more than
78,600 transgender
residents. Between
2014 and 2016, 3,314
transgender people
received HIV-related
services in New York, and
2,365 transgender people
were living with HIV.
IN NEW YORK CITY, it is
estimated that there are
more than 25,000 trans-
gender people. Between
2014 and 2016, 792 were
living with HIV, of whom
the majority (93%) were
people of color.
10
Breaking Barriers to Transgender Health Care
AMIDA CARE RECOMMENDS THE FOLLOWING measures to address the barriers to care
outlined in this whitepaper. Our recommendations support the more expansive Ending
the Epidemic recommendations outlined by the New York State AIDS Institute Ending the
Epidemic Transgender and Gender Non-Conforming People Advisory Group.
21
HEALTH CARE
TGNC INDIVIDUALS REQUIRE ACCESS TO physical, sexual, mental, and behavioral health care
that is regionally accessible, aordable, and delivered by sta that are both skilled in trans-specic
care and provide services in a trans-arming manner.
Create a transgender-inclusive environment for transgender patients and employees
at health care providers:
N Integrate gender-arming care in all aspects of the patient experience.
N Educate physicians and patients about after-care for gender-arming surgeries, treatments, and
other procedures.
N Implement cultural competency training for all care provider and institution sta. This includes all
sta in supportive roles, such as security guards, police ocers, and administrative sta.
N Hire transgender people as sta and provide career-building opportunities that nurture leadership.
N Update forms, surveys, identication, and other materials to provide options for gender markers
that allow transgender people to indicate their gender identities.
Increase access to TGNC-competent health insurance coverage:
N Mandate coverage of comprehensive gender-arming care services in all health insurance plans for
transgender employees in the private and public sectors, including mental health screenings and
hormone therapy.
N Implement TGNC cultural competency trainings for health insurance plans, surgery to change
physical characteristics, speech and voice therapy, and urogenital care.
N Verify cultural competency of network providers before referring patients.
EMPLOYMENT
TGNC INDIVIDUALS REQUIRE ACCESS TO living-wage employment that provides
opportunities for advancement, competitive wages and benets, and environments free
of discrimination and harassment.
N Hire transgender people as sta and provide opportunities for career growth.
N Mandate health insurance coverage for gender-arming care for all transgender employees
in the private and public sectors.
Recommendations to Address
Transgender Health Barriers
Breaking Barriers to Transgender Health Care
11
Breaking Barriers to Transgender Health Care
N Implement and enforce anti-discrimination employment policies. Commit to and implement
diversity readiness policies, including annual or more frequent cultural competency trainings.
N Pass legislation to end employment discrimination.
› Equality Act of 2017 (H.R. 2282 Rep. Cicilline (Rhode Island)/S.1006 Sen. Merkley (Oregon)
is a federal bill that would implement protections that end discrimination on the basis of
sexual orientation, gender identity, and sex in the areas of employment, housing, public
accommodations, public education, federal funding, credit, and the jury system.
HOUSING
TGNC INDIVIDUALS NEED ACCESS TO safe, aordable, and gender-arming housing
that is not exclusively dependent on HIV status. This includes transitional living, long-term
housing, and various sheltering services.
N Welcome transgender people as residents by implementing anti-discrimination policies
that comply with New York State law that prohibits housing discrimination based on gender.
Conclusion
THE RIGHT TO HEALTH AND HEALTH CARE is essential to serve and care
for transgender populations, particularly in the elds of public health, medi-
cine, and health policy. As transgender communities face multi-level barriers to
health care and insurance, it is critical for stakeholders including health insurers,
policymakers, providers, and community members to communicate and work
together to eliminate these barriers. This includes addressing critical health
concerns such as HIV/AIDS and mental health among underserved communities.
Providing support and adequate funding for transgender programs, as well as
welcoming transgender people in the housing and employment sectors, are crit-
ical components of eliminating barriers to care and negative health outcomes.
Transgender people must be able to live their lives authentically and healthily,
without fear, stigma, and shame. Health care environments play a critical role
in supporting transgender people’s lives and health. By ensuring that policies
protect coverage of gender-arming health services, expanding the number
of transgender-competent providers available, creating a culturally competent
environment by training sta, armatively hiring transgender people, and
ensuring that the gender identities of transgender individuals are accurately
reected, it is possible to create an inclusive society that supports people of
transgender experience in all aspects of their lives.
Recommendations to Address
Transgender Health Barriers
(cont’d)
Breaking Barriers to Transgender Health Care
“By providing
critical rental
assistance,
New York’s HIV/
AIDS Services
Administration
(HASA) has helped
people living
with HIV/AIDS to
obtain safe, secure
housing. But,
stable housing is
one of the most
urgent challenges
that transgender
people face
because of stigma,
discrimination,
and economic
challenges,
which puts them
at elevated risk
for HIV. Waiting
until transgender
people become
HIV positive before
helping with
housing is not
good enough.”
– Lyndel Urbano,
Director of Public
Policy, Amida Care
12
Breaking Barriers to Transgender Health Care
Amida Care Case Study: A Not-for-Prot
Medicaid Special Needs Health Plan
Serving Transgender New Yorkers
AMIDA CARE IS A NOTFORPROFIT
Medicaid Special Needs Health Plan (SNP) at the
forefront of transgender advocacy eorts in New
York City. Amida Care specically tailors its services
to the health needs of New Yorkers living with or at
higher risk for HIV, including people of transgender
experience regardless of their HIV status. Since its
inception, Amida Care has made eorts to help
transgender members—who comprise over 7% of
its total membership—to access the full continuum
of transgender health services and culturally com-
petent care, including gender-arming services, to
live healthier, authentic lives without fear or shame.
GENDERAFFIRMING
POLICY ADVOCACY
AMIDA CARE HAS A HISTORY of helping
to advance gender-arming legislation in New
York City and State. New York was the rst state
to ban discrimination based on gender identity,
and Governor Andrew Cuomo announced new
regulations in January 2016 that further supports
anti-discrimination in health care and insurance
for transgender members.
Amida Care worked to make hormone therapy
accessible for its members of transgender experi-
ence and advocated for this to be a state Medicaid
benet. As of March 2015, New York Medicaid
covers hormone therapy and gender-arming sur-
geries for transgender patients. This policy removes
barriers to health care and insurance due to cost
on many high-priced surgeries and other related
care that would otherwise be dicult to attain.
Medicaid coverage of gender-arming surgery
and hormones is only the rst step toward making
“health and health care as a human right” a reality.
HOLISTIC CARE ADDRESSING
SOCIAL DETERMINANTS
OF HEALTH
THROUGH CLOSE PARTNERSHIPS
with community-based organizations,
Amida Care is able to address multiple social
determinants of health and help transgender
members access supportive services such
as housing referrals, education programs,
employment programs, and legal services.
This also includes addressing factors such
as mental health and substance use.
“Amida Care’s
success with
the transgender
community lies
in their cultural
competence, their
willingness to learn
about new inno-
vations regarding
transgender care,
and their accep-
tance of virtually all
insurance-driven
claims. Amida Care
has been a pioneer:
they have been
doing the work
since before it was
topical or glamor-
ous to talk about
transgender care,
never mind oer-
ing transgender
individuals ser-
vices. Amida Care
excels at meeting
patients where
they are without
having to put
patients in a
category or a box.”
– Freddy Molano,
MD, Community
Healthcare Network
Community Healthcare Network’s 2018 Conference on Transgender Health: TRANSforming
Social Justice through Healthcare, sponsored by Amida Care and The New School
13
Breaking Barriers to Transgender Health Care
CREATING A TRANSGENDER
INCLUSIVE ENVIRONMENT
AMIDA CARE’S STAFF UNDERGO IN
HOUSE TRAININGS
in transgender health
to improve cultural competency. Amida Care
collects gender identity information and pronouns
for all members, which is an important rst step
to establishing trust with transgender members.
Amida Care’s hiring process welcomes
transgender people.
HIV CARE AND PREVENTION
BY ADDRESSING THE COMPREHENSIVE
MEDICAL,
behavioral, and supportive needs
of its members, Amida Care has proven to have
a highly eective care model to help members
living with HIV become virally suppressed. This
means they have the chance to live longer,
healthier lives and cannot transmit the virus to
others. Amida Care has increased the viral load
suppression rate among its HIV-positive members
from 60% in 2006 to 76% in 2018, achieved by
engaging 94% in regular outpatient care, which
led to a 74% decrease in hospital admissions/
readmissions, a 64% decrease in emergency
room visits, and a 35% reduction in hospital
length of stay. These improvements have resulted
in Medicaid savings of $150 million for New York
State (2008-2017).
On November 1, 2017, New York State Medicaid
SNPs, including Amida Care, expanded to serve all
transgender individuals who qualify, regardless
of their HIV status. This helps to break down the
barriers faced by transgender communities in ac-
cessing sexual health services and HIV prevention
methods such as PrEP. Improving access to PrEP
is crucial to empower transgender people to take
control of their health and to end the HIV/AIDS
epidemic. Amida Care has enrolled more than 230
HIV-negative members of transgender experience
since November 2017; all have been screened for
HIV risk, and nearly 25% are now on PrEP.
CARE COORDINATION
AMIDA CARE WORKS CLOSELY with each
transgender member and surrounds them with a
dedicated integrated care team of providers, social
workers, health navigators, and behavioral health
specialists. Care coordination and a focus on
wraparound supportive services ensures hormone
therapy and other services are well integrated.
“In order to best understand the needs of our transgender members,
Amida Care works directly with our members and involves TGNCNB
people in the work. We host town halls informed by our members,
and collaborate with trans-identied providers as well as community-
based organizations that provide services to the TGNCNB community
to develop benets that align with the community’s needs.”
– Alicia Rubenstein, Transgender Program Coordinator, Amida Care
“When addressing barriers to
care, it is important to look at
the whole person.”
– Kevin Steens, RN, MBA, Vice
President of Clinical Services
and Programs
14
Breaking Barriers to Transgender Health Care
Gender-arming services often require
procedures and processes for approvals, which
can be dicult and costly to obtain separately. For
example, for gender-arming surgery, a patient
needs to 1) provide two letters, including one from
a psychologist/psychiatrist; 2) demonstrate well-
documented gender dysphoria; 3) undergo 12
months of mental health counseling; 4) undergo
12 months of hormone therapy for some surgeries
such as genital surgery and transgender feminine
top surgery (breast augmentation); and 5)
demonstrate no signicant medical/mental health
conditions. Amida Care works to ensure that any
prior authorizations needed for providing gender-
arming care can be done in-house. This strategy
reduces time, cost, and multiple travels, and allows
for better care coordination.
RELATIONSHIPS BETWEEN
MEMBERS, HEALTH CARE
PROVIDERS, AND INSURERS
DOCTORPATIENT RELATIONSHIPS
are a critical part of transgender people’s health
care experience. Amida Care works to ensure
that any new and current providers and sta are
equipped with expertise in transgender health.
It is important that network providers and sta
are culturally competent in delivering gender-
arming services and understand the lived
realities and complex health issues among
transgender communities. Amida Care fosters
connections with providers who are leading the
eld of community health for transgender people
in New York City, such as Callen-Lorde Community
Health Center, Community Healthcare Network
(CHN), Mount Sinai Center for Transgender
Medicine and Surgery, and New York University.
For example, CHN serves hundreds of transgender
individuals and has mobile units that are staed
with health outreach workers to meet people
where they are and provide HIV testing, PrEP
education, and linkage to other social services.
Amida Care is a lead sponsor in CHN’s annual
Conference on Transgender Health in New York
City, which is designed to improve understanding
and build cultural competency around
transgender health issues.
“Amida Care follows the
lead of its members.
Initiatives that were created
and followed through by
Amida Care have been led
by transgender members.”
– Julian Cabezas, LMSW,
Manager of Outreach
Programs, Amida Care
“Amida Care was
the rst insurance
program to
include hormone
therapy on the
formulary when
other Medicaid
programs still had
an active exclusion.
They also provided
support for people
who are having
surgery, created
surgery checklists,
and trained nurses
to provide at home
services for people
post-operation.”
– Asa Radix, MD,
Callen-Lorde
Community
Health Center
15
Breaking Barriers to Transgender Health Care
Message from Amida Care President
and CEO Doug Wirth
HEALTH CARE IS A RIGHT, not
a privilege. People of transgender
experience need and deserve access to
comprehensive, culturally competent,
gender-arming health care. As
President and CEO of Amida Care, a
not-for-prot Medicaid Managed Care
SNP serving people living with HIV and
at higher risk for acquiring HIV, I’ve seen
rsthand that providing a high-touch
model of care is highly eective in
addressing the complex health needs of
transgender individuals.
Amida Care strives to be a safe haven for
people of transgender experience, who
are eligible to join the plan regardless
of HIV status. As a specialized health
plan that has a history of supporting the
transgender community, Amida Care
is nimble, attentive, and aware of our
members’ needs. People of transgender
experience are an integral part of our
sta and health care team. We know
that services and care are better when
we listen rst. We work closely with
our members and surround them with
a dedicated, integrated care team
of providers, social workers, health
navigators, behavioral health specialists,
and a designated health home.
Our transgender program aims to take
care of the whole person, including
primary care, hormone therapy,
gender-arming surgeries, sexual
health services, HIV treatment and
prevention, substance abuse treatment,
and mental health
services. In developing
our transgender health
program, we held
trainings for sta and
modied our systems
and operations, including
adding gender identity
and pronouns to our
member database, hiring
sta of transgender
experience, creating a
Transgender Clinical
Advisory Committee, and
developing a culturally
competent and robust
provider network.
To improve health
outcomes, we need
to break down the
barriers that keep health
care out of reach for
many in the transgender community,
including violence, lack of employment
opportunities, housing instability, and
discrimination. Amida Care is committed
to being an innovator in advancing
access to the full continuum of care and
services for transgender individuals.
Amida Care works with community-
based organizations to help members
access support for housing, employment,
and legal issues. We’re proud to help
our 500+ transgender members—who
comprise 7% of our total membership—
access respectful, culturally competent
care to live healthier, authentic lives.
Acknowledgments
Breaking Barriers to Transgender Health Care
16
Breaking Barriers to Transgender Health Care
This report was prepared in part by Arjee Javellana Restar, MPH, and
reviewed by the Amida Care team including Kevin Steens, Shakira
Croce, Ethan Fusaris, Alicia Rubenstein, Lyndel Urbano, and Teri Wade.
We would like to acknowledge the following health care professionals
sharing their views: Kevin Steens, Julian Cabezas, Alicia Rubenstein,
Octavia Lewis, Luis Freddy Molano, Asa Radix, and Zil Goldstein.
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SERVICES AND SUPPORT
For information about transgender health
resources, visit the Amida Care website at:
https://www.amidacareny.org/
health-resources/trans-health-resources/
