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7 takeaways for HR from the new transgender guidelines

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Patricia Toro, M.D.
Patricia Toro, MD, is a Senior Director in the Health, Equity and Wellbeing practice of WTW. She is trained in infectious diseases and works with payors, providers and employers to improve the quality and outcomes of healthcare delivery.

Employers are increasingly aware of the needs of the transgender and gender diverse (TGD) population and many have modernized their benefits to address transgender medical care. This medical care is largely guided by various professional organizations, including the World Professional Association for Transgender Health (WPATH), the Endocrine Society and the American Academy of Pediatrics. WPATH recently released new Standards of Care version 8 (SOC 8), with substantial updates over the prior recommendations that were released in 2012.

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Led by HR, employers that seek to meet the specific needs of TGD employees can use the updated WPATH guidance as a benchmark. This article outlines seven key issues HR professionals can consider as they evaluate how, or whether, to incorporate these new guidelines in their health benefits.

  1. The new WPATH Standards of Care uses more inclusive nomenclature that applies to the broader transgender and gender diverse community.

The WPATH guidance has updated language to reflect that gender is broadly defined and fluid. The revised language focuses on the dignity of the individual, bodily integrity and respect for the lived experience of TGD individuals. The WPATH guidance also now explicitly includes recommendations for eunuch and nonbinary individuals.

HR should use inclusive language in their benefits documents and communication so that transgender, nonbinary, eunuch or other gender diverse individuals can be appropriately supported within employers’ benefits.

  1. Gender diversity is not a mental illness, and the new WPATH guidance doesn’t recommend requiring a mental health exam before gender affirming therapy.

The new WPATH guidelines underscore that being a TGD individual—by itself—is not a mental health diagnosis. The SOC8 continues to recommend mental health support for individuals who need it. That support can now be given by any master’s level-plus educated clinician with experience treating this population and doesn’t have to be given by a mental health professional.

Operationally, this means that TGD individuals do not require a mental health evaluation in order to obtain medical or surgical services. This is quite different from the prior guideline, which required mental health sign-off from one or two mental health providers in order to obtain gender-affirming surgery. HR leaders should work with their health plans to evaluate the role mental health providers can play to appropriately support the TGD community.

  1. Gender-affirming adolescent care remains unclear and controversial.

While early drafts of the new WPATH SOC 8 included explicit age guidelines, final standards continue to recommend individually tailored care. The new standards recommend puberty blockers at the first sign of sexual maturity, and no longer suggest limiting hormonal therapy to those over the age of 16. The SOC 8 emphasizes balancing risks and benefits for the adolescents regardless of age. This may allow transgender adolescents to obtain hormonal therapy or some surgeries prior to age 18. The implications of long-term puberty blockers are not fully known, but concerns have been raised around issues of bone health for these patients, particularly transgender males.

  1. WPATH recommends an expanded list of surgical procedures and is less directive about pre-surgery hormonal therapy.

The new WPATH guidelines recommend coverage of many additional surgical procedures, such as facial feminization, which are currently regarded by many health plans as cosmetic and therefore not covered. The new guidelines also recommend coverage for procedures to reverse previous gender-affirming surgeries, if requested. The length of hormone therapy prior to surgery has also been made more individually based, which supersedes the previous recommendation to have at least 12 months of hormone therapy prior to most surgeries.

  1. Transgender and gender diverse medical needs intersect broadly with other health benefits, like fertility and travel.

The new guidelines put more emphasis on fertility benefits to allow non-traditional partners to form a family. This support can range from preservation of sperm or eggs prior to hormonal or surgical therapy, to pre- and post-natal support for individuals with a uterus.  Travel benefits can also allow TGD individuals to obtain care from a high-quality multidisciplinary team. HR leaders may want to consider alignment of TGD and other benefits within their health plans.

  1. Recommendations for nonbinary and eunuch care may be challenging to address.

The new WPATH Standards of Care offer explicit guidance about how to support nonbinary and eunuch individuals. The guidelines recommend covering treatments for nonbinary individuals that allow them to live in their particular gender identity. Given the wide range of desired outcomes for these individuals, it may be difficult to create a benefit design that will be appropriate for all nonbinary individuals. Similarly, the new guidelines open the door to chemical or physical castration for individuals who identify as eunuchs. Few providers have experience treating these individuals, so standardizing high-quality interventions could be a challenge.

  1. It’s unclear how these WPATH guidelines will be incorporated into the Human Rights Campaign’s Corporate Equality Index.

The WPATH Standard of Care recommendations are widely used and cited by health plans, but they are separate and distinct from the Human Rights Campaign’s Corporate Equality Index (CEI). While the CEI and WPATH SOC’s recommendations tend to move in the same direction, they do not fully align. Employers that wish to have perfect scores on the CEI should monitor the CEI scoring rubric carefully for any future changes based on the new WPATH SOC 8.

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The new WPATH Standards of Care have broad implications, and the costs of implementing them are not yet known. It will take time for health plans to integrate these changes into their medical policies and update their systems to accept the billing codes to align with those changes. Before that occurs, HR has an opportunity to collaborate with their health plans to operationalize any benefit modifications. Regardless of how employers incorporate the WPATH SOC 8, they can continue to provide inclusive communication, mental health access and social support for TGD employees.