Grand Rounds Blog

Grand Rounds hosts several roundtable discussions throughout the year with benefits executives and leading clinical experts. The goal is to help our customers better understand important healthcare issues, including new treatment guidelines and best practices for insurance coverage. Based on feedback from some of our customers, we recently hosted a session on how to best provide comprehensive benefits to transgender employees and/or their transgender children. The experts on the panel were Stephen Rosenthal of UCSF Benioff Children’s Hospital and Norman Spack of Boston Children’s Hospital.

Below are the top questions and key takeaways that came out of this session:

What are the correct terms to use when discussing the topic of transgender care?

There are many terms that the general public often uses interchangeably and incorrectly—for example, the terms “gender nonconformity” and “gender dysphoria.” The first refers to a person experiencing a different gender identity or role than what is considered the social norm. Gender dysphoria, on the other hand, is the discomfort caused by this discrepancy. Only some gender nonconforming people experience gender dysphoria during their lives.

Two other terms often mistaken are “transsexual” and “transgender.” Transsexual refers to people that transition from one sex to another through medical means, whereas transgender refers to a person whose general sense of self does not conform with what’s usually associated with their anatomical parts. To explain it another way: terms with “sex” refer to the body, and those with “gender” refer to a feeling or a state of mind.

How prevalent is gender nonconformity?

This is very difficult to quantify for a variety of reasons—many people do not seek out care, the care they seek out is not reported, and for females it is easier to blend into the lesbian culture than affirm male. Epidemiological studies report 1 in 11,900 to 1 in 45,000 transgender individuals in the male population, and 1 in 30,400 to 1 in 200,000 in the female population. Some identification studies put the figure closer to 1 in 200 people (male and female). The truth of the matter is that the figure is likely somewhere in between, meaning that at any average sized U.S. high school, there is likely at least one transgender individual grappling with a potential identity crisis.

What treatment is most important to these patients?

It depends on the age and affirmed sex of the individual. The Standards of Care Version 7 (SOC 7) guidelines provide specifics, but ultimately, the key to comprehensive care is to ensure you’re treating the whole person by taking into consideration social factors that affect their transformation. What this means is to partner up the individual with a therapist, an endocrinologist that can help with hormone replacement, and—if necessary—a surgeon that has experience in genito-plastic reassignment surgery. There are actually only five or six reputable surgeons nationwide. These individuals are referred to by other experts in the field, as there is not a residency or fellowship program in this subspecialty yet.

Many insurance plans do not cover surgery until the patient is over the age of 18. What is the medical community’s consensus on the best age for treatment?

Some insurance companies are beginning to cover drugs that suppress puberty in pre-teens. When transgender individuals are able to suppress puberty, they’re often able to avoid costly treatments down the line (e.g., mastectomy, voice modification therapy, etc.). And for those wishing to undergo gender confirmation surgery later in life, this makes the transition easier. Patients that begin this treatment before hitting puberty have the best outcomes, especially when treated appropriately with a therapist, endocrinologist, and eventually surgeon if applicable.

While most insurance plans do not cover gender confirmation surgery until the age of 18, it’s important to consider the support system that the patient will have during the recovery period. At age 18, many teenagers are preparing to leave for college and live away from home for the first time. Patients recovering from surgery away from home tend to be less successful than those recovering at home. Experts in the field recommend that a teenage patient spends around a year at home with an adult helping with recovery.

Have a topic in mind for a future panel? Let us know! Leave a comment below or send your suggestions to brooke.clemmensen@grandrounds.com.

References & Materials

How I help transgender teens become who they want to be (2013) Available at: https://www.ted.com/talks/norman_spack_how_i_help_transgender_teens_become_who_they_want_to_be

Bockting, W. O. (1999). From construction to context: Gender through the eyes of the transgendered. Siecus Report, 28(1), 3–7.

Fisk, N. M. (1974). Editorial: Gender dysphoria syndrome—the conceptualization that liberalizes indications for total gender reorientation and implies a broadly based multi-dimensional rehabilitative regimen. Western Journal of Medicine, 120(5), 386–391.

Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender
people: Building a foundation for better understanding. Washington, DC: The
National Academies Press.

Knudson, G., De Cuypere, G., & Bockting, W. (2010b). Recommendations for revision of the DSM diagnoses of gender identity disorders: Consensus statement of The World Professional Association for Transgender Health. International Journal of Transgenderism, 12(2), 115–118. doi:10.1080/15532739.2010.509215

Spack, N. and Rosenthal, S. (2015) ‘Grand Rounds Transgender Panel’. Interview on 13 November, 2015.

Transgender-Inclusive benefits for employees and dependents (no date) Available at: http://www.hrc.org/resources/entry/transgender-inclusive-benefits-for-employees-and-dependents (Accessed: 16 November 2015).

Transequality.org (2012) Available at: http://www.transequality.org/sites/default/files/docs/resources/NTDS_Exec_Summary.pdf (Accessed: 16 November 2015).

WPATH (2012) Available at: http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351 (Accessed: 16 November 2015).

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