North Carolina Passes
Law Over Transgender
legislature just passed
a shocking anti-
governor signs bill
bathroom use, limiting
Survey: One-Third of
Avoided Food or Water Due
to Restroom Discrimination
Begin in Target's
Obama directs public
After North Carolina’s
Law, Trans Suicide
Hotline Calls Double
AS ‘BATHROOM BILL’
DEBATES HEAT UP,
Family says school
teacher's cries for
help before suicide
Commits Suicide by Stepping
into Trafﬁc After Writing About
Depression: 'Please Share My
Leelah Alcorn: ‘My
death needs to mean
Transgender teen who
spoke on YouTube of
bullying takes her own
TSA to stop using
Assault of two
transgender women in
Maryland leads to hate-
Pope Francis calls the
disordered appetite of the
'annihilation of man'
understand the diversity of transgender identities
understand the transgender minority stress model
understand transgender health and healthcare disparities
understand mental health problems in the transgender community
understand how anti-discrimination laws opened access to
understand trans-afﬁrmative mental health services
understand current KPCO healthcare beneﬁts
identify what transgender services are currently provided at KPCO
How many Americans Are
• UCLA Williams Institute estimates 0.6% of Americans identity as
transgender, equivalent to 1.4 million people.
• Colorado: 20,850 people or .53%.
Flores, A.R., Herman, J.L., Gates, G.J., & Brown, T.N.T. (2016). How Many Adults
Identify as Transgender in the United States? Los Angeles, CA: The Williams
Transgender in Colorado
27% were found to be uninsured, compared to 21% nationally
57% concerned about access to transgender sensitive health care
compared with the overall national sample 47%
78% have received counseling related to being transgender/gender non-
conforming and 61% have received a gender related diagnosis
National Transgender Discrimination Survey (NTDS) was conducted in 2010 by the National Gay
and Lesbian Task Force and the National Center for Transgender Equality. The NTDS was the
largest survey of transgender people ever conducted in the US with more than 6,000
transgender and gender non-conforming participants.
Access to Healthcare
1. The Internet created a global transgender community and expanded knowledge: Twitter, Facebook, Reddit,
2. Transgender activism with the support of allies, including National Center for Transgender Equality,
Transgender Law Center, HRC, GLAAD, PFLAG, etc.
3. Changing societal attitudes toward transgender people.
GLAAD/Harris poll: number of Americans who know or work with a transgender person has increased
from 8% (2008) to 16% (2015),.
27% of Millennials know or work with a transgender person,
only 9% of people 45 years old+ say they know or work with a transgender person.
Pew poll: 87% of Americans personally know someone who is gay, lesbian or bisexual.
4. DoD Instruction 1300.28 In-Service Transition for Transgender Service Members, June 30, 2016.
5. Anti-discrimination laws, policies, and regulations include gender identity: Affordable Care Act 2010, state
regulatory agencies and departments of insurance.
6. Colorado Department of Regulatory Agencies, Division of Insurance, Bulletin No.B-4.49.
Affordable Care Act 2010
1. Section 1557 prohibits sex discrimination, including
discrimination based upon gender identity.
2. Section 1557 goes into full effect in 2017.
3. Prohibits automatic and/or blanket exclusions of transition
related healthcare based on gender identity (i.e., transgender,
gender dysphoria, etc).
4. Prohibits refusing gender-speciﬁc treatment (e.g., PAP smear)
on basis of gender identity.
5. A treatment cannot be denied based on gender identity if it is
provided to other patients in the plan (e.g., hormone therapy,
Colorado Department of Regulatory Agencies
Division of Insurance
March 18, 2013
1. Provides guidance about the anti-discrimination provisions of Colorado State law.
2. Colorado law deﬁnes “sexual orientation” as “a person’s orientation toward
heterosexuality, homosexuality, bisexuality, or transgender status or another
person’s perception thereof”.
3. Declares that a (healthcare) carrier may not:
impose any differential in premium rates or charges with regard to an applicant
or covered person’s sexual orientation;
designate an individual’s sexual orientation as a pre-existing condition for the
purpose of denying or limiting coverage;
deny, exclude, or otherwise limit coverage for medically necessary services, as
determined by an individual’s medical provider, if the item or service would be
provided based on current standards of care to another individual without regard
to their sexual orientation.
Costs and Beneﬁts of Providing Transition-related
Health Care Coverage in Employee Health Beneﬁts
Plans: Findings from a Survey of Employers
Eighty-ﬁve percent (85%) of the 26 employers that provided information on costs of adding
coverage to their existing health beneﬁts plans reported no additional costs to add the coverage.
Two-thirds of the 21 employers that provided information on actual costs from employee
utilization of the coverage reported zero actual costs due to utilization.
Based on the experiences of surveyed employers, 1 out of 10,000 employees (among employers
with 1,000 to 10,000 employees) and 1 out of 20,000 employees (among employers with 10,000 to
50,000 employees) will utilize transition-related health beneﬁts annually when they are available.
The type, number, and cost of services accessed by individuals will vary, yet as described
above, the costs of these beneﬁts, if any, are very low, as is the utilization of the beneﬁt
These ﬁndings are consistent with prior research that has shown employers generally beneﬁt
from providing LGBT-inclusive workplace policies. Survey participants for this study were all
employers known to provide transition-related health care coverage for employees through their
health beneﬁts plans.
Discrimination Survey (NTDS)
Transgender people experience high rates of rejection by family and friends, discrimination,
victimization, and violence and have elevated prevalence of suicide attempts,
Family chose not to speak/spend time with them: 57%
Harassed or bullied at school (any level): 50-54%
Experienced discrimination or harassment at work: 50-59%
Doctor or health care provider refused to treat them: 60%
Suffered physical or sexual violence:
At work: 64-65%
At school (any level): 63-78%
Disrespected or harassed by law enforcement ofﬁcers: 57-61%
Suffered physical or sexual violence: By law enforcement ofﬁcers: 60-70%
Experienced homelessness: 69%
Discrimination Survey (NTDS)
The prevalence of suicide attempts among respondents is 41 percent, which vastly exceeds the 4.6
percent of the overall U.S. population who report a lifetime suicide attempt, and is also higher than the
10-20 percent of lesbian, gay and bisexual adults who report ever attempting suicide.
of lesbian, gay and bisexual adults who report ever attempting suicide.
Suicide attempts among trans men (46%) and trans women (42%) were slightly higher than the full
sample (41%). Cross-dressers assigned male at birth have the lowest reported prevalence of suicide
attempts among gender identity groups (21%).
“Overall, the most striking ﬁnding of our analysis was the exceptionally high prevalence of lifetime
suicide attempts reported by NTDS respondents across all demographics and experiences.”
Analysis of other demographic variables found prevalence of suicide attempts was highest among
those who are younger (18 to 24: 45%), multiracial (54%) and American Indian or Alaska Native
(56%), have lower levels of educational attainment (high school or less: 48-49%), and have lower
annual household income (less than $10,000: 54%).
Prevalence of suicide attempts is elevated among those who disclose to everyone that they are
transgender or gender-non-conforming (50%) and among those that report others can tell always
(42%) or most of the time (45%) that they are transgender or gender non-conforming even if they
don’t tell them.
Gendered Restrooms and Minority Stress:
The Public Regulation of Gender and its
Impact on Transgender People’s Lives
68% reported verbal harassment: told they were in the wrong bathroom, told to leave, questioned about
their gender, ridiculed or made fun, verbally threatened, and stared at or given strange looks.
9% reported at least one instance of physical assault in gender-segregated public restrooms: physically
removed, hit or kicked, physically intimidated and/or cornered, and slapped, and one sexual assault (MtF).
27% reported problems using restrooms at work that, in some cases, caused them to change jobs or leave
their employer entirely.
54% reported health problems from trying to avoid using public restrooms, such as dehydration, kidney
infections, and urinary tract infections.
58% reported that they have avoided going out in public due to a lack of safe public restroom facilities.
reported stressors included absences from work and school, poor performance at work or school,
choosing to not participate in public life, avoiding particular places or events, and having to develop
strategies to navigate gender segregated restrooms.
expressed dismay or sadness due to other people consistently challenging their gender identity.
n=93 on-line sample
Coping With Stigma by
In a sample of 889 TGNC individuals:
38.8% reported avoiding public restrooms
38.4% reported avoiding gyms
29.8% reported avoiding clothing shops,
24.0% reported avoiding public transportation.
Ellis SJ, McNeil J, Bailey L. Gender, stage of transition and situational
avoidance: a UK study of trans people’s experiences. Sex Marital Ther.
Minority Stress Case Example
Argument with brother over NC bathroom bill.
I know his feelings now. My brother was the only one I
have left. I had a panic attack for an hour. I was
planning to kill myself.
One of the things that really effected me during the
depression was the North Carolina bathroom thing.
It makes me feel vulnerable. I have to be careful of the
people I mingle with. I don’t trust people.
Its okay to go into a ladies room because I have a
vagina, but that wouldn’t be okay before the surgery.
Case Example: 66 year old divorced Caucasian transgender female.
Gender transition 2012. Hormone therapy 2012. Vaginoplasty November
2014. Employed as accountant for small company. Two daughters,
Rejected by one since gender transition.
Pt is transgender and she had a realization with her brother last week. She went to
his house to visit him and have dinner. They got into a discussion about the North
Carolina bathroom law forcing transgendered people to use the bathroom that
correlates to their sex at birth. Brother loves her and "puts up with me" but "doesn't
believe in me." She was very hurt by this, tearful with writer. States it came as a
surprise to her. She is beginning to think people think all people think she is a
pervert. She states brother got belligerent and got in her face. She was afraid of
him. She states she has difﬁcult relationships with other family, has lost one of her
daughters. She feels lost. She does have friends, other support. Her next door
neighbor came over Saturday. Pt said if she didn't come over she would have taken
her pills. She is afraid she cannot accept brother and go back to his house. She
says she "needs" family support, but she knows she will not get it. Discussed
importance of possibly redeﬁning rel with brother and understanding that he cannot
make his brother accept something he is not ready to accept, and also working on
accepting brother for who he is and where he is. That may be understanding that
certain subjects are off the table. Feels this set him back into a depression. He had
been doing better.
many transgender people avoid seeing a medical provider because
they fear they will be discriminated against, humiliated, or
33% delayed or did not try to get preventive health care due to
discrimination by health care providers.
28% had postponed necessary medical care when sick or injured.
50% report having to teach their doctors about transgender care.
19% reported having been refused medical care by providers.
28% reported verbal harassment in medical settings.
Grant J, Mottet LA, Tanis J, et al. Injustice at Every Turn: A Report of the National Transgender Discrimination
Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.
Available at: www.thetaskforce.org/downloads/reports/reports/ntds_full.pdf
Mental Health Disparities of Transgender
Compared to Non-transgender LGB
After controlling for the effects of age, race, SES, self-rated health, and other
Transgender respondents were more likely than nontransgender respondents
to report high levels of discrimination.
Transgender respondents were more likely to report depression symptoms in
the past week, and the proportion of transgender respondents who reported
attempted suicide was over twice that of nontransgender respondents.
Respondents who perceived above-average discrimination were more likely
to report depression symptoms
For both transgender and nontransgender respondents, a high level of
identity acceptance was associated with fewer depression symptoms.
Mental Health Disparities Within the LGBT Population: A Comparison Between Transgender and Nontransgender Individuals,
Meyer’s Minority Stress Model
Transgender people face enacted stressors
(distal), the external processes and experiences
of stigma, discrimination, and victimization.
These enacted stressors have a detrimental
effect on the physical health and mental health
of transgender people and are associated with
more frequent risk behaviors.
Meyer’s Minority Stress Model
Transgender people also experience internal
stressors (proximal) that are subjective and related
The three speciﬁc proximal stressors are:
1. identity concealment (non-transition, passing).
2. internalized stigma (internalized transphobia).
3. expectations of rejection.
A form of felt stigma understood as an
individual’s knowledge of society’s stance toward
minority individuals, and expectations regarding
the likelihood of stigma being enacted in a given
situation as a result of having a minority status, for
example, transgender individuals.
Having a dual minority status, for example being a
person of color and transgender, further
complicates and heighten experiences of enacted
Expecting Rejection: Understanding the Minority Stress Experiences of
Transgender and Gender-Nonconforming Individuals, 2016.
Where to expect rejection
anytime away from home and entering a public space or meeting
new people, for example grocery stores, restaurants, and hotels.
when interacting with others in a way that exposes gender
identity and markers, for example public restrooms, locker/ﬁtting
rooms and medical visits. Also, in situations that requires legal
identiﬁcation, for example, airport security or being stopped by the
when around people who are well known and cannot be avoided,
for example work/employment, and at home when family are not
when not ‘‘passing’’ as cis-gender or ‘‘blending’’ while in public,
and early in medical transition without the beneﬁts of masculinizing
or feminizing hormone therapy and other medical procedures.
Thoughts and feelings associated
with expecting rejection
Fearful, hypervigilant, worried about personal safety and being a target of
discrimination and violence, being on alert or on guard, and ready to react
to threats from others.
Anxious, stressed, and nervous, and internal stress is overwhelming,
crushing, and awful.
Physically and mentally exhausted by the end of the day. Managing the
internal stress, over the course of the day and in different contexts, is
physically and mentally taxing.
Depressed, sadness, self-loathing, “I am at fault”, shame, embarrassment,
mood disturbances associated with the expectation of rejection.
Anger, frustration,and disappointment over the idea of expecting rejection
Not supported, ignored, and rejected.
Coping strategies used to manage
the expectation of rejection
Avoidance or escape.
Substance use, such as alcohol, smoking
cigarettes, marijuana, and prescription
drugs.Cognitive or emotional coping strategies.
Cognitive coping startegies, such as ruminating
on what could occur, or what had already
happened in the past.
Role of Mental Health Provider
• Exploration of gender identity. This includes expressing and clarifying
one's gender identity, self-acceptance and individuation, and exploring
individual–level ways to actualize this identity in the world. This may also
include assessment and preparation for gender afﬁrming treatments and
• Assist with coming out and social gender transition. This includes coming
out to family, friends, and coworkers, dating and relationships, and
developing tools to cope with being transgender in a stigmatizing
• Trans-Afﬁrmative assessment and treatment of mental health issues within
the context of Minority Stress Theory, including strengthening resilience.
Mental health problems may not be caused by oppression and
stigmatization and may be complicated and intensiﬁed. Transgender
people have higher rates of depression and anxiety, psychological
trauma, substance abuse, self-harm and suicide ideation and behaviors.
• Advocacy for access to medically necessary health care.
KPCO Transgender Healthcare
1. Transgender “rider” (2013): no longer operative.
2. In 2015-16, base transgender healthcare beneﬁts aligned across KP
regions. Speciﬁc regions (California and Northeast) include additional
beneﬁts over base beneﬁts (laser facial hair removal, tracheal shave) and
are exploring additional medical services for inclusion.
3. Commercial plans (large and small employer groups).
4. Individual and family self-pay plans.
5. Self-funded plans include base beneﬁts, but some have requested
additional beneﬁts, laser hair removal, and facial feminization surgery.
6. Medicare covers surgery since January 1, 2016.
7. It is unclear how the OCA will impact Medicaid, federal government
plans, and the VA healthcare system.
KPCO Base Healthcare Beneﬁts
1. Mental Health Services
2. Medical Services
Gender Afﬁrming Surgery
KPCO Mental Health Beneﬁts
Note: some plans have limited coverage for mental health
individual counseling related to gender dysphoria, gender
transition, and transition related interpersonal and family
problems, as well as mental health conditions.
couples and family counseling.
psychosocial assessment and referral for hormone therapy and
gender-afﬁrming surgery following the clinical guidelines of the
World Professional Association for Transgender Health,
Standards of Care.
KPCO Mental Health
Rachael St.Claire PsyD (303-471-7725): children, adolescents and adults.
Amy Trifonov LCSW (303-367-2975) adolescents and adults.
Eli Johnson PsyD (303-367-2903) adults
Teresa McPhee LCSW (303-650-3831) children, adolescents and adults
Shannon Paulson LCSW (303-650-xxxx) children and adolescents
Contracted therapists to provide additional specialty services as needed.
1. Hormone medications (including those administered in the ofﬁce) for
members who have a medication beneﬁt.
Hormone therapy (adults): PCP or Endocrinology.
Hormone therapy (adolescents): The Children’s Hospital,
2. Medically necessary treatment and follow-up related to hormone
therapy (labs, etc).
KPCO Hormone Therapy Beneﬁt
1. Hormone Therapy Adults after behavioral health assessment.
A. Masculinizing: testosterone (IM injection).
B. Feminizing: estrogen (oral or IM injection).
C. Androgen blockers (spironolactone)
2. Hormone Therapy Adolescents after behavioral health assessment.
A. Puberty Suppression (Lupron IM injection)
B. Masculinizing: testosterone (IM injection).
C. Feminizing: estrogen (oral or IM injection).
KPCO Surgery Beneﬁt
Masculinizing Gender Afﬁrming Surgery
1. Bilateral mastectomy with male chest contouring.
nipple and areola reduction.
2. Phalloplasty is a set of multiple staged surgeries.
3. Metoidioplasty is a masculinizing genital surgery.
Feminizing Gender Afﬁrming Surgery
1. Vaginoplasty/Orchiectomy with genital hair removal prior to surgery.
1. Hysterectomy/Oophorectomy with or without phalloplasty.
2. Orchiectomy with or without vaginoplasty.
Who Performs Our Surgeries
1. Bilateral mastectomy/male chest contouring.
Joseph Eby MD is moving, not yet replaced.
Jens Burli MD, Oregon Health Sciences University
Daniel Dugi MD, Oregon Health Sciences University.
Hormone therapy may adversely effect
reproductive ability in the future. Little research.
Gonadal and genital surgery permanently
terminates reproductive options.
Clients are counseled to consider gamete
preservation options, but are expensive.
Few clients chose gamete preservation services.
Medical Care Not Covered at KPCO
1. The following gender afﬁrming procedures are not covered at
KPCO but are important for gender afﬁrmation and safety:
laser facial hair removal.
chondrolaryngoplasty: thyroid cartilage reduction.
facial feminization surgery: feminizes masculine boney features.
2. Some of these procedures are covered in other KP regions.
3. Members have begun to appeal denials of these procedures.
Understand how to respect a transgender
member’s name and gender pronouns.
Educate yourself about transgender identities.
the gender binary and the minority stress model.
Request transgender competency training.
Transgender Training Resources
1. World ProfessionalAssociation for Transgender Health
2. American Psychological Association. www.pa.org/pi/lgbt/
3. Optimizing Transgender Health: A Core Course for Healthcare
Providers. Fenway Institute. www.fenwayhealth.org/the-
fenway-institute and www.lgbthealtheducation.org.
4. Center of Excellence for Transgender Health.
5. Twitter: transgendersoul by Rachael St.Claire PsyD.
6. www.transgendersoul.io by Rachael St.Claire PsyD.
Transgender Training Resources
7. Center of Excellence for Transgender Health, Department of Family
and Community Medicine, University of California San Francisco.
Guidelines for the Primary and Gender-Afﬁrming Care of
Transgender and Gender Nonbinary People; 2nd edition. Deutsch
MB, ed. June 2016. Available at www.transhealth.ucsf.edu/
8. Transgender Health. http://www.liebertpub.com/overview/
9. International Journal of Trangenderism. http://www.tandfonline.com/
10.The Lancet: Transgender Health Series. http://www.thelancet.com/
Transgender Training Resources
11. Introducing TransTalks – a new online training series on the health care needs of the transgender
community for medical professionals. This new series, featuring presentations given by nationally-
recognized experts at Fenway’s 2015 Advancing Excellence in Transgender Health Conference, covers
topics critical to the foundation of quality care for the transgender community, and and will provide free
continuing education credits for medical professionals. The training, comprised of six videos, each
dedicated to a critical topic – from primary and preventative care to surgical options and hormone
treatments; to caring for youth and adolescents and case scenarios – will be made available over the
next three weeks, with two videos released every week. www.lgbthealtheducation.org/transtalks
12. All webinars sponsored by the National LGBT Health Education Center are available on-demand for
viewing. Access a recording of the webinar, download a copy of the presenter’s slides, and ﬁll out an
evaluation all from your home or ofﬁce, at any time. CME/CEU credit is also offered for on-demand
webinars. Detailed information about CME/CEU credits can be found here. To receive CME/CEU credit,
you will need to login or register an account. www.lgbthealtheducation.org/lgbt-education/webinars
13. Drs. Malebranche and Hollenbach discuss gender identity development, creating a supportive and
welcoming clinical environment for transgender patients, the key concepts health professionals should
know about transgender health, and where and how to best include these topics in the medical
education curriculum. www.aamc.org/initiatives/diversity/axis/educationalresources/441828/
14. In HRC's four-part video series, transgender people, medical professionals and other experts team
up to dispel some common and harmful misconceptions surrounding the lived experiences of
transgender and gender nonconforming people. http://www.hrc.org/resources/debunking-the-myths-
Transgender Training Resources
15. This course encompasses a basic overview of individuals experiencing gender
dysphoria. It begins with an understanding of the spectrum of gender identity
variations and gives best estimates of the prevalence of transgender individuals in
the population. Discussion will focus on barriers to care, the unique healthcare
needs of these individuals, and approved standards of care. Speciﬁc discussion
will focus on endocrine management of transgender individuals, non-surgical
interventions such as voice therapy and counseling, and surgical interventions for
both male-to-female and female-to-male transsexuals. Discussion will also include
the emerging science of caring for transgender children and adolescents.
16. Transgender and gender nonconforming patients are often unable to access
culturally-competent medical care. This presentation will outline several health care
disparities faced by transgender and gender nonconforming patients. From a
primary care physician’s perspective, it will also discuss the provision of
appropriate primary care, including the initiation of gender-afﬁrming hormonal
therapy as part of medically necessary treatment for those with gender dysphoria.
Resources for providing such care will be provided. www.acha.org/ACHA/
Transgender Training Resources
17. This webinar was conducted by the ACHA Coalition of Allies for LGBT Health and is an extended version of the session
"Primary Care for Transgender and Gender Nonconforming Patients" that was originally presented at the 2015 Annual Meeting.
18. This is part 1 of a two-part independent study series entitled Clinically Competent and Culturally Proﬁcient Care for
Transgender and Gender Nonconforming PatieTransgender and gender nonconforming people experience high levels of
stigma and discrimination in health care. This course gives people who work in health care settings tools that will allow them to
better understand their patients’ needs so they can provide culturally proﬁcient care to transgender and gender nonconforming
19. This is part 2 of a two-part independent study series entitled Clinically Competent and Culturally Proﬁcient Care for
Transgender and Gender Nonconforming Patient No matter what level of services you provide, you can serve the health care
needs of your transgender patients. This course covers preventive care, health education and health promotion, reproductive
health services and medical management of gender transition. It will help you provide culturally proﬁcient, evidence-based
care to transgender and gender nonconforming people. www.glma.org/index.cfm?
20. The webinar will be framed using GLMA’s Top Ten Things Transgender Persons Should Discuss with their Health Providers,
an evidence-based patient education resource. During this 90 minute webinar, the presenters will provide clinical best
practices on salient health issues for the transgender population.
Centers for Disease Control and Prevention, Lesbian, Gay, Bisexual, and Transgender Health www.cdc.gov/lgbthealth/health-
FTM International www.ftmi.org
Gay and Lesbian Medical Association www.glma.org
Gender Spectrum www.genderspectrum.org
Human Rights Campaign, Transgender Visibility Guide www.hrc.org/resources/entry/transgender-visibility-guide
Lambda Legal, Creating Equal Access to Quality Health Care for Transgender Patients: Transgender-Afﬁrming Hospital Policies