Trans-Ition

Andre Wilson considers himself one of the luckier ones. When he decided to undergo sexual reassignment surgery as a graduate student at the University of Michigan, Wilson had the financial and emotional support of his family. While student health insurance didn’t cover the procedure at the time, Wilson still had the wherewithal to make the change from female to male that he now says saved his life.

“For people to only be able to access these services because they have privilege is unconscionable,” said Wilson, who is pursuing a master’s degree in social work at Michigan.

Wilson was the lead negotiator for Michigan’s Graduate Employees’ Organization in 2005, when the union successfully fought to have sexual reassignment surgery covered by the university’s graduate student health insurance.

While still relatively uncommon, there is a fledgling movement across higher education to expand health care benefits as Michigan has done. In the University of California's 10-campus system, seven campuses have such benefits for students or will offer them next year, and two more are formally negotiating to include them. Faculty and staff across the entire California system already have transition-related care covered, but each campus has to independently approve the expansion for students.

“Quite honestly, this is where it should be for all plans,” Wilson said. “These are medically necessary procedures. These are lifesaving procedures. …

“If you can’t have these services, it’s devastating. People end their lives [without these procedures], but people who don’t end their lives live with a great deal of suffering.”

Wilson’s view is increasingly shared by the medical establishment. In 2008, the American Medical Association passed a resolution opposing any exclusion of insurance coverage for gender identity disorder treatments when prescribed by a physician. Failure to provide such treatment can have deleterious consequences, including "stress-related physical illness, depression, and substance abuse problems," according to the AMA.

The AMA drew upon the recommendations of the World Professional Organization for Transgender Health, which has rejected notions that surgeries for transgender patients are “cosmetic” or “experimental.”

It’s difficult to discern how many colleges have expanded insurance policies to accommodate transgender students and employees, in part because some universities may have made the change with little fanfare. The Transgender Law & Policy Institute,, however, has done some tracking of the trend. In addition to Michigan and campuses in the California system, the institute lists the University of Vermont and Emerson College among the growing number of colleges that cover reassignment surgery.

American University expanded coverage for faculty and staff in November of 2008, although the push began well before that time.

“It took a solid four years to really get this conversation started,” said Sara Bendoraitis, director of the Gay, Lesbian, Bisexual, Transgender and Ally Resource Center at American.

As with other colleges and universities that have expanded coverage, officials at American saw the move as a logical extension of an action they took in 2002, when the university added gender identity to its nondiscrimination policy.

In order to provide coverage to transgender employees, American had to negotiate with its carrier to remove language that specifically exempted procedures that fall under the umbrella of “transition-related” care. The university negotiated this, in addition to expanding coverage for several services unrelated to transition. A total of seven new procedures were added to its coverage, and the university found minimal change in premiums, according to Bendoraitis.

“It ended up being less than 1 percent increase for everybody across the board,” she said. “You’re talking a couple of bucks – one or two dollars per person.”

American officials hope to expand student health care to include the same services now offered to employees, Bendoraitis said.

Cost Increases Minimal, Proponents Say

When calculating the potential cost impact of expansion, universities have frequently turned to the data compiled by the City and County of San Francisco – the first U.S. municipality to remove exclusions for transgender-related services in its health plan. The City projected that it would need to collect an additional $1.70 per month from its 100,000 members in order to meet projected cost increases. It turned out, however, that the city had overestimated what would be required. Between 2001 and 2004, the City collected about $4.3 million specifically to cover the transgender benefit, but it only paid out $156,000 on seven claims for surgery during that period, according to a report compiled by the mayor.

Universities and other employers that are considering expanding benefits are often deterred by a “myth” that the change will dramatically increase premiums, according to Mara Keisling, executive director of the National Center for Transgender Equality.

“It just isn’t that expensive,” she said. “It’s partially this myth that all trans people get and need the exact same care.”

There are a variety of medical services prescribed to transgender patients, and many fall short of surgery. Hormone therapy and mental health treatment, for instance, are nonsurgical treatments that are typically covered by insurance policies for all but transgendered patients. The fact that some services would be provided to one part of the covered population and not another has given rise to criticism that universities may be in violation of their own nondiscrimination policies by not expanding coverage.

Erin Cross, associate director of LGBT Center at the University of Pennsylvania, argues that Penn’s lack of coverage for reassignment surgery constitutes a violation of its nondiscrimination policy. The university added gender identity to its policy in 2003, and in so doing created a “different level of obligation” for insurance coverage that it has yet to meet, Cross says.

“I think we do need to set an example as one of the Ivy League institutions that many folks look toward as an example,” she said. “We can really be groundbreaking on this, and I think Penn should really do so and has an obligation to do so.”

Ronald Ozio, a spokesman for Pennsylvania, said in an e-mail Friday that the university is “currently reviewing [its coverage], a process that will require time.”

Sheldon Steinbach, a lawyer based in Washington, D.C. who specializes in higher education, says he’s unsurprised some universities are expanding converge, because academic institutions often lead the way in reform. At the same time, however, Steinbach says he’s unconvinced universities’ nondiscrimination policies create new legal obligations.

“It’s a potential argument, but medical services of one kind or another are oftentimes either gender specific [or] illness specific, and as such there is a total potpourri of health benefits that may have a greater impact on one group than another,” he said. “The choice for the institutions is what best serves their community as they see it.”

Stacey Jackson, a staff member at American University’s law school, may be one of the early beneficiaries of the expanded coverage at her institution. Jackson is pursuing reassignment surgery, and says the university’s efforts to accommodate transgender employees were part of what drew her to work there in the first place.

“It was tremendously reassuring,” Jackson said, “that I’m with an employer that sees this as a social justice issue and an equality issue.”