STATE OF CALIFORNIADEPARTMENT OF INSURANCE
300 South Spring Street
12th Floor, South Tower
Los Angeles, CA 90013
ECONOMIC IMPACT ASSESSMENTGENDER NONDISCRIMINATION IN HEALTH INSURANCEREGULATION FILE NUMBER: REG-2011-00023

Dated April 13, 2012ACTUARIES: Ali Zaker-Shahrak, Lai Weng (Carol) Chio
ECONOMIST: Rani Isaac
HEALTH PROGRAM SPECIALIST: Jason Tescher
Description of Proposal
The proposed regulation clarifies the prohibition against discrimination on the basis of gender orsex. AB 1586 (2005) prohibits plans and insurers from denying an individual a plan contract orpolicy, or coverage for a benefit included in the contract or policy, based on the person’s sex,
defined as "includ[ing] a person's gender identity and gender related appearance and behavior
whether or not stereotypically associated with a person's assigned sex at birth."
The proposed regulation specifies forms of gender discrimination that are a violation of thediscrimination prohibition in California Insurance Code (Ins. Code) section 10140 including: Denying or cancelling an insurance policy on the basis of gender identity;
 Using gender identity as a basis for determining premium; Considering gender identity as a pre-existing condition; or Denying coverage or claims for health care services to transgender people when coverage
is provided to non-transgender people for the same services.
The California Department of Insurance (the “Department”) has determined that denying claims
as listed in the bullet points above is a violation of the discrimination prohibition in Ins. Codesection 10140. The proposed regulation clarifies the obligation of insurers to refrain fromdiscriminatory practices and results in a prohibition on the denial of claims solely due to anindividual’s transgender status. Furthermore, the proposed is consistent with recently enacted
legislation, AB 887 (Atkins, 2011), which specifically prohibited discrimination based on gender
identity and gender expression. This document constitutes the Department’s Economic Impact
Assessment (EIA), which considers the economic impact of this prohibition and assesses
whether and to what extent the proposed regulation affects the criteria set forth in Government
Code Section 11346.3(b)(1).
Economic Impact Findings
The Department has determined that the adoption of the proposed regulation would have an
insignificant and immaterial economic impact on the creation or elimination of jobs, the creation
or elimination of new businesses, and the expansion of businesses in the State of California.

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Prohibiting the four types of discrimination listed in the bullets above will be of significant
benefit for transgender people and should thereby potentially improve their health and welfare
since they have been targets of discrimination and violence.1 The regulation may also have apositive impact on transgender worker safety. Since these workers will have improved access tohealth care coverage, under the proposed regulation, they should be in better health and moreproductive at work. However, while the proposed regulation may have a positive impact on thehealth, welfare and worker safety of the transgender population, which is a very small subset of
California residents, the aggregate cost to the state population as a whole will be very
insignificant (see “Prevalence of the Transgender Population” section).
The Department finds that nothing in the proposed regulation prohibits an insurer from using
objective, valid, and up-to-date statistical and actuarial data or sound underwriting practices.
While insurers may use someone’s health status to determine their premium, analysis of thepotential increase in claim costs from the proposed regulation shows that any such costs are
immaterial and insignificant.
To arrive at these conclusions, Department staff conducted a thorough literature review, analyzed
existing data, and obtained cost and premium data from employers. Department staff used avariety of data sources to reach these conclusions, including actuarial and utilization data related
to potential increased claim costs resulting from the prohibition of the four types of
discrimination listed in the bullets, above.
Impact on Employment and Business
Based on the very small size of the population that may be impacted by the proposed regulation,
the Department has concluded that the proposed regulation will have an insignificant andimmaterial impact on the creation or elimination of jobs, the creation of new business or theelimination of existing business, and the expansion of business currently doing business in
California (see “Prevalence of the Transgender Population” section below).
Department staff have determined that the adoption of the proposed regulation will have an
immaterial impact on extra demands for treatments, because of the low prevalence of the
impacted population. Consequently, there will be immaterial changes in the labor force.
In addition, the proposed regulation requires equality of treatment. If a medically necessary
treatment is not available to any insured, the insurer is not obligated to provide that treatment totransgender individuals. Because no new treatments are required, there is no impact on thecreation or elimination of existing businesses, nor the expansion of established businesses in
California.
Prevalence of the Transgender Population
Because the proposed regulation will give transgender Californians access to the same treatments
offered to non-transgender Californians, the Department’s analysis included a review of thenumber of the individuals in the California population that could contribute to increased claim
1

See the “Impact on Health and Welfare” section.

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costs. The transgender population is much smaller than the overall lesbian, gay, and bisexual
population and is more difficult to track and follow due to the significant disenfranchisement anddiscrimination that transgender individuals face.2 The Department has published a range of
estimates (see table below).
The classic estimate for prevalence of transgender individuals (using gender identity disorder asa measurement) comes from the 1994 Diagnostic and Statistical Manual, Fourth Edition(DSM-IV), which reported 1:30,000 natal males and 1:100,000 natal females.3 More recently, a2009 review by Zucker and Lawrence concluded that the prevalence may be 3 to 8 times thenumbers reported in the DSM-IV, based mostly on reports from Western European clinics.4, 5
In 2007, De Cuypere, et al., reviewed ten studies from eight countries; plus, they conducted theirown study. “The prevalence figures reported in these ten studies range from 1:11,900 to 1:45,000
for male-to-female individuals and from 1:30,400 to 1:200,000 for female-to-male individuals.
Some scholars have suggested that the prevalence is much higher, depending on themethodology used.”6
Department staff utilized data from these studies, and estimates of the uninsured population, toarrive at a range of estimates for the insured transgender population in California based upon
2010 Census figures.7
Out of the 37.3 million California residents, transgender people make up between 0.0065 and0.0173 percent of the total population in California, using the two highest estimates in order to beconservative (see the last two columns of the table below). When the rate of uninsured
Californians (19 percent) is factored in, only 0.0052 to 0.014 percent of the state population
would be impacted by the proposed regulation — or between 1,955 and 5,214 people. 82(Baker, Kesteren, Gooren, & Bezemer, 1993)(American Psychiatric Association, 1994)
4(Zucker & Lawrence, 2009)5(Olson, Forbes, & Belzer, 2001)
6(The World Professional Association for Transgender Health, 2011)
7(U.S. Census Bureau, 2010)
8(The Kaiser Family Foundation, 2009)3

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Since the number of transgender people in the general population is so small, the subpopulationof insured individuals is even less significant. The following estimates by the Department ofcosts and utilization are conservative, considering that the transgender population has higher than
average rates of poverty and unemployment and lower rates of insurance coverage. A 2008
survey conducted by the Transgender Law Center indicates that transgender people are twice as
likely to live below the poverty line.9 Because transgender people have less access to insurance
coverage than average Californians, they are more likely to be covered by a public program andwould not contribute to increased claims against private insurers.
Utilization and Impact on Claim Costs and Premiums
While there is limited actuarial data publically available on the impact that the Department’s
proposed regulation would have on claim costs and premiums, the Department has identified
enough existing data to make conclusions about the economic impact of the regulation.
Department staff reviewed data from five employers that have internal policies prohibiting
discrimination in health care coverage and reviewed their related cost studies. For reasons
discussed in the following section, the Department has concluded the impact on costs, due to theadoption of the proposed regulation, would be immaterial.
Utilization
Utilization data is important because it is used by insurers to calculate expected claim costs andthen premiums. As utilization increases, the expected claim costs increase and in general theincrease will be reflected in setting premiums. In this section, the Department presents data thatindicates extremely low utilization resulting from elimination of gender discrimination, as would
be expected with such a small population.
Once again, the proposed regulation requires that treatments available to non-transgenderinsureds not be denied based on an insureds actual or perceived gender identity or transgenderstatus, as defined. If a medically necessary treatment is not available to any insured, the insurer is
not obligated to provide that treatment to transgender individuals. Department staff usedutilization data from employers that offer transgender employees equal health care benefits as aproxy for increased utilization that we may expect to see as a result of implementing the
proposed regulations. Department staff determined that this data most closely represents the kindof increased utilization that we can expect based on prohibition of the four types of
discrimination listed in the first section of this assessment.
While the move to eliminate this type of gender discrimination in health policies was rare among
employers ten years ago, many more employers are adopting internal policies offering equal
access to health care services for their transgender employees. The number of Fortune 500
companies that have eliminated discrimination in health care benefits offered to their transgender
employees has increased from 49 in 2009 to 207 in 2012.10 Presenters at the Out & Equal
Workplace Summit 2011 indicated that the utilization, and thus costs, for prohibiting
discrimination are very low. “[M]any employers around the country have eliminated the910(Transgender Law Center, 2008)(Human Rights Campaign, 2012)

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exclusions in their health plans…Utilization is very low and there has been little or no impact topremiums.”11
Existing utilization data is limited due to extremely low utilization coupled with the concern that
releasing this data could be traced back to individuals and violate health privacy laws. However,Department staff obtained and reviewed three sources of utilization data: (1) The City andCounty of San Francisco; (2) The University of California; and (3) Jamison Green and
Associates report on utilization and costs to private companies with voluntary internal
nondiscrimination policies similar to the proposed regulation.
The City and County of San Francisco (San Francisco) prohibited gender-based discrimination in2001 for all City and County employees and their dependents. In the following five years, there
were only 37 claims. A report by Jamison Green and Associates estimated that utilization rates(claimants per employee) ranged from 0.0325 to 0.104 claimants per thousand employees per
year.12In March 2012, the University of California (UC) released utilization and cost data from one ofits health plan insurers, for the 6.5 years since UC first prohibited discrimination against
transgender employees in its health care plans.13 The utilization rates, as summarized in the tablebelow, ranged from 0.011 to 0.093 claimants per thousand covered lives per year.14 In order tomake comparisons with other utilization data, the Department converted the UC data toutilization rates per 1,000 covered employees. Using a member-to-employee ratio of 2:1,
Department staff arrived at utilization rates per 1,000 employees, from a minimum of 0.022 in
CY 2006 to a maximum of 0.187 in CY 2009 (see far right column in table below).

Coverage Period

Number of
Claimants

Average Covered
Lives

Est. Average
Number of
Employees*

Utilization Rates Utilization Rates
per 1,000
per 1,000
covered lives
employees*

Jul - Dec 2005
CY 2006

1

92,47091,705

46,23545,853

0.011

0.022

CY 2007
CY 2008
CY 2009
CY 2010
CY 2011

3
9
11
10
8

86,868120,905
117,945
115,087
111,571

43,43460,45358,97357,54455,785

0.035
0.074
0.093
0.087
0.072

0.069
0.149
0.187
0.174
0.143

Total

42
Average utilization rates (excl. 2005 data)

0.062

0.124

Min utilization rates (excl. 2005 data)
Max utilization rates (excl. 2005 data)

0.011
0.093

0.022
0.187

*Estimated number of employees based on a member-to-employee ratio of 2:1

11(Green, Wilson, & Fidas, 2011). Slide #5.
(Wilson, 2012); Slide # 11
13
(Manning, 2012)
14
ibid.
12

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Further underscoring evidence of extremely low utilization, the insurer reported that only 27
individuals sought treatments, some with multiple claims, over the period of 6.5 years.15 Using
the number of (distinct) members, rather than the number of distinct claims, Department staff
obtained an average utilization rate of 0.039 per thousand covered lives per year. Department
staff made the conversion because utilization data relying on covered lives is a more accurate
representation of actual utilization. As expected, the average utilization rate per thousand
covered lives (0.062 per thousand) is significantly lower than the utilization per thousand
employees (0.124) because the rate per covered lives represents utilization spread across all
insureds.
In addition, a report issued by Jamison Green and Associates estimated utilization rates in therange of 0.0015 to 0.325 per thousand employees per year, based on interviews with fifteen
Fortune 500 companies who have eliminated the discriminatory policies.16 Their broader
estimates discussed below included the experience of San Francisco.
The table below summarizes the utilization rates from all three sources mentioned above.
Utilization Rates per 1,000 employees per year

Case

City and County of
San Francisco

Minimum
Maximum

0.0325
0.104

University ofCalifornia
0.022
0.187

Sample of Private
Employers
0.0015
0.325

The utilization rates for San Francisco and UC fall within the range of utilization estimates of
Jamison Green and Associates discussed above.
Claim Costs and Premium History
The Department augmented the limited claim cost and utilization data available by reviewing
premium data from several employers to determine the additional amount their insurers havebeen charging to extend equal coverage to transgender employees and dependents.
For San Francisco, the initial cost per employee was $1.70 per member per month (PMPM) in2001. Due to low utilization, San Francisco reduced the PMPM to $1.16 in 2004-2005 and thecity’s self-insured plan reduced its charge to $0.50 PMPM. As of July 1, 2006, the cost data
demonstrated that no separate rate was required, so the charge was removed entirely. Initialclaims were first subject to a lifetime maximum of $50,000 then increased to $75,000 in 2004.17

15

There were 27 unduplicated individuals who received treatment during this time period. There were 42 claimants because someprocedures for the same individual occurred over more than one year.
16(Wilson, 2012) Slide #13
17(The City and County of San Francisco Human Rights Commission, 2007)

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The University of California eliminated transgender discrimination in 2005 without being
charged an additional premium.18 Claim cost data from the UC health plan with the largest
enrollment shows that the claim costs PMPM attributed to the elimination were very low. The
maximum of claim costs during the 6.5 years was $0.20 PMPM, or 0.05 percent of the total
premium.
As of January 1, 2012, the City of Berkeley removed discriminatory provisions within its healthplans. Berkeley’s insurers charged a premium of 0.2 percent of the total annual budget for
healthcare benefits. The total projected monthly increase was 0.25 percent (223 covered lives in
one plan) and 0.19 percent (938 covered lives in another plan) as of March 2012.19
Two other cities have had experiences similar to Berkeley’s. The City of Portland removed
discriminatory policies beginning July 1, 2011. The cost projection for Portland was $32,302 outof a total $41,615,000 health care budget – a 0.08 percent increase.20 The City of Seattle
absorbed a premium increase of $200,000 per year of a total $105 million health care budget –just 0.19 percent of total health costs based on insurer estimates of increased utilization.21
It is a standard practice for insurers to charge a premium to cover expected claim costs of the
proposed regulation, administrative expenses, taxes, profit and any provisions for adverse
deviation. When credible cost and utilization data is absent or limited for new benefits, insurers
tend to be conservative by including a larger provision for adverse deviation. This is evidenced
by San Francisco’s experience, where “[f]rom July 2001 through July 2006, the grand total ofreported monies collected (for this purpose) is $5.6 million. The grand total of reported monies
expended is $386,417.”22 Since cost assumptions were nearly 15 times higher than actual
claims, the city eventually eliminated the additional premium.
Using the impact on premiums as a proxy for anticipated increased claim costs, the range of the
impact on costs for the proposed regulation would be a minimum of no increase (the case of San
Francisco and the University of California), to a maximum increase of 0.2 percent in expectedclaim costs (the cases of Berkeley and Seattle). However, changes to policies in Berkeley andSeattle were recent, limiting data availability. As stated before, the 0.2 percent estimate may very
likely include a large provision for adverse deviation. The Department’s conclusion is supportedby the actual claims data collected for the UC system, which shows the claims costs accounted
for only 0.05 percent of premiums.
In addition to the employer information, Department staff also reviewed the Sylvia Rivera Law
Project white paper discussing the impact of a similar prohibition for Medicaid in the State of
New York. “A preliminary estimate by the New York State Department of Health in 2010
approximated that it would cost about $1.7 million to cover gender-confirming care through18(Manning, 2012)(Hodgkins, 2012)
20(The City of Portland, Oregon, 2011)
21(Freiboth, 2012)
22(The City and County of San Francisco Human Rights Commission, 2007)
19

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Medicaid. As the state Medicaid budget totals $52 billion, this represents only 0.003 percent of
the total budget.” 23
Based on evidence of low utilization and prevalence rates shown above, the Department hasdetermined that the impact on costs or increases in premiums due to the adoption of the proposed
regulation would be immaterial.
Utilization Assumptions
There are a number of assumptions that contribute to lower-than-expected utilization seen in
San Francisco. Like any other condition, treatment options for GID vary greatly and not alltransgender people with the diagnosis will undergo surgical intervention. It appears thatutilization projections are made with:…the belief that all transgender people undergo genital surgery as the primary
medical treatment for changing gender. In fact, gender-confirming healthcare isan individualized treatment that differs according to the needs and pre-existing
conditions of individual transgender people. Some transgender people undergo no
medical care related to their expression of a gender identity that differs from theirbirth-assigned sex. Others undergo only hormone therapy treatment or any
number of surgical procedures.24
The assumption that treatment utilization and costs are the same for each transgender person isreflected in the significant difference between premium charges by insurers and actual utilization
costs and evidenced in the wide range of claims costs reported by the University of California.
The claims varied from $67 to $86,800 with an average cost of $29,929 per transgender person
requiring treatment.
Additional factors that impact utilization and cost include, but are not limited to:






23
24

Transgender insureds may have already undergone treatment;
Surgical treatment for gender identity disorder (GID) is usually a once-in-a-lifetime
event, and many costs are spread over a lifetime, and do not occur in just a single year;
Transgender people do not always have a diagnosis of GID and thus have no medicallynecessary indication for treatment;
Almost all surgical treatments for treatment of GID are treatments that are provided to
non-transgender insureds for other indications; andOther health factors can contraindicate treatment.

(The Sylvia Rivera Law Project, 2011)(Spade, 2010)

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A detailed analysis of the impact of each of these assumptions on utilization is beyond the scopeof this assessment, but is illustrative of what may be the reasons for the apparent gap between
premiums charged to employers for prohibiting health care discrimination against transgenderinsureds and the actual reported utilization and cost.
In addition, the Department believes that there may be a possible spike in demand for suchservices in the first few years after the adoption of the proposed regulation due to the possible
existence of some current unmet demand. This may lead to higher costs, in the near-term,
following the adoption of the proposed regulation. While this is possible, this was not theexperience of the University of California or San Francisco. In any case, the small size of the
impacted population will likely make the magnitude of such an increase insignificant andimmaterial.
Impact on Health and Welfare
As discussed in the Prevalence and the Utilization and Claims sections, prohibiting the fourtypes of discrimination listed in the bullets on page one will be of significant benefit for a verysmall class of California residents who are directly impacted. The proposed regulation should
thereby potentially improve their health and welfare since transgender people have been targetsof discrimination and violence.25 The proposed regulation may also improve worker safety, as
explained above. However, while the Department found that the proposed regulation may have asignificant beneficial impact on the health, welfare and safety of the transgender population, theaggregate costs will be very insignificant. The Department has determined that the benefits ofeliminating discrimination far exceed the insignificant costs associated with implementation of
the proposed regulation. Based on this assessment, the Department has determined that there areno significant adverse impacts of the regulation to the health and welfare of California residents,
nor will it impact overall worker safety, and the state’s environment.
Further, the Department’s evidence suggests that benefits will accrue to insurance carriers andemployers as costs decline for the treatment of complications arising from denial of coverage fortreatments. The evidence suggests that there may be potential cost savings resulting from theadoption of the proposed regulation in the medium to long term, such as lower costs associatedwith the high cost of suicide and attempts at suicide, overall improvements in mental health andlower rates of substance abuse, as discussed in the following section.
The Benefit and Cost Savings of Suicide Reduction26
One of the most severe results of denying coverage of treatments to transgender insureds that areavailable to non-transgender insureds is suicidal ideation and attempts. The Centers for Disease
Control and Prevention estimate the average acute medical costs of a single suicide completionor attempt in the United States is $2,596 and $7,234 respectively.27 This only includes acute careand hospitalization costs. While there are studies that provide higher estimated costs per suicide
attempt and completion, we choose to conservatively use the lower bound cost to keep estimates

25(Tannis, Grant, & Mottat, 2010)(Gorton, 2011)
27(The Centers for Disease Control, 2010)
26

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as relevant to health insurers as possible. 28,29 A more in-depth analysis might include the costs ofmental health treatment or other medical costs following a suicide attempt.
A meta-analysis published in 2010 by Murad, et al., of patients who received currently excluded
treatments demonstrated that there was a significant decrease in suicidality post-treatment. The
average reduction was from 30 percent pretreatment to 8 percent post treatment.30
De Cuypere, et al., reported that the rate of suicide attempts dropped dramatically from 29.3
percent to 5.1 percent after receiving medical and surgical treatment among Dutch patientstreated from 1986-2001.31
According to Dr. Ryan Gorton, “In a cross-sectional study of 141 transgender patients, Kuiper
and Cohen-Kittenis found that after medical intervention and treatments, suicide fell from 19
percent to zero percent in transgender men and from 24 percent to 6 percent in transgenderwomen.32)”33
Clements-Nolle, et al., studied the predictors of suicide among over 500 transgender men andwomen in a sample from San Francisco and found a prevalence of suicide attempts of 32
percent.34 In this study, the strongest predictor associated with the risk of suicide was gender
based discrimination which included “problems getting health or medical services due to theirgender identity or presentation.”35 According to Gorton, “Notably, this gender-based
discrimination was a more reliable predictor of suicide than depression, history of alcohol/drug
abuse treatment, physical victimization, or sexual assault.”36
A recent systematic review of largely American samples gives a suicide attempt rate of
approximately one in every three individuals with higher rates found among adolescents andyoung adults.37 According to Dr. R. Nicholas Gorton, MD, who treats transgender people at a
San Francisco Health Clinic, “The same review also noted that while mental health problems
predispose to suicidality, a significant proportion of the drivers of suicide in the LGBT
population as a whole is minority stress.” He continues to conclude that, “[f]or transgenderpeople such stress is tremendous especially if they are unable to 'pass' in society. Surgical andhormonal treatments — that are [also] covered for non-transgender insureds — are specifically
aimed at correcting the body so that it more closely resembles that of the target gender, so
providing care significantly improves patients' ability to pass and thus lessens minority stress.”38
These studies provide overwhelming evidence that removing discriminatory barriers to treatment
results in significantly lower suicide rates. These lower rates, taken together with the estimated28(Yang & D.Lester, 2007)(Corso P, 2007)
30(Murad M, 2010)31(DeCuypere, 2006)
32(Kuiper M, 1988)
33(Gorton, 2011)34(Clements-Nolle K, 2006)
35(Clements-Nolle, Marx, & and Katz, 2006)
36(Gorton, 2011)37(Haas, 2011)38(Gorton, 2011)
29

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costs of a suicide attempt and completion, demonstrate that the proposed regulation will not only
save insurers from the costs associated with suicide, but prevent significant numbers oftransgender insureds from losing their lives.
Additional Benefits
Overall improvements in mental health. Transgender insureds who have access to treatment see
rates of depression drop and anxiety decrease. Evidence supporting this conclusion comes from ameta-analysis of 28 studies showing that 78 percent of transgender people had improved
psychological functioning after treatment.39 In another recent study, transgender women who
had had any relevant surgeries had mental health scores comparable to women in general, while
those who were not able to access care scored much lower on mental health measures.40 In
another study, participants improved on 13 out of 14 mental health measures after receiving
treatments.41 This overall improvement in mental health and reduction in utilization of mental
health services could be a source of cost savings for employers, insurers, and insureds.
Substance abuse rates decline. There are numerous studies that provide evidence that substanceabuse rates decline including one where participants, “describe how substance use was a coping
mechanism for their gender dysphoria before they had access to treatment.”42, 43 Another study
found an overall reduction in substance use after receiving treatment.44
Further, the Sylvia Rivera Law Project suggests that treatment for GID could combat other typesof substance abuse since it is well known that “[i]ncreased smoking and drug and alcohol use
correlates with increased rates of lung cancer, heart disease, stroke, and liver disease.”45
HIV Rates and Care. Transgender people have significantly higher rates of HIV than the general
population (28 percent in a meta-analysis46 as compared to a general population rate of 0.6
percent).47 It is also significant that studies show “high rates of adherence to HIV care for transpeople when combined with hormonal treatment.”48, 49 This is particularly relevant to insurers
because it provides evidence that offering treatment may reduce the long-term costs of treatment
for HIV/AIDS. It is particularly relevant for the welfare of all Californians because, “[w]hen
compliant with care, HIV-positive people stay healthier longer and are far less likely to transmit
the virus to others.”50
Other Benefits. Transgender people who are denied access to treatment and suffer fromdysphoria associated with gender identity disorder sometimes turn to self-medication for relief.
39(Murad M, 2010)(Ainsworth & Spiegel, 2010).
41(Smith Y, 2005)
42(The Sylvia Rivera Law Project, 2011)43(Cole, 1997)
44(Rehman, 1999)
45(The Sylvia Rivera Law Project, 2011)
46(Operario D., 2010)47(United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO), 2007)
48(The Sylvia Rivera Law Project, 2011)49
Grimaldi J; Jacobs J. (1998.) “The HIV/Hormone Bridge, Int Conf AIDS; 12: 981, abstract no. 571/44225.
50(The Sylvia Rivera Law Project, 2011)40

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Silicone injections, for example, are sometimes used in lieu of medically available treatments.
Prevalence of this has been documented in needs assessments in Washington D.C., Chicago, and
Los Angeles, where respondents reported having injected silicone into their bodies at a rate of25, 30, and 33 percent of the time, respectively.51, 52, 53 Construction-grade silicone is used toalter body shape sometimes resulting in deadly consequences.54 Several researchers suggest thatlack of early access to GID treatments and care costs more.
Increased socioeconomic status for transgender insureds. Lack of access to treatment due tocoverage denials also results in a greater likelihood of adverse socioeconomic consequences forthe insured. A single group pre- and post-study demonstrated improvements in socioeconomic
status or employment status in transgender patients after hormonal and surgical treatment. 55
Additional studies conclude that transgender persons have higher employment rates after they
have access to treatments.56
For the reasons cited above, Department staff concluded that ending these four types of
discrimination will cost little or nothing in the short run and may produce longer-term costsavings and improved health benefits for transgender people.

51(Xavier, 2000)(Bostwick, 2001)
53(Reback, Simon, Bemis, & Gatson, 2001)
54(Komenaka, 2004); (Fox, 2004); (Hage, 2001).
55(Bodlund O, 1996)
56(Grant, 2010); (Murad M, 2010); (Rakic, 1996).
52

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Works Cited
Ainsworth, T., & Spiegel, J. (2010). Quality of life of individuals with and without facial
feminization surgery or gender reassignment surgery. Quality of Life Research, 19, 1019–
1024.
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition. Washington, D.C.: American Psychiatric Association.
Baker, A., Kesteren, P. V., Gooren, L., & Bezemer, P. (1993). The prevelence of transexualism
in the Netherlands. Acta Phsychiatrica Scandinavica(87), 237-238.
Bodlund, O., & Gunnar, K. (1996). Transsexualism – General outcome and prognostic factors: A
5 year follow-up study of 19 TSs in the process of changing sex. Arch. Sexual Behavior,
25, 303-316.
Bostwick, W., & Kenagy, G. (2001). Health and social service needs of transgendered people in
Chicago. Chicago: Jane Addams College of Social Work, University of Illinois at
Chicago.
Census Bureau. (2010). Profile of General Demographic Characteristics, California. Retrieved
from Table DP-1: www.census.gov
Centers for Disease Control. (2010). Fact Sheet: The Medical Cost Associated with Suicide in the
United States. Retrieved 2012, fromhttp://www.cdc.gov/ncipc/factsheets/images/Medical_Costs.pdf;
City and County of San Francisco Human Rights Commission, The. (2007). Report on San
Francisco City and County Transgender Health Benefit. San Francisco: The City andCounty of San Francisco.
City of Portland, Oregon. (2011). Mayor Sam Adams. Retrieved fromhttp://www.portlandonline.com/mayor/?a=351892&c=49278
Clements-Nolle, K., Marx, R., & and Katz, M. (2006). Attempted suicide among transgenderpersons: The influence of gender-based discrimination and victimization. Journal of
Homosexuality, 53(3), 53-69.
Cole, C., O'Boyle, M., Emory, L., & Meyer, W. (1997). Co-morbidity of Gender Dysphoria andOther Major Psychiatric Diagnoses. Archives of Sexual Behavior, 26(1), 13-19.
Corso, P., Mercy, J., Simon, T., Finkelstein, E., & Miller, T. (2007). Medical Costs andProductivity Losses Due to Interpersonal and Self-Directed Violence in the United States
32(6) : 474-482. Am J Prev Med, 32(6), 474-482.
De Cuypere, G. E. (2006). Long-term follow-up: psychosocial outcome of Belgian transsexuals
after sex reassignment surgery. Sexologies, 15, 126–133.
Fox, L., Geyer, A., Husain, S., Della-Latta, P., & Grossman, M. (2004). Mycobacterium
abscessus cellulitis and multifocal abscesses of the breasts in A transsexual from illicit
intramammary injections of silicone. Journal of the American Academy of Dermatology,
50, 450.
Freiboth, R. (2012, March 6). Transgender Benefit Insurance Premium Increase Data. (emailcommunication). (C. o. Manager, Ed.) Seattle, WA.
Gorton, R. N. (2011). The Costs and Benefits of Access to Treatment for Transgender People.
Prepared for the San Francisco Department of Public Health, San Francisco.
Green, J., Wilson, A., & Fidas, D. (2011). Transgender Inclusive Health Benefits: Costs,
Medical Models & Best practices. Dallas.

Economic Impact Assessment: Gender Nondiscrimination Regulations

Page 13 of 15

Haas, A., Eliason, M., Mays, V., Mathy, R., Cochran, S., D'Augelli, A., . . . Diamond, G. (2011).
Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review
and recommendations. Journal of Homosexuality, 58(1), 10-51.
Hage, J. (2001). The devastating Outcome of Massive Subcutaneous Injection of Highly Viscous
Fluids In Male to Female Transsexuals. Plastic and Reconstructive Surgery, 734.
Hodgkins, D. (2012, March 15). Transgender Benefit Insurance Premium Increase Data. (emailcommunication). Berkeley, CA: City of Berkeley, Department of Human Resources.
Human Rights Campaign. (2012). Corporate Equality Index 2012. Washington, D.C.: Human
Rights Campaign.
Institute of Medicine of the National Academies. (2011). The Health of Lesbian, Gay, Bisexual,and Transgender People: Building a Foundation for Better Understanding. National
Academies, Board on the Health of Select Populations. Washington, D.C.: The National
Academies Press.
Kaiser Family Foundation, The. (2009). State Health Facts. Retrieved 2011, fromhttp://www.statehealthfacts.org/profileglance.jsp?rgn=6
Komenaka, I. (2004). Free silicone injection causing polyarthropathy and septic shock. The
Breast Journal, 10(2), 160.
Kuiper, M., & Cohen-Kittenis, P. (1988). Sex reassignment surgery: A study of 141 Dutch
transsexuals. Arch Sex Behav, 5, 439-457.
Manning, J. (2012, April). University of California Transgender Benefit Cost and Utilization
Letter. University of California Transgender Benefit Review 2012(email communication).
Oakland, CA, United States: University of California, Office of the President.
Murad, M., Elamin, M., Garcia, M., Mullan, R., Murad, A., Erwin, P., & Montori, V. (2010).
Hormonal therapy and sex reassignment: a systematic review and meta-analysis ofquality of life and psychosocial outcomes. Clinical Endocrinology, 72, 214-231.
Olson, J., Forbes, C., & Belzer, M. (2001, February). Management of the Transgender
Adolescent. Archives of Pediatrics and Adolescent Medicine, 165(2), 171-176. Retrieved
from http://archpedi.ama-assn.org/cgi/content/full/165/2/171
Operario, D., & Nemoto, T. (2010). HIV in Transgender Communities: Syndemic Dynamics anda Need for Multicomponent Interventions. Journal of Acquired Immune Deficiency
Syndrome, 55(2), S91–S93.
Rakic, Z., Starcevic, V., Maric, J., & Kelin, K. (1996). The Outcome of Sex Reassignment
Surgery in Belgrade: 32 Patients of Both Sexes. Archives of Sexual Behavior, 25, 515.
Reback, C., Simon, P., Bemis, K., & Gatson, B. (2001). Los Angeles Transgender Health Study:
Community Report. Los Angeles.
Rehman, J., Lazar, S., Benet, A., Schaefer, L., & Melman, A. (1999). The Reported Sex andSurgery Satisfactions of 28 Postoperative Male to-Female Transsexual Patients. Archives
of Sexual Behavior, 71.
Smith, Y., Van Goozen, S., Kuiper, A., & Cohen-Kettenis, P. (2005). Sex Reassignment:
Outcomes and Predictors of Treatment for Adult and Adolescent Transsexuals.
Psychological Medicine, 35, 89-99.
Spade, D., Arkles, G., Duran, P., Gehi, P., & Nguyen, H. (2010). Medicaid Policy & GenderConfirming Helathcare for Trans Prople: An Interview with Advocates. Seattle Journalfor Social Justice, 8(2), 497-514.

Economic Impact Assessment: Gender Nondiscrimination Regulations

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Sylvia Rivera Law Project, The. (2011). Eliminating the Medicaid Exclusion for TransitionRelated Care in NYS: Good Public Health, the Right Thing to Do and Ultimately a CostSaving Measure. New York: Sylvia Rivera Law Project.
Tannis, J., Grant, J., & Mottat, L. (2010). Injustice at Every Turn: A Report of the National
Transgender Discrimination Survey. Washington, D.C.: National Center for Transgender
Equality and National Gay and Lesbian Task Force.
Transgender Law Center. (2008). The State of Transgender California: A report on the 2008
California Transgender Economic Health Survey. San Francisco: The Transgender Law
Center.
United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO).
(2007). AIDS Epidemic Update. Retrieved fromhttp://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.
Wilson, A. (2012). Transgender-Inclusive Health Benefits: Costs, Data for Cost Calculation.
Jamison Green and Associates.
World Professional Association for Transgender Health, The. (2011). Standards of Care for the
Health of Transexual, Transgender, and Gender Nonconforming People, 7th ed. The
World Professional Association for Transgender Health.
Xavier, J. (2000). The Washington Transgender Needs Assessment Survey. Washington, D.C.:
The Administration for HIV and AIDS of the District of Columbia Government.
Yang, B., & Lester, D. (2007). Recalculating the Economic Cost of Suicide. Death Studies, 31,
351–361.
Zucker, K., & Lawrence, A. (2009). Epidemiology of Gender Identity Disorder. International
Journal of Transgenderism, 11(1), 8-18.

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