Cost of health care for people who are transgender and economic cost of homophobia

The Economic Cost of Homophobia: How LGBT Exclusion Impacts Development: World Bank Live

As I continue research for speaking at the 2nd Annual Kaiser Permanente LGBTQI Health Symposium on being a trans person ally and unconscious bias, I am preparing a reflection of the various things people have said and say to me.

One of the most common is: “Ted, this care (for people who are transgender) is very expensive.”

This is a pervasive misperception, unlinked to actual data and probably linked to bias.

This was really driven home for me when I was peer reviewing a medical school LGBT curriculum – the only slide in a 80+ slide deck that had any cost numbers on it was the one that covered transgender person health care. There were no cost numbers on any of the slides covering HIV care, depression, or any other health challenge faced by LGBT people.

I was very intrigued, then, when the World Bank produced a panel on The Economic Cost of Homophobia: How LGBT Exclusion Impacts Development | World Bank Live. The response to the statement, “this care is expensive,” is a well-reasoned, “so is homophobia.”

I’ve embedded the presentation below and noted:

1. The data

  • Homophobia (which includes transphobia) does have costs associated with it, estimated at up to 1.7% of the GDP of India (where good data exists)
  • The costs are in areas that often not accounted for by the health system and include, behavioral health, lost productivity/wages, overall disability and lost lives from suicide and other medical conditions.
  • In a Google survey of its consumers, a significant percentage (in the 50% range) of people of all ages report concern about their career development based on their LGBT status
  • The Google data also reveal a higher than expected percentage of the population who are LGBT using a novel query of searches for pornography – This percentage, in the 5% range, is generally the same in all of the United States (except DC, where the percentage of these searches is 10%) despite Gallup numbers that record LGBT “identification” with wide variation in our States.

2. “a discussion that, to be frank, met more consistent internal resistance than I ever expected.” 

This is what session chair Fabrice Houdart (@Homophobiacosts) said at about 9:07 in the presentation, and I immediately knew what he was referring to. Sometimes allies find themselves working to educate organizations that behave in ways to deny that the world is changing around them. I noticed that Qing Wu, the presenter from Google, does not have diversity in his job description, maybe he would classify himself as an ally as well.

I’m careful to say the word “behave” rather than “believe,” because this is where implicit bias comes in.

What we are all united by is the belief, as Fabrice also says, “Prejudice destroys promise and economic opportunities.” Of course health is intimately tied to that, and it is the health professionals in society who should be leaders in producing health by eliminating bias.

Enjoy the panel discussion below, beneath it I’ll link to useful data about the value of transgender person health.

Is the care of people who are transgender expensive? A look at the facts

Cost of coverage: negligible

  • San Francisco  – “The city dropped the surcharge (for transgender person health care) altogether because the cost was de minimus – or so small as to be neglibile.”
  • Portland – Only 0.08% of its health care insurance budget
  • Multnomah County – “low utilization”
  • United Kingdom – 47 years of experience – most patients do not pursue surgery, I was given a figure of between 4,000 – 6,000 British Pounds per case, far less than treatment for hypertension over a lifetime. This is in the most permissive health system in the world, from a coverage perspective – see Visiting the oldest Gender Identity Clinic in the World: NHS’ Charing Cross, London England | Ted Eytan, MD
  • State of California – Economic Impact Assessment – Gender Nondiscrimination (via Transgender Law Center @translawcentersee the full report here) – very exhaustive literature review by actuaries concluding that “While insurers may use someone’s health status to determine their premium, analysis of the potential increase in claim costs from the proposed regulation shows that any such costs are immaterial and insignificant.”

The coverage information is compiled together here as well: The Benefits of Equality toolkit : Basic Rights Oregon

Cost of complications of uncovered care: significant

Even if an insurance policy excludes transgender person health care, it includes care for complications for care received that is purchased out of pocket. So any infections or other potentially life threatening events that occur when a person travels to receive medically necessary care, are fully covered, including intensive care, emergency rooms, etc.

Cost of care required to compensate for unreceived, but covered care: significant

I have not seen any studies on this, however, it can be inferred that a person who is excluded for care because of their identity is also likely to receive less preventive care and other life preserving/saving treatments. I would argue that a study doesn’t need to be done to verify this, any more than doing a study to show that any protected class routinely excluded from the health system will have worse health outcomes. We already know this to be the case.

Cost to society of homophobia: significant – see above 🙂

Comments/questions welcome.


Ted Eytan, MD