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Serving Transgender Victims of Sexual Assault
Message From the DirectorAbout This Guide
Transgender 101Sexual Assault in the Transgender CommunityTips For Those Who Serve Victims
June 2014
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Standard Practices

Insurance and Financial Matters

Compared to the general population, transgender individuals are more likely to be uninsured or underinsured and unemployed or underemployed. Insurance disparities are often the result of joblessness and poverty related to discrimination.39 The number of transgender individuals who are uninsured ranges from 19 to 64 percent.40

Transgender individuals who are insured may be concerned about the transgender exclusions of many health insurance policies. These exclusions systematically deny care related to being transgender and are sometimes used to justify not covering any care, even when the condition needing treatment is not related to a transgender-specific medical or mental health concern. In 2011, the University of California's Department of Family and Community Medicine released a protocol on primary care for transgender patient care that concisely reviews some key concerns related to insurance billing and medical records.41

When a transgender person's insurance does cover medical care, the coverage may be so minimal that the person fears exhausting their insurance benefits before their health needs are met, or the care may involve copayments and high out-of-pocket costs that they cannot afford.

In some cases, transgender people choose to self-pay rather than processing claims through insurance companies. Paying out of pocket allows for privacy and allays concerns or fears that transgender histories will be disclosed to employers or others. However, many transgender individuals—just as many non-transgender people—cannot afford the high cost of health care, which may discourage or prohibit transgender victims from seeking care after a sexual assault.

Depending on the service you are providing, you may or may not need to know about a transgender victim's insurance or financial status.

Implications and Actions for ...

Health Care Providers

It is not uncommon to see transgender patients who are overdue for medical care or who have been living with a condition or infection for a long time because they were unable to seek care sooner. In many cases, this is due to insurance and related financial issues.

Having a nonjudgmental attitude toward all patients, and overtly expressing an understanding that many factors play a role in when and how someone initiates medical care, may put transgender patients at ease and help them feel less shame and self-blame about delaying medical care. Phrases such as "I'm glad you came to see me today" let transgender patients know that you are willing and able to accept them where they are, when they are able to walk through the door.

If the patient has insurance and decides to use it, it is vitally important to select an accurate and carefully chosen International Classification of Diseases (ICD) code. Accurate diagnoses are important for all patients but may be especially so for transgender patients.

When unsure of how to proceed with billing, engage the transgender patient in the process and work together to decide the best course of action. Additionally, be conscientious when preparing clinical notes that include transgender-related content, and be mindful about using either preferred or former names in official medical records. If a transgender patient's insurance policies are in another name, ask the patient for clarification and confirmation when needed.

For patients who are uninsured or underinsured and have limited incomes, consider offering sliding scale rates, payment plans, pro bono services, or assistance in enrolling in public insurance options. You may have to discuss these options first with your billing specialist, who may direct patients to social or case workers for help with payment arrangements. If these alternatives are unavailable, be prepared to offer referrals to local providers and services that offer transgender-inclusive care at reduced or no cost. Connecting with a local transgender group may yield referrals to these providers and services (see Outreach in this e-pub); if you cannot identify any local groups, contact the nearest LGBT community center. Looking online may also be a useful source for referrals; screen the providers you find, however, to ensure that their information is accurate and try to find out if they actively work with transgender individuals.

The cost of medication may also be an issue for uninsured, underinsured, or low-income clients. Even if a transgender patient has health insurance, it may not cover medications. Frequently, low-income patients leave a health care providers' office with a prescription in hand but will never fill it due to lack of funds. Whenever possible, offer patients medically appropriate, free drug samples or starter kits for medication or prescribe medications that are available in generic brands.

Emergency Medical Personnel

As a first responder, you may need to know a patient’s insurance or financial status. For example, they may be concerned about how they will pay for an ambulance ride to the hospital or may strongly oppose being taken to a hospital or other care facility.

A calm, informing presence can help them understand how necessary it is for them to go to the hospital or to see a physician. Consider sharing information about programs that will help patients pay health care costs, or refer them to agencies or advocates that can provide that information, to help ease their immediate financial concerns.

As always, be careful, accurate, and detailed when reporting on the patient’s medical condition. An accurate and detailed report increases the likelihood that the patient will qualify for victim compensation, if other requirements are met.

Law Enforcement

As a law enforcement officer, you may need to know a victim's insurance or financial status. For example, victims may be concerned about how they will pay for an ambulance ride to the hospital or may strongly oppose being taken to a hospital or other care facility.

A calm, informing presence can help them understand how necessary it is for them to go to the hospital or to see a physician. Consider sharing information about programs that will help victims pay health care costs, or refer victims to agencies or advocates that can provide that information, to help ease their immediate financial concerns.

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As always, be careful, accurate, and detailed in your report about the crime. An accurate and detailed crime report increases the likelihood that the victim will qualify for victim compensation, if other requirements are met.

Advocates

When transgender individuals seek health care, they may be unfairly expected to educate their health care professionals about being transgender before being able to receive care. In a time of crisis, this can be especially challenging. A provider's lack of knowledge about transgender health care and insurance exclusions further complicates the situation.

If the victim decides to release health care insurance information to a provider, sensitively and privately ask the victim to consider what gender is on file with the insurance company, how the victim would like to have any gender-linked procedures handled (e.g., pregnancy tests, cervical pap smears), and whether these procedures should be billed to the insurance company or paid for privately or through another public source. Ideally, you would want to have this conversation with the victim before information is released to the insurance provider. Having specific information readily available about alternate sources of payment helps to increase the likelihood that victims will seek care, that the services they receive will meet their needs, and that the care will be delivered appropriately.

Therapists

When mental health care is covered as a part of an insurance plan, the coverage may be minimal or for short-term treatment only. Clients are often concerned about running out of coverage before they reach their mental health goals. Transgender clients who are medically transitioning may feel additional financial pressure because they may be required to see a therapist before the transition. Many of these survivors segment their mental health care—one therapist for trauma, one therapist for gender-related issues—which increases the financial burden.

If the client has insurance and decides to use it, it is vitally important to select an accurate and carefully chosen Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Disease (ICD) code. Accurate diagnoses are important for all clients but may be especially so for transgender clients.

In general, survivors who are in therapy are usually not in treatment for their gender identity, but rather are working on the trauma, grief, anger, depression, sleep disruption, or loss associated with the sexual violence they experienced. Use the code that best applies to the disorder you are treating (e.g., adjustment disorder, anxiety). When unsure of how to proceed with billing, engage the transgender client in the process and work together to decide the best course of action. Additionally, be conscientious when preparing clinical notes that include transgender-related content, and be mindful about using either preferred or former names in official records. If a transgender client’s insurance policies are in another name, ask the client for clarification and confirmation when needed.

For clients who are uninsured or underinsured and have limited incomes, consider offering sliding scale rates, payment plans, pro bono services, or assistance in enrolling in public insurance options. You may have to discuss these options first with your billing specialist, who may direct clients to social or case workers for help with payment arrangements. If these alternatives are unavailable, be prepared to offer referrals to local providers and services that offer transgender-inclusive care at reduced or no cost. Connecting with a local transgender group may yield referrals to transgender-inclusive therapists who may offer lower cost care or culturally competent free clinics (see Outreach in this e-pub); if you cannot identify any local groups, contact the nearest LGBT community center. Looking online may also be a useful source for referrals; screen the therapists you find, however, to ensure that their information is accurate and try to find out if they actively work with transgender individuals.

Support Group Facilitators

Transgender individuals who are insured have many of the same concerns about insurance benefits as non-transgender people. Insurance companies often have limited mental health benefits, and clients are often concerned about running out of coverage before they reach their mental health goals. If a transgender individual in your group has insurance and decides to use it, it is vitally important to select an accurate and carefully chosen diagnostic code. Accurate diagnoses are important for all clients, but may be especially so for transgender clients.

Many insurance companies are noticing perceived discrepancies in what the insured individual is eligible for and which services they are receiving. If your support group is segregated by gender, for example, and a client's insurance coverage is under a gender not included in that group, the insurance company may deny payment and may even drop other types of medical coverage.

Many transgender people experience employment discrimination or they work in low-paying jobs, and a substantial number do not have health insurance and also do not have enough income to pay for services out of pocket.1 For clients who are uninsured or underinsured and have limited incomes, consider offering sliding scale rates, payment plans, pro bono services, or assistance in enrolling in public insurance options. You may have to discuss these options first with your billing specialist, who may direct clients to social or case workers for help with payment arrangements. If these alternatives are unavailable, be prepared to offer referrals to local providers and services that offer transgender-inclusive care at reduced or no cost. Connecting with a local transgender group may yield referrals to these providers and services (see Outreach in this e-pub); if you cannot identify any local groups, contact the nearest LGBT community center. Looking online may also be a useful source for referrals; screen the providers you find, however, to ensure that their information is accurate and try to find out if they actively work with transgender individuals.

In some circumstances, transgender survivors may benefit from simply connecting with other transgender individuals and their loved ones at support groups that do not focus on sexual assault. All states have transgender support groups of some kind; see FORGE's Web site for a support group directory.

1. J.M. Grant, L.A. Mottet, J. Tanis, J. Harrison, J.L. Herman, and M. Keisling, 2011, Injustice at Every Turn: A Report of the National Transgender Discrimination Survey, Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force, accessed June 18, 2013.