Gender affirmation coverage a win for diversity: Experts

Extended health benefits support transitioning workers

Gender affirmation coverage a win for diversity: Experts
The transgender pride (left), pride (centre) and Canada 150 pride flags fly on Parliament Hill in Ottawa on June 14, 2017. Credit: REUTERS/Chris Wattie

Transgender rights and issues continue to gain prominence in Canada.

Except for the Northwest Territories and Nunavut, all Canadian jurisdictions now provide public health insurance coverage for gender or transition-related medical procedures, though most plans only cover the basic surgical procedures for transitioning.

In April, Sun Life began offering extended health coverage to plan members for surgical procedures not covered under the public plans, such as surgeries that feminize or masculinize an individual’s features, according to Marie-Chantal Côté, vice-president of market development at Sun Life Financial Canada in Montreal.

“There can be a significant impact on an individual’s mental, emotional and physical well-being when they do not feel connected to their gender,” she said. “Gender affirmation procedures and hormone therapies can help a person feel empowered to align their body with their gender expression.”

And there is growing interest from Canadian employers for this type of coverage, said Côté.

“Everyone’s needs are unique when it comes to health and wellness, so we continue to evolve and diversify our health benefit plans in order to help meet the diversity of Canadians.”

Supporting a diverse workforce

The move comes at a time when trans individuals are highly underemployed, according to Preston Parsons, employment lawyer at Overholt Law in Vancouver.

“(It’s) a great change to hopefully continue to increase the societal awareness, and change norms and stigma with respect to trans people in the workplace,” he said.

“People have been having gender affirming surgeries for some time. Some people have been doing it on their own dime, and now that that coverage is available, those employers will be more attractive to trans individuals.”

Many transitioning Canadians have already spent thousands of dollars on gender affirmation journeys, said Elizabeth Saewyc, executive director at the Stigma and Resilience Among Vulnerable Youth Centre and nursing professor at the University of British Columbia in Vancouver.

“Having an additional insurance with work that does provide some of those necessary surgery supports or… partially supports some of those out-of-pocket expenses is really something that seems quite beneficial,” she said. “It really is a benefit to have that kind of support.”

“Equally important is the message that it sends from employers to their employees. This coverage says, ‘We recognize and value you and your health care is also important to us.’”

Employers offering gender affirmation benefits could see better health outcomes amongst staff along with increased work attendance and less time lost to sick days, said Saewyc.

“Getting one’s health care taken care of and making it accessible and affordable certainly tends to be really good for employers,” she said.

“By providing this sort of coverage as part of the insurance package that an employer is offering to their employees, it says, ‘We take equity seriously. We recognize that your health needs are important.’”

Offering gender affirmation benefits will make for more diverse and inclusive workforces, said Parsons.

“Knowing that the insurer is going to approve gender affirming surgeries makes it an attractive recruitment and retention policy, certainly for employers that would be at risk of losing somebody to a like organization simply on that basis.”

While employers won’t have legal obligations to add the coverage to benefits plans, many will as a recruitment and well-being perk, he said.

“Those type of policy decisions over what is insured, and what’s not insured are difficult. It would be pretty difficult to advance a case on the basis of liability for not paying for the additional coverage in the plan.”

Coverage costs will vary, according to Côté.

“It’s quite complicated to just state a cost because it varies by group, by demographic, by funding type, by benefit maximum.”

The benefit works in a similar fashion to other extended health-care options, with annual and lifetime maximums set by plan sponsors, she said.

In conjunction with the person’s provincial or territorial health-care plan, Sun Life’s core coverage will reimburse some procedures not covered by their place of residence.

And as each transition journey is unique, so is the recovery process, said Côté.

With that in mind, there is no general recovery timeline associated with coverage, though plan sponsors are encouraged to talk to employees to determine appropriate timelines for a safe return to work, she said.

Additionally, recovery time depends on the type of surgery, which can include several procedures, said Saewyc.

“There are a number of different kinds of surgeries depending on the needs of the particular person, depending on their gender and transitions, whether we’re talking about chest surgery, top surgery, bottom surgery, facial reconstruction or other kinds of things,” she said. “Each of those surgeries may have very different recovery times.”

Coverage for psychological and mental health issues associated with gender affirmation journeys are already available through various other benefits, said Côté.

“We know that mental, emotional and physical well-being could be part of the areas that tie into not feeling connected to one’s gender.”

Advice for HR

The gender affirmation benefit offering provides an opportunity for employers to reflect, according to Parsons.

“Whether you’ve got the coverage or not, it’s a timely topic for employers and particularly senior HR staff to be having a conversation about and training people with respect to.”

Even without providing the coverage, an employer may need to go through the process of having an employee transition by using personal funds, he said.

And pressure on plan sponsors could increase when employees begin to understand their insurance carrier provides gender affirmation coverage, said Parsons.

“That’s just the natural if-you-build-it, they-will-come kind of deal. If that’s the case, HR professionals need to be aware that there’s important privacy requirements under privacy law, and depending on the province you’re in, there’s different legislation.”

While medical procedures typically are highly confidential, broader communication with staff could be preferred by a transitioning employee.

HR must be mindful to handle each situation with sensitivity, said Parsons.

For example, in the absence of gender-neutral washrooms, accessibility policy should be addressed.

And if human resources is updating respectful workplace policies, it is appropriate to make mention of expanded grounds under human rights codes — including protection for expressed gender identity and gender expression, he said.

There are workplace guides on how to respect preferred pronouns, navigate transitions, and respect confidentiality, said Saewyc.

“A lot of times, people haven’t necessarily given a lot of thought to it, or if they haven’t encountered a lot of gender diverse people in their lives, they may not know how to actually provide a respectful, inclusive environment,” she said.

“Obviously, the privacy and confidentiality around health-care coverage and health-care issues is just as important for these kinds of health issues as it is for cardiac bypass surgery or cancer.”

And while the additional benefits are a step forward, more work still needs to be done. Employers valuing diversity could encourage organizational audits, or form focus groups that help keep workplace policy up to date on minority issues, said Saewyc.

“In our society, although we are making great progress in paying attention to equity and diversity, there’s always ways that we can up our game,” she said.

“There’s definitely more that we can do to create environments that support and recognize and celebrate the diversity of our workforces.”

However, as many employers do a benefits review annually, it may take some time for this benefit to be added to many plans, said Parsons.

“As part of standard operation, most companies aren’t tweaking them throughout the year.”

Cost will also be a factor for plan sponsors, though an inability to provide coverage does not mean HR professionals are not required to gain training and understanding about workplace procedures in this area, he said.

“People will still go and get it done,” said Parsons. “And so just having that conversation is important and being prepared... if somebody comes to HR and says, ‘Look, I’m transgender. I’m looking to transition. I’m going to be taking part in this surgery.’”

“Knowing that this request could come to your desk, it’s good to be educated about how to go about a plan about keeping that information confidential and on a need-to-know basis.”


Expenses reimbursed

Sun Life’s offering will provide financial support to plan members by reimbursing expenses covered by their workplace plan. Employers can offer two types of coverage:

•core coverage: For basic surgical procedures not covered under the individual’s provincial or territorial health-care plan (for example: reduction of the Adam’s apple or voice surgery)

•enhanced coverage: For surgical procedures to align feminine or masculine features to the transitioned gender, such as facial bone reduction or cheek augmentation.

Procedures that would fall under Sun Life’s core and enhanced gender affirmation coverage include:


• remove or create penis and testicles

• remove or create vagina, clitoris, labia

• augment or remove breasts 

• shave Adam’s apple 

• voice surgery

• remove uterus, ovaries, fallopian tubes

• add penile/testicular implants

• create scrotum.


• facial bone reduction (brow and jaw), eye lift, face lift, rhinoplasty

• lipofilling, gluteal implants

• liposuction/contouring of the torso/waist

• hair reconstruction

• facial bone reconstruction (brow, chin)

• cheek augmentation.

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