Report

Healthcare Equality Index 2020

Promoting Equitable and Inclusive Care for Lesbian, Gay, Bisexual, Transgender & Queer Patients and Their Families

Published by the HRC Foundation, 2020

Healthcare Equality Index 2020

Table of Contents
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To the Heroes on the Frontlines of COVID-19: We Are With You!

To our Heroes on the Frontlines,

In the early days of the AIDS epidemic, many of you were among our only allies — LGBTQ and allied doctors, nurses, researchers and others who took care of us when no one else would. Over the years, more and more of you have come to provide essential affirming care for transgender people. You've worked with LGBTQ youth in crisis and with older LGBTQ communities in transition. As we note each year in HRC Foundation’s Healthcare Equality Index (HEI), facilities across the country are becoming more inclusive to LGBTQ folks…and that’s certainly because of the work you do.

Today, you're on the frontlines of this epidemic. You're the support staff in the hospitals. You're the first responders and home health care workers. You're health care providers wearing homemade masks. Many of you aren't even making it home each night, and for those who are, you're isolating yourself in other rooms, not able to hug your spouses or kids. You're putting your lives on the line for all of us.

We're taking this pledge to do everything we can to bring an end to COVID-19. We'll stay at home. We'll wash our hands. We'll social distance. And we'll encourage others to do the same.

You’ve been there for us, and now we want you to know that the LGBTQ community is with you. You're putting your lives on the line and we want you to know we thank you. We see you. And we are with you.

Nearly 5,000 of HRC’s members and supporters signed on to this statement in mid-April. Close to 1,000 of them also shared their own messages of gratitude and thanks. Throughout this report you will see quotes from the HRC community thanking our healthcare heroes.


Message from the President

“From the previously unimaginable impact of the COVID-19 pandemic to the horrific incidents of racial violence targeting the Black community, the events of the past year have brought about so much pain and uncertainty. Yet, even during this moment of profound unrest, we are seeing more of our humanity and resilience come to life. For me, nowhere is that more true than through the tireless dedication of our healthcare providers and the intrepid support and administrative staff members by their sides that show up every day to ensure this life-saving work continues. The healthcare facilities participating in the HRC Foundation’s Healthcare Equality Index (HEI) are not only on the front lines of the COVID-19 pandemic, they are also making it clear from their participation in the HEI that they stand on the side of fairness and are committed to providing inclusive care to their LGBTQ patients. In addition, many have made strong statements on racial justice and equity and are engaging in efforts to address racial inequities in their institutions and their communities. We commend all of the HEI participants for their commitment to providing inclusive care for all.”

Alphonso David

Why the HEI?

The Human Rights Campaign Foundation developed the Healthcare Equality Index to meet a deep and urgent need on the part of lesbian, gay, bisexual, transgender and queer Americans: the need for equitable, knowledgeable, sensitive and welcoming health care, free from discrimination. No one facing health concerns should also have to worry about receiving inequitable or substandard care because of their LGBTQ status.

To prevent experiences like these...

When I walked toward the women’s bathroom in the waiting area, the receptionist jumped up and told me to use a McDonald’s restroom down the street. I felt like leaving and never going back.

- A transgender woman waiting for her first physical in years

After I mentioned that my husband would be visiting me, the staff, who had been very friendly, turned very cool — and I saw a lot less of them, even when I really needed help.

- A gay man hospitalized for a lung condition

I couldn't believe it! As I walked back to see my partner and our newborn, an employee stopped me and asked who I was. When I said ‘the other mom,’ she rolled her eyes and walked away saying, ‘I don’t believe this.’

- A lesbian mother after the birth of her first child

Yet many LGBTQ Americans experience these challenges when seeking health care, which can intensify whatever worries they may have about their health. In Lambda Legal’s landmark study, When Health Care Isn’t Caring, 73% of transgender respondents and 29% of lesbian, gay and bisexual respondents reported that they believed they would be treated differently by medical personnel because of their LGBTQ status. Equally disturbing, 52% of transgender respondents and 9% of lesbian, gay and bisexual respondents reported that they believed they would be refused medical services because of their LGBTQ status.*

When asked why they had such concerns, more than half of all respondents reported that they had experienced at least one of the following types of discrimination from healthcare providers: refusing to provide needed care, refusing to touch them or using excessive precautions, using harsh or abusive language, blaming them for their health status, or being physically rough or abusive. Transgender and gender non-conforming people are particularly vulnerable: 70% of transgender and gender non-conforming respondents reported at least one of these experiences. Fifty-six percent of lesbian, gay or bisexual respondents reported at least one of these experiences.

The HEI exists because the HRC Foundation believes that most of American healthcare facilities do not want LGBTQ individuals in their communities to have — or to worry about having — these kinds of experiences. But facilities are often unsure how to protect their LGBTQ patients from discrimination, provide them with optimal care and extend a warm welcome to allay their concerns.

The HEI was developed to give healthcare facilities the information and resources they need to ensure that LGBTQ people have access to truly patient-centered care. HRC also uses this report to applaud the facilities that have shown their commitment to LGBTQ patient-centered care by taking the HEI survey and to award those facilities that receive the top score in the survey the coveted designation of “LGBTQ Healthcare Equality Leader.” During the past decade, the HEI has become even more relevant and useful. In 2011, The Joint Commission issued a standard that required accredited facilities to include sexual orientation and gender identity in their non-discrimination policies, thus extending vital protection to LGBTQ patients.**

In another giant step toward LGBTQ equality in healthcare, both The Joint Commission and the federal Centers for Medicare and Medicaid Services now require that facilities allow visitation without regard to sexual orientation or gender identity.*** Additionally, Section 1557 of the Affordable Care Act prohibits sex discrimination in any hospital or health program that receives federal funds. Federal courts have determined that this prohibition extends to claims of discrimination based on gender identity and sex stereotyping. Additionally, the Supreme Court of the United States ruled in Bostock v. Clayton County that a corollary statute that prohibits discrimination on the basis of sex must be understood to also prohibit discrimination on the basis of sexual orientation and gender identity.

The HEI offers healthcare facilities a powerful way to affirm that they comply with these requirements and are committed to LGBTQ patient-centered care. The HEI also urges facilities to extend non-discrimination protections to their LGBTQ employees, who play a key role in ensuring sensitive, knowledgeable LGBTQ care.

Equally important, the HEI offers all participating facilities expert training in LGBTQ healthcare needs, recognizing that staff education is critical to the success of any policy. Facilities may enroll as many staff as they would like in free, online training, that has been widely hailed as groundbreaking and invaluable.

In short, the HEI offers healthcare facilities unique and powerful resources for providing the care everyone deserves to a long-overlooked group of patients, while also complying with new regulatory requirements and receiving access to high-quality staff training.

If you are affiliated with an HEI-participating facility, the HRC Foundation extends its deepest thanks for your commitment to LGBTQ patient-centered care. And if you are affiliated with or know of healthcare facilities not yet engaged with the HEI, we hope you will bring this report to their attention. We are confident that they will thank you for informing them about this vital resource for ensuring high-quality health care for LGBTQ Americans.

* When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV. New York: Lambda Legal, 2010. Available at: http://www.lambdalegal.org/publications/when-health-care-isnt-caring

** See RI.01.01.01 EP 29, Comprehensive Accreditation Manual for Hospitals, Update 1, January 2011 and Comprehensive Accreditation Manual for Critical Access Hospitals, Update 1, January 2011.

***See RI.01.01.01 EP 28, Joint Commission manuals referenced above and Code of Federal Regulations 42 C.F.R. § 482.13(h) (for hospitals) and 42 C.F.R. § 485.635(f) (for critical access hospitals).

Executive Summary

The Human Rights Campaign Foundation's Healthcare Equality Index continues to show incredible growth in the number of healthcare institutions that are embracing and adopting LGBTQ-inclusive policies and practices. A record 765 healthcare facilities actively participated in the HEI 2020 survey.

The HEI began transforming healthcare for LGBTQ people in 2007 when the first report contained 10 recommendations for healthcare facilities to be more welcoming and inclusive of LGBTQ patients and families. Those recommendations included four foundational elements of LGBTQ patient-centered care: an LGBTQ-inclusive patient non-discrimination policy, an LGBTQ-inclusive visitation policy, an LGBTQ-inclusive employment non-discrimination policy, and staff training in LGBTQ patient-centered care. In 2016, HEI-participating facilities began demonstrating near-perfect levels of adoption of the first three foundational elements, which has continued in subsequent years. In addition, 92% of this year’s participants met our staff training requirement. The HEI recorded more than 150,000 hours of training in LGBTQ patient-centered care provided to the staff at HEI-participating facilities.

In addition to active survey participants, the HRC Foundation proactively researched the key policies at over 1,000 non-participating hospitals. Unfortunately, the adoption rate at these researched hospitals stands in stark contrast to the near-perfect adoption by active participants.

Among the researched hospitals in which we were able to find or obtain enumerated patient non-discrimination policies, only 67% have policies that include both “sexual orientation” and “gender identity,” and only 63% were found to have an LGBTQ-inclusive employment non-discrimination policy. The equal visitation policy, at 93%, is the only one that comes close to matching the rate of the participating facilities.

This year marks the fourth year that HEI participants were given a score based on how many LGBTQ-inclusive policies and practices they have in place in four different criteria. The first criteria consist of the foundational elements of LGBTQ patient-centered care. The three remaining criteria are Patient Services and Support, Employee Benefits and Policies, and Patient and Community Engagement. In addition, this is the second year that participants had to demonstrate that they offered transgender-inclusive healthcare benefits to their employees to receive a score of 100 points and earn HRC’s coveted “Leader in LGBTQ Healthcare Equality” designation. An impressive 495 participants met this higher standard.

Another 193 facilities earned the “Top Performer” designation for scoring from 80 to 95 points. With 90% of participating facilities scoring 80 points or more, healthcare facilities are going beyond the basics when it comes to adopting policies and practices in LGBTQ care.

As this overview of the HEI 2020 indicates, diverse healthcare facilities across the U.S. are making tremendous strides toward LGBTQ patient-centered care. In unprecedented numbers, they are changing key policies, implementing best practices and training their staff.

We heartily applaud all the facilities that participate in the HEI and make a commitment to LGBTQ patient-centered care. We also encourage healthcare facilities that have yet to participate in the HEI to use this unique and invaluable resource to enhance LGBTQ care and signal their commitment to LGBTQ equity and inclusion. The HRC Foundation looks forward to welcoming them to the HEI in future years — and helping them extend a warm welcome to LGBTQ Americans.

By The Numbers

HEI Participants at a Glance

765 Participants

495 Leaders / 65%

193 Top Performers / 25%

370 Teaching Hospitals

35 Pediatric Hospitals

41 Faith-Based Hospitals

Participants include more than 120 different non-profit, for profit, and public health systems/Systems with 10 or more participating facilities:

The First Half of 2020 in Review

Every year, we recognize the healthcare facilities that participate in the HEI for their dedication and commitment to LGBTQ inclusion. This year, however, we must also extend our deepest gratitude to these facilities for their courageous fight against COVID-19 and their commitment to addressing racism and injustice.

As the final HEI surveys were submitted in March, healthcare facilities were kicking into overdrive to meet the challenges of COVID-19. Many faced a lack of equipment, staffing shortages and surging demand unlike anything they’d ever seen. Two months later, as the fight against COVID-19 continued, George Floyd’s murder by police officers thrust America’s structural racism into the spotlight. Mass protests followed, ignited by Floyd’s murder and those of Ahmaud Arbery, Elijah McClain, Breonna Taylor, Tony McDade, Rayshard Brooks and far too many others. Healthcare facilities, like many Americans, grappled with how they could help address an issue that has plagued our country for hundreds of years.

HEI participants issued strong statements on racial justice and equity, participated in White Coats for Black Lives demonstrations, and announced new programs to address racial inequities in their institutions and their communities. We hope that these efforts reflect long-standing commitments to dismantling the structural racism that threatens the health and well-being of so many in our community.

Though only halfway through 2020 at the time of this report’s publication, it’s easy to feel that this year has lasted forever. As both new and existing challenges continue to affect the work of healthcare facilities, we extend our thanks to the HEI 2020 participants for their continued commitment and courage during this unprecedented time.

COVID-19 and the LGBTQ Community

LGBTQ people are more vulnerable to the risks of COVID-19 than their peers. Research by the HRC Foundation shows that LGBTQ people are less likely to have health coverage and more likely to smoke, be asthmatic and have a variety of chronic illnesses. LGBTQ people are also more likely to work in sectors highly affected by the virus, including those with greater exposure and/or higher economic sensitivity to the COVID-19 crisis.*

LGBTQ people of color in particular have been disproportionately impacted by COVID-19, according to research by the HRC Foundation and PSB Research. Compared to their white LGBTQ counterparts, LGBTQ people of color are more likely to have become unemployed, reduced their work hours, or asked for delays in rent or other bills during the pandemic.**

Unfortunately, it is impossible to calculate the full impact of COVID-19 on the LGBTQ community and LGBTQ people of color because sexual orientation and gender identity (SOGI) data is not consistently collected during testing. In April 2020, HRC joined over 170 organizations in signing an open letter to health and policy leaders urging providers and public health authorities to collect SOGI data in addition to data on race, ethnicity, age, sex and disability. This step is essential to better document and address the pandemic’s impact on minority communities.***

For more on HRC’s work on COVID-19 visit hrc.org/resources/covid-19.

* Human Rights Campaign Foundation, The Lives and Livelihoods of Many in the LGBTQ Community Are at Risk Amidst COVID-19 Crisis, 2020.

** Human Rights Campaign Foundation and PSB Research, The Impact of COVID-19 on LGBTQ Communities of Color, 2020.

*** National LGBT Cancer Network and Whitman-Walker, Second Open Letter & Press Release, 2020, https://cancer-network.org/coronavirus-2019-lgbtq-info.

HEI 2020 LGBTQ Healthcare Equality Leaders

This year marks the fourth year that HEI participants were given a score based on how many LGBTQ-inclusive policies and practices they have in place in four different criteria. The first criteria consist of the foundational elements of LGBTQ patient-centered care. The three remaining criteria are Patient Services and Support, Employee Benefits and Policies, and Patient and Community Engagement. In addition, this is the second year that participants had to demonstrate that they offered transgender inclusive healthcare benefits to their employees to receive a score of 100 points and earn HRC’s coveted “LGBTQ Healthcare Equality Leader” designation. An impressive 495 (65%) of HEI participants met this higher standard and earned the LGBTQ Healthcare Equality Leader designation.

This list features the 495 HEI 2020 LGBTQ Healthcare Equality Leaders. In addition to being celebrated in the HEI report, LGBTQ Healthcare Equality Leaders receive a special logo and a toolkit of resources for outreach to LGBTQ residents in their service area.

Healthcare Facilities by State

Findings

The Healthcare Equality Index 2020 asked participants a series of questions about LGBTQ-inclusive policies and practices. Those questions are divided into four criteria outlined in more detail in Appendix A beginning on page 52. Responses to the criteria are reported in aggregate in the following pages to indicate national trends and facilitate benchmarking.

Individual facility scores for these criteria can be found online at hrc.org/hei/search.

Criteria 1 – Non-Discrimination and Staff Training

  • Patient Non-Discrimination
  • Equal Visitation
  • Employment Non-Discrimination
  • Staff Training

Criteria 2 – Patient Services and Support

  • LGBTQ Patient Services and Support
  • Transgender Patient Services and Support
  • Patient Self-Identification
  • Medical Decision-Making

Criteria 3 – Employee Benefits and Policies

  • Employee Benefits and Policies
  • Transgender-Inclusive Health Insurance



Criteria 4 – Patient and Community Engagement

  • Patient and Community Engagement

HEI 2020 / Criteria One

Patient Non-Discrimination

The first section of the HEI Non-Discrimination and Staff Training criteria calls for a written patient non-discrimination policy (or patients’ bill of rights) that includes both “sexual orientation” and “gender identity.”

Lesbian, gay, bisexual, transgender and queer people continue to face discrimination in healthcare because of their sexual orientation and/or gender identity, creating a need for explicit non-discrimination policies.

of HEI participants (756 of 765 respondents) documented that they include both “sexual orientation” and “gender identity” in their patient non-discrimination policy.

Since The Joint Commission issued a standard in 2011 requiring hospitals to prohibit discrimination based on sexual orientation and gender identity, the percentage of HEI survey participants that have adopted fully inclusive, written patient non-discrimination protections has steadily grown from 60% to this record level.

A patient non-discrimination policy is only effective if patients and staff know about it. Thus, the HEI requires survey participants to document not only that they have an LGBTQ-inclusive non-discrimination policy, but that they also make it readily accessible to patients and communicate it to their staff.

of HEI participants with an LGBTQ-inclusive patient non-discrimination policy documented that the policy is readily accessible and communicated to patients in at least two different ways.

Healthcare facilities most frequently communicated this policy to patients in these ways:

  • Posted on facility website (98%)
  • Included in materials given to patients at admitting/ registration or at other time(s) (83%)
  • Posted or displayed in waiting rooms and other public areas of the facility (89%)

of HEI participants with an LGBTQ-inclusive patient non-discrimination policy documented that the policy is readily accessible and communicated to staff in at least one way.

Healthcare facilities most frequently communicated this policy to staff in these ways:

  • Posted on facility intranet site (92%)
  • Included in materials routinely given to employees at orientation (74%)
  • Reviewed in employee training (either in-person or online) (64%)

In addition to the facilities that actively participated in the HEI 2020 survey, the HRC Foundation proactively researched the patient non-discrimination policies at more than 1,000 hospitals. We were unable to find patient non-discrimination policies for some of the hospitals we researched as these facilities do not include a nondiscrimination statement or patient bill of rights on their hospital website and did not respond to invitations to submit their policies to us. We found or obtained the patient non-discrimination policies for 959 hospitals.

Of those hospitals that published or provided a policy, only 645 or 67% were found to have a patient non-discrimination policy that includes both “sexual orientation” and “gender identity.”

For more information about this criterion, visit The HRC Foundation's Patient Discrimination resources.

In 2011, The Joint Commission issued a standard that requires hospitals to prohibit discrimination based on sexual orientation and gender identity. Learn more at jointcommission.org/lgbt

HEI 2020 / Criteria One

Equal Visitation

The second section of the HEI Non-Discrimination and Staff Training criteria calls for a written visitation non-discrimination policy or an equal visitation policy. Across the U.S., same-sex couples, same-sex parents and other LGBTQ people fear that they could be prevented from visiting their loved ones in healthcare settings because of bias or discomfort on the part of hospital employees regarding same-sex relationships and LGBTQ people.

In 2010, after learning of a tragic incident in which a lesbian was denied visitation to her dying partner, then President Barack Obama directed the United States Secretary of Health and Human Services to develop regulations protecting the visitation rights of all patients. These regulations, known as the Conditions of Participation, are now in effect at all hospitals that accept Medicare or Medicaid payments—the vast majority of facilities.

of the HEI 2020 participants for which this question was applicable (674 of 678 in-patient respondents) documented that they have equal visitation policies.

Since the Conditions of Participation went into effect in 2011, the percentage of HEI survey participants that have adopted equal visitation policies has steadily grown from 53% to this record level.

An equal visitation policy is only effective if patients and staff know about it. Thus, the HEI requires survey participants to document not only that they have an equal visitation policy but that they also make it readily accessible to patients and communicate it to their staff.

of HEI participants with an equal visitation policy documented that the policy is readily accessible and communicated to patients in at least two different ways.

Healthcare facilities most frequently communicated this policy to patients in these ways:

  • Posted on facility website (97%)
  • Included in materials given to patients at admitting/registration or at other time(s) (84%)
  • Posted or displayed in patient waiting area(s) (74%)

of HEI participants with an equal visitation policy documented that the policy is readily accessible and communicated to staff in at least one way.

Healthcare facilities most frequently communicated this policy to staff in these ways:

  • Posted on facility intranet site (96%)
  • Included in materials routinely given to employees at orientation (61%)
  • Reviewed in employee training (either in-person or online) (59%)

In addition to the facilities that actively participated in the HEI 2020 survey, the HRC Foundation proactively researched the visitation policies at more than 1,000 hospitals. We were unable to find visitation policies for some of the hospitals we researched as these facilities do not include a statement on their hospital website indicating which individuals may visit the patient and did not respond to invitations to submit their policies to us. We found or obtained the visitation policies for 846 hospitals. Of those hospitals that published or provided a policy, 791 or 93% were found to have an equal visitation policy in place. While this number is quite high, given that this is required by the Conditions of Participation, it is disturbing that it is not closer to 100%.

For more information about this criterion: The HRC Foundation's resources on Equal Visitation.

Since 2011, the Conditions of Participation of the federal Centers for Medicare & Medicaid Services have required hospitals to permit patients to designate visitors of their choosing and to prohibit discrimination in visitation based on sexual orientation and gender identity.

HEI 2020 / Criteria One

Employment Non-Discrimination

The third section of the HEI Non-Discrimination and Staff Training criteria calls for an employment non-discrimination policy (or an equal employment opportunity policy) that includes both “sexual orientation” and “gender identity.” Such a policy typically covers all conditions of employment, including hiring, promotion, termination and compensation. Federal law does not protect employees from discrimination based on real or perceived sexual orientation or gender identity.

Furthermore, fewer than half of states have passed laws prohibiting discrimination based on sexual orientation or gender identity. Only 22 states and the District of Columbia provide workplace protections based on sexual orientation and gender identity. This criterion calls on healthcare facilities to protect their LGBTQ employees from discrimination regardless of state non-discrimination laws. LGBTQ staff members not only deserve a discrimination-free workplace, but they also informally educate co-workers, provide valuable guidance to facility leadership and serve as ambassadors for LGBTQ communities.

of HEI participants (758 of 765 respondents) documented that they include both “sexual orientation” and “gender identity” in their employment non-discrimination policy.

This total represents a continued and welcome increase over past years. Notably, HEI survey participants have closed the gap between policies that provided protections for “sexual orientation” but not “gender identity,” and now almost all participants include protections for both populations in their employment non-discrimination policies. These protections are critical for transgender employees. In a national survey of transgender Americans, 30% of respondents who were employed in the past year had either been fired, denied a promotion or experienced some other form of mistreatment related to their gender identity or expression in the workplace.*

To fully meet this criterion, participants are required to demonstrate that they made the public and potential applicants aware of their LGBTQ-inclusive employment
non-discrimination policy.

of HEI participants with an LGBTQ-inclusive employment non-discrimination policy documented that the policy is readily accessible and communicated to the public and potential applicants in at least one way.

Healthcare facilities most frequently communicated this policy in these ways:

  • Posted on employment page of website (92%)
  • Included on job applications or in the job application system (68%)
  • Included on job announcements (62%)

In addition to the facilities that actively participated in the HEI 2020 survey, the HRC Foundation proactively researched the employment non-discrimination policies at more than 1,000 hospitals. We were unable to find employment non-discrimination policies or statements for many of the hospitals we researched as these facilities do not include an employment non-discrimination policy or statement on their hospital website and did not respond to invitations to submit their policies to us. We found or obtained the employment non-discrimination policies for 890 hospitals.Of those hospitals that published or provided a policy or non-discrimination statement, only 558 or 63% were found to have an LGBTQ-inclusive employment non-discrimination policy in place.

For more information about this criterion:
thehrcfoundation.org/professional-resources/employment-non-discrimination

HRC’s Corporate Equality Index (CEI) evaluates LGBTQ inclusion at the nation’s largest employers.

For more information about this unique and comprehensive resource for LGBTQ workplace equity, visit hrc.org/cei

HEI 2020 / Criteria One

Staff Training in LGBTQ Patient-Centered Care

The fourth section of the HEI Non-Discrimination and Staff Training criteria calls for key facility employees to receive expert training in LGBTQ patient-centered care. This criterion recognizes that training is critical for policies to be successful and for LGBTQ patients to feel welcome. Training programs should offer all incoming and current staff the information and skills they need to provide culturally competent care and services to their LGBTQ patients.

The HEI training requirements vary by facility and are based upon the facility’s previous HEI training participation. During the first year of participation in the HEI training, a facility must have a core group of executive-level staff members participate in online training that covers systemic strategies for delivering LGBTQ-accessible and -affirming health care. In subsequent years, facilities must demonstrate that they have provided a minimum number of hours of HEI-approved training to any of their staff in LGBTQ patient-centered care.

of HEI participants met the requirement to provide their employees with training in LGBTQ patient-centered care.

To assist facilities in meeting this HEI criteria and ensure high-quality training, the HRC Foundation partners with two different learning platforms, the National LGBT Health Education Center and The Center for Affiliated Learning. The HRC Foundation and its partners offer more than 60 online and on-demand training options that include both interactive eLearning courses and recorded webinars. Topics range from the basics of LGBTQ patient-centered care to more specialized topics for clinicians. All these training options are free to staff of HEI-participating facilities and offer CME/CEU credit. In addition, with pre-approval, participating facilities can receive ongoing training credit for their own course(s) on LGBTQ culturally competent care and/or specific LGBTQ health topics.

More than 150,000 hours of training in LGBTQ patient-centered care were provided to the staff at participating facilities during the HEI 2020 survey year.

“This was one of the best online learning resources I have encountered. This training was well organized and provided information that ranged from basic to substantial. I appreciated learning about how to structure hiring policies to be more inclusive of LGBTQ communities.”

Kelly Wesp, PhD Director of Quality and Evaluation Equitas Health

“The HEI learning resources have equipped our team members with the confidence and courage to interact and engage with our LGBTQ patients. As a leader, my strongest takeaway from our HEI training is my resolve to ask, listen and learn when I don’t know the answer. This small shift in my approach has helped me treat each patient situation uniquely and has reminded me to empower our patients to advocate for their distinct health care needs.“

Gary A. Balcerzak Vice President of Operations Aurora Sinai Medical Center

HEI 2020 / Criteria Two

LGBTQ Patient Services and Support

The first section of the HEI Patient Services and Support criteria asks about key best practices in support of LGBTQ patients as a group. This section includes best practices from The Joint Commission and other sources to enhance care for LGBTQ patients.

Planning to Serve LGBTQ Populations

of HEI participants have an internal planning or advisory committee focused on LGBTQ patient care issues.

of HEI participants have an official plan for reducing health disparities that specifically includes LGBTQ patients in addition to race, ethnicity and linguistic concerns.

In 2013, the Office of Minority Health of the U.S. Department of Health & Human Services (OMH) updated the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (the National CLAS Standards), a blueprint for healthcare organizations to implement culturally and linguistically appropriate services. As a nationally recognized and utilized tool for culturally competent healthcare, the CLAS Standards are intended to advance health equity, improve quality and help eliminate health care disparities.

The updated CLAS standards fully incorporate the concerns of LGBTQ people into the framework of culturally and linguistically appropriate care and specifically include sexual orientation and gender identity in their broader definition of culture. OMH’s accompanying publication, “A Blueprint for Advancing and Sustaining CLAS Policy and Practice,” shares examples of health disparities experienced by LGBTQ people and includes specific references to LGBTQ health in many of the standards. One of the standards encourages healthcare organizations to conduct ongoing assessments of their CLAS-related activities and integrate CLAS-related measures into continuous quality improvement activities. The HEI 2020 survey found that 87% of participants reported that they have an official plan, strategy or goals for reducing health disparities among their patients and/or providing culturally and linguistically appropriate services to their patient population, and 77% of those participants indicated that they include LGBTQ populations in this plan or otherwise have a plan for reducing LGBTQ health disparities.

Serving LGBTQ Populations

of HEI participants inform interested patients of LGBTQ-knowledgeable and -friendly providers.

One of the ways that hospitals can help ease the fears of LGBTQ patients who need to choose a provider is to inform them of LGBTQ-knowledgeable and -friendly providers. Among HEI participants, 73% indicated that they do this in some way. Of those who make LGBTQ-friendly providers known, 65% post a list externally, 58% publicly promote their clinics or medical practices that have an explicit LGBTQ focus, 36% display “tags” in an online “find a provider” system and 34% include them in a community listing.

Percentage of HEI participants that indicated they offered the following specific service to meet the needs of LGBTQ patients*

of HEI participants have dedicated LGBTQ clinics that are externally promoted.

of HEI participants indicated that they have an externally promoted LGBTQ-focused office, point-person, patient advocate or ombudsman.

LGBTQ-focused programs can provide a wide variety of services to improve LGBTQ patient-centered care. For example, The Penn Medicine Program for Lesbian, Gay, Bisexual and Transgender Health focuses on five areas: patient care, research, health education, institutional climate and visibility, and community outreach. Mount Sinai Beth Israel’s LGBT Health Services program offers a number of LGBTQ patient services, including comprehensive transgender health services; information, referral and patient navigation for LGBTQ patients and consumers; and professional education and training for providers in LGBTQ healthcare topics.

Communications

HEI participants indicated that they communicate with their LGBTQ patients about LGBTQ-specific health concerns in the following ways:

  • 69% provide information about LGBTQ services and/or health concerns on their public website
  • 55% publish a brochure or other print material(s) designed to educate or support LGBTQ patients on specific health topics and how they impact LGBTQ people

1.2 Million Americans

are likely candidates for PrEP (Pre- Exposure Prophylaxis), according to the Centers for Disease Control and Prevention. The CDC found that one in four gay and bisexual men, one in five injectable drug users and one in 200 heterosexual adults are good candidates for PrEP and should be counseled about the HIV prevention method. Studies have shown that PrEP reduces the risk of getting HIV from sex by about 99% when taken consistently. Among people who inject drugs, PrEP reduces the risk of getting HIV by at least 74% when taken consistently.

While 90% of HEI participants indicated that they provide HIV testing and counseling, only 84% indicated that they provide PrEP for patients who are at risk of contracting HIV. HEI participants can continue to close this gap and do their part to meet the CDC’s recommendations by adding education and counseling about PrEP to their existing HIV testing and counseling programs.

HEI 2020 / Criteria Two

Transgender Patient Services and Support

Transgender patients are particularly vulnerable in healthcare settings. A large survey by Lambda Legal revealed that 70% of transgender respondents had experienced serious discrimination in health care at some point in their lives.* They can face long waits for care, pointing and laughter, negative comments, violations of confidentiality, inappropriate questions and examinations, denial of (or challenges to) bathroom use, and room assignments that reflect the sex assigned to them at birth rather than their actual gender identity.

In a 2015 survey of more than 27,000 transgender Americans, 33% of respondents who had seen a provider in the past year reported one or more negative experiences due to their transgender or gender non-conforming status and 23% of respondents reported that they avoided seeking necessary health care when sick or injured in the past year because of fear of being mistreated as a transgender person.**

* When Health Care Isn’t Caring: Lambda Legal’s Survey on Discrimination Against LGBT People and People Living with HIV. New York: Lambda Legal, 2010.

** James, S. E.; Herman, J. L.; Rankin, S.; Keisling, M.; Mottet, L.; and Anafi, M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, D.C.: National Center for Transgender Equality.

Serving Transgender Patients

of HEI participants indicated that their facility has a policy or policies that specifically outline procedures and practices aimed at eliminating bias and insensitivity, and ensuring appropriate, welcoming interactions with transgender patients.

Of the 408 facilities that indicated that they have a specific policy or policies for transgender patients, the following procedures and practices were covered:

  • Recording of preferred name and pronouns in paper and/or electronic admitting/registration records (86%)
  • Use of preferred name and pronouns when interacting with and referring to transgender patients (96%)
  • Protocols for interacting with transgender patients (88%)
  • Guidelines for room assignments for transgender patients (73%)
  • Access to restrooms (89%)
  • Compliance with privacy laws (81%)
  • Access to items that assist gender presentation (54%)
  • Addressing potential problems with insurance/billing claims (40%)
  • Access to hormone therapy (72%)

The Affordable Care Act raised the importance of creating policies and procedures aimed at eliminating bias and insensitivity, ensuring appropriate, welcoming interactions with transgender patients, and training staff on those policies. Section 1557 of the ACA prohibits sex discrimination in any hospital or health program that receives federal funds. Numerous federal courts have determined that this prohibition extends to claims of discrimination based on gender identity and sex stereotyping. Additionally, the Supreme Court of the United States ruled in Bostock v. Clayton County that a corollary statute that prohibits discrimination on the basis of sex must be understood to also prohibit discrimination on the basis of sexual orientation and gender identity.

In 2015, the Brooklyn Hospital Center entered into a voluntary resolution agreement with the Department of Health and Human Services’ Office for Civil Rights to ensure that transgender patients at its hospital receive appropriate and equitable care and treatment. The agreement resolved a complaint filed by a transgender patient alleging discrimination under Section 1557 based on sex in the assignment of patient rooms. Under the terms of the two-year settlement, the hospital agreed to adopt new policies and procedures tailored to transgender patients and to train its employees on those policies.

For more information about best practices for care of transgender patients see the publication, Creating Equal Access to Quality Health Care for Transgender Patients: Transgender-Affirming Hospital Policies, from HRC Foundation, Lambda Legal, and the LGBT Rights Committee of the New York City Bar Association:

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Creating Equal Access to Quality Health Care for Transgender Patients: Transgender-Affirming Hospital Policies

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Percentage of HEI participants that indicated they offered the following specific services to meet the needs of transgender patients.

of HEI participants indicated that they do not provide any transgender-specific services.

While more people have access to transgender-inclusive healthcare insurance coverage, there are not enough providers or healthcare facilities that offer transgender-specific services. Therefore, we would like to see more facilities indicating that they are offering these services.

of HEI participants have an externally promoted multidisciplinary gender clinic for either adults and/or youth.

of HEI participants indicated that they have an externally promoted specific program to provide patient navigation or advocacy services to transgender patients.

of HEI participants indicated that they have gender-neutral bathrooms in their facility and/or have clear posted signage that allows individuals to use the restrooms that aligns with their gender identity.

Patients whose appearances might not conform to gender stereotypes may feel more comfortable and safe in a single-stall or all-gender restroom. Although providing an all-gender restroom is an important signal of acceptance, facilities should also adopt policies that allow patients to be permitted to use restrooms that comport with their gender identity.

For more information about best practices for clinics and hospitals that seek to promote the health and well-being of transgender and non-binary youth through the creation of multidisciplinary care clinics see the publication, Comprehensive Care Clinics for Transgender & Non-Binary Youth from the HRC Foundation.

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Comprehensive Care Clinics for Transgender & Non-Binary Youth

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HEI 2020 / Criteria Two

Patient Self-Identification

Many healthcare authorities such as the Institute of Medicine and The Joint Commission have recommended the routine collection of sexual orientation and gender identity data in healthcare settings.

These critical data provide hospitals with information on the potential cultural needs of each patient, as well as an opportunity to monitor and analyze health disparities at the population level.

Collecting Information About Sexual Orientation and Gender Identity

of HEI participants indicated that their organization's electronic health records offer an explicit way to capture a patient’s sexual orientation.

Another 32% of participants indicated that this information may be captured in free-form notes, while 4% of participants are not capturing this information at all in their patients’ health records.

of HEI participants indicated that their organization's electronic health records offer an explicit way to capture that a patient’s current gender identity differs from the sex they were assigned at birth and/or the sex shown on any identification, insurance or other documents used in admitting/registration.

The remaining 13% of participants indicated that this information may be captured in free-form notes.

of HEI participants that collect gender identity data use the recommended two-question process (i.e., first asking current gender identity and then asking sex assigned at birth).

Documentation of both current gender identity and sex assigned at birth is critical for delivering appropriate care to transgender patients. Some transgender people may not identify as transgender, but only as male or female. In these cases, sex assigned at birth can indicate that the individual is transgender, which allows providers to offer the full range of care — such as anatomically appropriate preventive screenings — that meets the individual’s needs. Therefore, the current recommended best practice involves asking both current gender identity and sex assigned at birth.

Current gender identity and name pronouns currently used should be documented and used for communications with the patients as well as for name bands and room assignments.

of HEI participants capture a patient’s name in use if it differs from their legal name AND prominently display this name in a banner or pop-up so that front line staff and providers will see this information.

of HEI participants capture a patient’s pronouns in use AND prominently display these pronouns in a banner or pop-up so that front line staff and providers will see this information.

of HEI participants provide employees with training explicitly reminding them that LGBTQ status is confidential patient information.

This training should be in addition to standard HIPAA training or appear as a special module within training. Transgender patients especially are often the victims of privacy breaches, in which staff or providers feel the need to “warn” the patient’s roommate about the patient’s transgender status or invite other staff or providers to come see the patient. These privacy violations are not only unethical and illegal, they add to the high levels of discrimination transgender people already face in accessing healthcare and discourage them from continuing or returning to seek care.

of HEI participants have an explicit way to capture an organ inventory in their organization's electronic health records.

An organ inventory helps track the history of affirmation surgery in transgender people and helps providers to recognize the need for screenings based on a review of the patient’s current anatomy.

of HEI participants indicated that their organization's electronic health records include explicit options for pediatric patients' parents beyond "mother" and "father" (e.g., "parent/guardian 1, parent/ guardian 2, parent/guardian 3"), to be inclusive of same-sex parents and other diverse families.

Another 48% of participants indicated that this information may be captured in free-form notes, while 3% of participants are not capturing this information at all in their patients’ health records.

of HEI participants that record a patient’s marital or relationship status offer a way to record non-marital relationships by offering choices such as “domestic or life partner” or “significant other.”

There are many kinds of family structures in our community today, and hospital records should provide ways to record these relationships. This is a practice that will help provide a welcoming environment for all patients.

HEI 2020 / Criteria Two

Medical Decision-Making

of HEI-participating facilities explicitly inform patients of their right to designate a person of their choice, including a same-sex partner, as medical decision-maker.

Only 23% include LGBTQ-specific information in employee training about patient decision-making.

Healthcare organizations have sometimes failed to honor LGBTQ patients’ rights to designate the person of their choice, including a same-sex partner, to make medical decisions on their behalf should they become incapacitated even when legally valid medical decision-making documents have been presented. To prevent these failures, it is critical that healthcare organizations are aware that the Centers for Medicare & Medicaid Services issued guidance in 2011 to support enforcement of the right of patients to designate the person of their choice, including a same-sex partner, to make medical decisions on their behalf should they become incapacitated. In addition, employee training related to medical decision-making should affirm that LGBTQ people have the same medical decision-making rights as other patients.

HEI 2020 / Criteria Three

Employee Benefits and Policies

LGBTQ employees of healthcare organizations play a vital role in ensuring LGBTQ patient-centered care by informally educating co-workers about patient concerns, offering feedback about organizational policies and practices, and conveying to the local community the organization's commitment to equality and inclusion. It is critical that LGBTQ employees, like LGBTQ patients, receive equal treatment, particularly regarding health-related benefits and policies.

Equal Benefits

Competitive employer-provided benefits packages are critical to attracting and retaining talent. Providing LGBTQ employees and their families with inclusive benefits, from healthcare coverage to retirement investments and more, is a low-cost, high-return proposition for businesses. In addition, equitable benefits reflect the principle of equal compensation for equal work. Apart from actual wages paid, benefits account for approximately 30% on average of employees’ overall compensation. Therefore, employers should ensure that this valuable bundle of benefits is equitably extended to their workforce, irrespective of sexual orientation and gender identity. When denied equal benefits coverage, the cost to LGBTQ workers and their families is profound.

In 2015, the Supreme Court determined in Obergefell v. Hodges that same-sex couples have a constitutional right to marry nationwide. Any business that provides benefits based on marriage to an employee's different-sex spouse must also provide marital benefits to an employee's same-sex spouse.

Almost all the HEI participants provide healthcare benefits to spouses of benefits-eligible employees. Among those that do provide this coverage:

maintain a definition of spouse that include same-sex couples — this may include “legal spouse”

require the same documentation for same-sex and different-sex couples

The HRC Foundation urges the handful of employers that require different documentation for same-sex and different-sex couples and those that maintain definitions of spouse that do not include same-sex spouses to adjust these requirements to provide equal and inclusive benefits to same-sex spouses.

of HEI participants provide medical and comprehensive health benefits to domestic partners of benefits-eligible employees

Even though same-sex marriage is now legal, HRC continues to urge employers to maintain domestic partner benefits for their workers as a sign of sustained commitment to family diversity and to protect LGBTQ employees whose rights outside the workplace are not guaranteed by law in many states.

Another way to recognize and respect family diversity is through leave policies that allow employees to take off time for issues related to their same-sex domestic partners.

of HEI participants offer bereavement leave that allows employees to take time off following the death of a same-sex partner or their immediate family.

of HEI participants offer FMLA-equivalent benefits that allow employees to take family and medical leave to care for same-sex partners as well as the children of a same-sex partner, regardless of biological or adoptive status.

Please see the following special issue brief on Achieving a Healthier, Stronger Workforce Through Inclusive Paid Leave for more information about this important benefit.

HEI 2020 / Criteria Three

Achieving a Healthier, Stronger Workforce through Inclusive Paid Leave

The United States is the only industrialized nation in the world without some form of guaranteed paid leave. Currently, the federal Family and Medical Leave Act (FMLA) allows many American workers to take up to 12 weeks of unpaid, job-protected leave per year for significant family or medical events, including the birth and care of a newborn and the care of an immediate family member dealing with a serious health condition.1

However, workers are often unable to take this federally-guaranteed time off because they cannot afford the loss of wages. Employees who take unpaid leave can be thrown into financial chaos and struggle to cover everyday expenses like groceries and rent. To truly allow workers to provide vital care for themselves and their loved ones, employers are increasingly offering paid leave benefits, which permit employees to take sufficient paid, job-secured time off.

Paid Leave Is an LGBTQ Issue

LGBTQ people are particularly vulnerable in the absence of guaranteed paid leave, especially in states that lack explicit protections for employment discrimination based on sexual orientation and gender identity. LGBTQ people are more likely to be living in poverty,2 mistreated in the workplace,3 and discriminated against during the hiring process4—making a request for unpaid time off both impractical and unnavigable. A 2018 study by the Human Rights Campaign Foundation found financial concerns to be the greatest factor keeping LGBTQ people from taking time off or forcing them back to work early.5 LGBTQ people may be unable to take time off to care for a loved one without “outing” themselves at work, an action that could put their jobs at risk. Some may fear stigmatization if they reveal they need HIV-related or transgender-specific care. Too many others, especially transgender people of color and those who are low-income, face other forms of anti-LGBTQ discrimination, housing instability and violence. These hardships compound each other, especially as individuals grapple with significant life events.

Though some employers have recognized the imperative of offering paid leave benefits in the absence of nationwide protections, these benefits are not always inclusive of LGBTQ people, diverse families or LGBTQ-specific medical needs:

Parental leave policies may not equally cover parents of all genders or those who become new parents through surrogacy, adoption or foster care.

Family care leave may be restricted to legal guardians and their spouses, failing to cover domestic partners, close family members and other primary caregivers. Only 39% of HEI 2020 participants offer FMLA-like leave for same-and different-sex domestic partners.

Employers may offer paid leave as a benefit but deny individual requests, forcing employees to take unpaid time off, even when seeking medically necessary care.

Benefits of Inclusive Paid Leave

Enacting inclusive paid leave policies is not just the right thing to do, it also supports the bottom line by helping attract and retain top talent, improving morale and increasing productivity. Prospective and current employees, including LGBTQ people, value workplaces that demonstrate a commitment to the health and well-being of all employees and their diverse families. When employees can take leave without jeopardizing their family’s financial security, they are able to provide vital care for themselves and their loved ones, ultimately leading to healthier, happier workers.

Creating Inclusive Paid Leave Policies

Healthcare employers are encouraged to begin the process of adding paid leave to their employee benefits, taking care to account for the unique concerns of LGBTQ employees and their diverse family structures. If an employer currently has a paid leave policy, Human Resources and Diversity & Inclusion leadership teams should review it to ensure full inclusivity. The following principles should guide the creation or alteration of paid leave policies.

Paid leave policies should cover:

  • Parental leave to welcome children, including through childbirth, surrogacy, adoption, foster care, or other placement;
  • Family care leave to care for loved ones with serious medical conditions, including serving as a caregiver for a spouse, domestic partner, chosen family member, child, parent, or grandparent; and
  • Medical leave to manage their own health, including undergoing treatment for a serious health condition, recovering from a physical or mental illness, obtaining medically-necessary transition-related health care, and receiving HIV-related care.

Parental leave policies should use inclusive language like “birth parent” and not focus solely on “birth mothers” (e.g., maternity leave). A focus on “birth mothers” excludes fathers, non-birth mothers, and adoptive or foster parents, all of whom are equally deserving of bonding time with a new child. Moreover, policies that offer additional time off and/or short-term disability for “birth mothers” to physically recover from childbirth leave out parents of other genders who also give birth, including transgender men, non-binary individuals, and people of other identities.

Family care leave policies should be inclusive of diverse family structures. Policies should define “spouse” to mean all legal spouses, including those of the same sex, and also extend the same benefits to same- and different-sex domestic partners.

  • Policies should be inclusive of all parent-child relationships. In many American families — and especially in LGBTQ families — individuals have parental responsibilities for children they are not legally or biologically related to. Employers should follow existing U.S. Department of Labor guidance for FMLA when offering paid or unpaid leave benefits, allowing all employees with parent-child relationships to claim parental and family care leave, regardless of legal or biological standing.
  • Policies should include chosen family members. For a variety of reasons, there may be instances where an employee must take time off to care for a seriously ill loved one outside of the relationships listed above, including a grandparent, relative or close friend. LGBTQ people may be more likely to rely on and/or be responsible for care for such chosen family members, who may not have other immediate family able or willing to care for them.
  • Policies should include chosen family members. For a variety of reasons, there may be instances where an employee must take time off to care for a seriously ill loved one outside of the relationships listed above, including a grandparent, relative or close friend. LGBTQ people may be more likely to rely on and/or be responsible for care for such chosen family members, who may not have other immediate family able or willing to care for them.

Medical leave policies should expressly cover employees who are seeking paid leave to undergo medically-necessary transition-related care (including gender affirmation surgery, hormone therapy, and other gender-affirming care) and employees who need time off to receive HIV-related health care (including adjusting to new medications or grappling with co-infections).

All paid leave policies should offer full or partial wage replacement during leave and these benefits should be clearly communicated to employees. Human resources staff should ensure paid leave policies are detailed in employee handbooks alongside other benefits and guidelines and be prepared to answer employee questions. Managers should support their team members who need to take leave and protect their privacy. Finally, if an employee needs additional accommodations to manage their health or care for loved ones after their paid leave period ends, employers should offer flexible work arrangements, including part-time or telework options. For more on inclusive paid leave, see the Human Rights Campaign Foundation’s “2018 U.S. Paid Family Leave Survey,” available at hrc.org/resources/2018-u.s.-lgbtq-paid-leave-survey

1 “Family and Medical Leave (FMLA)” https://www.dol.gov/general/topic/benefits-leave/fmla. Accessed 21 July 2020.

2 The Williams Institute. “New Patterns of Poverty in the Lesbian, Gay, and Bisexual Community.” https://williamsinstitute.law.ucla.edu/wp-content/uploads/LGB-Poverty-Update-Jun-2013.pdf

3 Out and Equal Workplace Advocates. “2017 Workplace Equality Fact Sheet.”

http://outandequal.org/2017-workplace-equality-fact-sheet

4 The Williams Institute. “Gender Identity and Sexual Orientation Discrimination in the Workplace: A Practice Guide.” https://williamsinstitute.law.ucla.edu/wp-content/uploads/CH40-Discrimination-Against-LGBT-People-Sears-Mallory.pdf

5 Human Rights Campaign Foundation, 2018 U.S. LGBTQ Paid Leave Survey, https://www.hrc.org/resources/2018-u.s.-lgbtq-paid-leave-survey

HEI 2020 / Criteria Three

Other Support for LGBTQ Employees

of HEI participants have an organization-wide diversity and inclusion office, diversity council or working group focused on employee diversity that specifically includes LGBTQ diversity as part of its mission.

of HEI participants have an officially recognized LGBTQ employee resource group.

Many large employers have formally recognized employee resource groups (also known as employee networks, business resource or affinity groups) for diverse populations of their workforce, including women, people of color, people of varied abilities and LGBTQ/allied people.

The purpose of these groups is two-fold:

  • To foster a sense of community and visibility for these diverse populations within a business
  • To leverage each unique populations’ networks and skills to help accomplish business goals, such as market innovation, recruitment and retention of talent

Employee resource groups are great platforms for leadership opportunities for LGBTQ and allied employees to better their own work environments. In addition, the reach of many employee resource groups extends beyond the everyday affairs of an employer to policymaking, representing the employer at professional events and external activities, participating in prospective employee recruitment efforts, mentoring and other retention- focused programming.

Employers usually provide these groups with a budget and access to resources such as meeting rooms and e-mail networks. The groups provide a clear line of communication between employees and management. LGBTQ/allied employee resource groups empower employees as change agents and provide a sense of safety and acceptance for LGBTQ employees within the workplace.

of HEI participants have one or more openly LGBTQ people serving in a high-level leadership position that is visible organization-wide.

The presence of visible LGBTQ employees in management communicates to the LGBTQ employees of your company that their company is open and accepting and enables LGBTQ employees to be open at work, which in turn improves their engagement and retention.

Benefits and Policies Impacting Transgender Employees

of HEI participants provide to all employees at least one health plan that explicitly covers medically necessary health services for transgender people, including gender transition-related treatment.

These benefits are critical for the health and well-being of transgender people. This number is a welcome increase over previous years as healthcare facilities are finally starting to match their corporate counterparts when it comes to providing this important and necessary benefit. In the second year that this benefit was required to obtain Leader status in the HEI we saw an increase in the number and percentage of employers that are offering this benefit. See our feature on The Importance of Providing Transgender-Inclusive Health Coverage for more information on these important benefits.

of HEI participants have written gender transition guidelines documenting supportive policies and practices on issues pertinent to a workplace gender transition.

Having easily understandable and accessible guidelines on the gender transition process is a best practice in setting forth some structure to support a respectful and successful workplace transition. To meet everyone’s goal of a respectful transition process that retains the employee and individual engagement, the guidelines establish common reference points and expectations for all involved, including the transitioning employee, human resources, management and work groups. From suggestions on how to have respectful and informative conversations about transgender inclusion in the workplace to the administrative changes to one’s personnel and workplace documents, these guidelines clearly delineate responsibilities and expectations of transitioning employees, their supervisors, colleagues and other staff.

The HRC Foundation’s Transgender Inclusion in the Workplace: A Toolkit for Employers provides a comprehensive resource to guide employer transgender inclusion. The toolkit includes HRC’s best practice advice for implementing transgender inclusive policies and practices (including sample policies) as well as guidance for implementing transgender-inclusive healthcare benefits.

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Transgender Inclusion in the Workplace: A Toolkit for Employers

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HEI 2020 / Criteria Three

The Importance of Providing Transgender-Inclusive Health Coverage

Transgender individuals often face a significant number of discriminatory barriers in many aspects of life. While progress has been made in advancing workplace non-discrimination protections for transgender people working in healthcare facilities, one of the most important workplace benefits, healthcare coverage, has not kept pace.

Historically, many U.S. employer-based healthcare plans have explicitly contained “transgender exclusions.” These blanket exclusions prohibit coverage for medical care related to gender transition, known as transition-related health care. Transition-related health care encompasses mental health care, hormone therapy, gender-affirming surgeries and other medically necessary care. These discriminatory exclusions persist despite that the nation’s top professional health associations — including the American Medical Association and the American Psychological Association — have affirmed that transition-related care is medically necessary for the health and well-being of many transgender people.

Denying this medically necessary care is detrimental to a transgender individual’s health and well-being as well as their ability to contribute in the workplace. If the intention of employer-provided healthcare is to promote a healthy and productive workforce, then providing healthcare coverage that removes these exclusions and provides affirmative transition-related care helps achieve the goal of promoting health and wellness across a diverse workforce.

A Trend Toward Inclusive Benefits

A growing number of employers are eliminating transgender exclusions and affirmatively offering transition-related healthcare coverage. The Human Rights Campaign Foundation’s Corporate Equality Index (CEI), which assesses corporate policies and practices, tracks the number of major American private employers that offer transgender-inclusive healthcare benefits.

In the CEI 2020, 85% of rated businesses offer this important benefit. After many years of trailing their corporate counterparts in the provision of this benefit, HEI participating healthcare facilities are nearly on par with the CEI participants as 80% have at least one healthcare plan that offered this benefit.

Many large corporations have successfully negotiated with their carriers to remove transgender exclusions from their health insurance policies and replace them with affirmed benefits that provide a base level of coverage for transgender medical care, including mental health counseling, hormone therapy, medical visits and surgical procedures. These efforts are particularly successful when employers provide comprehensive information to their carrier in the process.

Costs

One of the most common reasons cited for not offering this coverage is misperceptions about cost. Studies have consistently shown that the cost of providing transgender-inclusive health coverage is negligible. According to a study by The Williams Institute, 85% of responding employers who provide transgender-inclusive benefits report no cost at all.*

There is a misconception that gender-affirming treatments are expensive. Like many healthcare treatments, these treatments can be prohibitively expensive for an individual, but the annualized cost to an employer’s health plan is low. This is due to extremely low utilization rates. Since such a small percentage of people undergo transition-related medical care, distributed costs are nominal or nonexistent.

Benefits

Providing transgender-inclusive health coverage is not just the right thing to do. Inclusive health coverage also brings many invaluable benefits. The Williams Institute study asked employers who provide transition-related health coverage about the benefits they receive as a result. A majority of responding employers, 60%, stated that providing inclusive health coverage makes them more competitive and improves recruitment and retention. Furthermore, 60% reported that providing transgender-inclusive benefits demonstrates and effectively communicates their commitment to fairness and equality. Moreover, employers noted that offering inclusive healthcare benefits increases employee satisfaction and morale, helps attract a diverse workforce and puts them on the “leading edge.”

* Jody L. Herman, Costs and Benefits of Providing Transition-related Health Care Coverage in Employee Health Benefits Plans: Findings from a Survey of Employers, The Williams Institute, 2013.

*Jody L. Herman, Costs and Benefits of Providing Transition-related Health Care Coverage in Employee Health Benefits Plans: Findings from a Survey of Employers, The Williams Institute, 2013.

HEI 2020 / Criteria Three

HEI Criteria Requirement for Transgender-Inclusive Health Insurance Coverage

Beginning last year, participants were required to have at least one firm-wide health insurance plan that affirmatively provides transgender-inclusive coverage to receive a top score in the HEI and obtain the “Leader in LGBTQ Healthcare Equality” designation.

Participants that demonstrated that they had at least one firm-wide health insurance plan that affirmatively communicates the availability of coverage to employees for transition-related treatment received 5 points in the employee benefits and policies criteria section.

The plan must meet the following baseline criteria:

Insurance contract must explicitly affirm coverage and contain no blanket exclusions for coverage.

Plan documentation must be readily available to employees and must clearly communicate inclusive insurance options to employees and their eligible dependents.

Benefits available to other employees must extend to transgender individuals. Where available for other employees, the following benefits should extend to transgender individuals, including for services related to gender transition (e.g., medically necessary services related to sex affirmation/reassignment): Short-term medical leave

  • Mental health benefits
  • Pharmaceutical coverage (e.g., for hormone replacement therapies)
  • Coverage for medical visits or laboratory services
  • Coverage for reconstructive surgical procedures related to sex reassignment
  • Coverage of routine, chronic or urgent non-transition services

The plan must eliminate other barriers to coverage:

  • No separate dollar maximums or deductibles limited to coverage of sex reassignment surgeries and related procedures.
  • The plan may not exclude any covered dependents, including children, from these benefits. If there are age limitations in your covered services for gender transition, non-surgical services must be affirmed and provided for beneficiaries under 18 years of age.
  • Explicit adequacy of network provisions apply. When the provider network has no adequate specialists (as determined by qualified area specialists), out-of-network providers will be covered at in-network rates, as well as coverage of travel and lodging to such specialists.
  • No other serious limitations. On a case by case basis, other serious limitations to coverage may be deemed sufficiently counterproductive to treatment success to disqualify a plan from eligibility. Two examples: a) Limitations on the time frame for or number of surgeries per individual would eliminate a plan from consideration (e.g., no “one surgery only” or “initial surgery” limitations); b) Similarly, exclusions for reversals of sex reassignment would also be regarded as unacceptable limits to coverage.


How plan documentation should clearly communicate inclusive insurance options to employees

Transition-related services must be outlined in plan documents such as the Summary Plan Document along with other “covered services.” In the section where covered services are outlined such as the “schedule of benefits” or “other covered services,” organizations are strongly encouraged to outline the full range of services available related to gender transition (i.e., mental health, prescription coverage, surgery, etc.).

HEI 2020 / Criteria Four

Patient and Community Engagement

Healthcare organizations can welcome LGBTQ people in their service area by implementing community engagement initiatives like those recommended in this section.

LGBTQ Community Engagement, Marketing and Advocacy

of HEI participants took part in or supported one or more LGBTQ-related events or initiatives in their service area. The vast majority of participants displayed their support for the LGBTQ community by participating in and sponsoring local pride events. Facilities also actively engaged with LGBTQ patients, employees and local communities through a variety of events and programs, including LGBTQ health fairs, educational talks for providers and community members, and celebration of LGBTQ-recognition days such as National Coming Out Day and Transgender Day of Remembrance.

of HEI participants have engaged in marketing or advertising to the LGBTQ community (other than sponsorships).

of HEI participants have designed an LGBTQ-specific logo for use in marketing materials, promotion of LGBTQ internal or external community events, or for providers and staff to wear to indicate that they are LGBTQ-inclusive. Ad campaigns, marketing, and LGBTQ-specific logos publicize a hospital’s values regarding LGBTQ inclusion. Increasingly, ads with authentic images of LGBTQ people appear in both LGBTQ media outlets and in the general press.

of HEI participants publicly supported LGBTQ equality under the law by speaking out on local, state, or federal legislation or initiatives.

During the 2019 state legislative sessions, over 100 anti-LGBTQ bills proliferated across the states. In turn, businesses spoke out and rebuked attempts to undermine LGBTQ civil rights at record rates. Increasingly, hospitals and other healthcare providers are adding their voice to those that support LGBTQ equality by speaking out against anti-LGBTQ bills in their states or supporting pro-equality legislation.

Understanding the Needs of LGBTQ Patients and Community: Percentage of HEI participants that indicated how they seek to understand the needs of their LGBTQ patients and community

Healthcare facilities can engage with the LGBTQ community in a variety of ways, such as targeted marketing or participating in or sponsoring a variety of LGBTQ-related events or initiatives in their service area. Participation in a community or hospital-based LGBTQ pride celebration is one of the most popular ways to engage with the LGBTQ community.

HEI 2020 / Appendix A

HEI 2020 Scoring Criteria

The Healthcare Equality Index 2020 is in its fourth year using a scoring criteria that focuses on foundational non-discrimination policies as well as a variety of policies and practices to promote LGBTQ patient-centered care. New last year was the additional requirement that healthcare facilities provide transgender-inclusive health insurance to their employees in order to receive a top score. This criteria change was announced in March of 2017.

The HEI 2020 implements four core objectives:

  • Ensure foundational protection for patients, visitors and staff in patient and staff policies and provide cultural competency training on LGBTQ inclusion
  • Demonstrate progress toward inclusion on LGBTQ patient care and support
  • Cultivate an inclusive workforce by providing LGBTQ-inclusive employee support and benefits
  • Demonstrate public commitment to the LGBTQ community
Download Scoring Criteria

Why the HEI?

To help LGBTQ patients find LGBTQ-friendly healthcare facilities

In addition to being a valuable tool and resource for healthcare facilities, the HEI is used by LGBTQ patients and their loved ones to find facilities that provide equitable and inclusive care. The list of LGBTQ Healthcare Equality Leaders is published in the HEI report and the ratings for each participating facility are available on our website and promoted to HRC’s more than 3 million supporters.

Consumers can easily search our online database or our interactive map to see how facilities near them rate — giving patients the ability to choose where they would like to receive care in their time of need.

To search the HEI, go to: hrc.org/hei/search

Why Participate?

  • Learn best practices for LGBTQ equity and inclusion
  • Provide patient-centered care to a long-overlooked group
  • Take advantage of free online,
    on-demand staff training from expert sources that includes CME/CEU credits
  • Enhance patient satisfaction ratings
  • Ensure compliance with legal, CMS and The Joint Commission requirements
  • Improve quality and safety
  • Reduce risk of litigation, complaints and negative publicity
  • Reach out to a highly loyal market segment
  • Enjoy recognition for commitment
    to equity, inclusion & diversity from the nation’s largest LGBTQ civil rights organization

How to Participate

What Organizations are Eligible?

The HEI is primarily intended for inpatient facilities that provide general medical and surgical care. However, specialty hospitals and certain outpatient healthcare facilities may request to participate in the HEI. Typically, a facility or organization must have at least 100 employees to be eligible to participate.

Clinic organizations with multiple locations such as Federally Qualified Health Centers (FQHCs) and FQHC look-alikes, Planned Parenthood Affiliates and other similarly structured organizations are eligible to participate - however, they have special guidelines related to meeting the training criteria.

To register to participate: thehrcfoundation.org/professional-resources/participation-request

Acknowledgements

About the HRC Foundation Health & Aging Program

The Healthcare Equality Index is a project of the Health & Aging Program at the Human Rights Campaign Foundation. In addition to the HEI, the Health & Aging Program also operates the Long-Term Care Equality Index (LEI) in partnership with SAGE. The Health & Aging Program researches, develops and advocates for LGBTQ health and aging initiatives at the federal, state and local levels, and provides support to institutions seeking to enhance LGBTQ wellbeing via education, policy, research and technical assistance.

Meet the Health & Aging Team

Tari Hanneman is the Director of the Health & Aging Program at the Human Rights Campaign Foundation and the author of the HEI. In addition to managing the development and publication of the Healthcare Equality Index, she oversees other projects related to LGBTQ health and aging including the new Long-Term Care Equality Index. Tari has more than 25 years of experience in the nonprofit and philanthropic sector, primarily focused in the areas of health and women’s issues. She holds a master’s degree in public administration with an emphasis on nonprofit management from the University of Southern California, where she also did her undergraduate work – Fight On!

Marcos R. Garcia is the Associate Director of the Healthcare Equality Project at the Human Rights Campaign Foundation and co-author of the HEI. In this role, he engages directly with hospitals and other healthcare facilities nationwide to identify and improve LGBTQ-inclusive policies and practices. Marcos also manages all aspects of the HEI database and survey implementation. Born and raised in New Jersey, Marcos holds a bachelor’s degree in neuroscience and behavior from Columbia University in the City of New York and previously worked in melanoma research at the National Cancer Institute.

Samuel Park is the Coordinator for the Health & Aging Program at the Human Rights Campaign Foundation. In this role, he fields questions from hospitals and other healthcare facilities nationwide about the HEI process, works on HEI survey review, and provides logistical support for the Health & Aging team. He holds a bachelor's degree in neurobiology and sociology from the University of Wisconsin-Madison.

Dan Stewart is the Associate Director of the Aging Equality Project at the Human Rights Campaign Foundation. In this role, he manages the Long-Term Care Equality Index, a tool that supports residential long-term care communities to adopt LGBTQinclusive policies and provides technical assistance to long-term care communities to help them become more LGBTQ inclusive. In addition, he develops resources on LGBTQ aging and supports the Health & Aging team with HEI survey review. Dan holds a bachelor’s degree in psychology from Saint Louis University and a master of science degree in gerontology from the University of Missouri - St. Louis.

Acknowledgments

Special thanks to Sunny Chen, Health & Aging Program Intern, for her assistance in reviewing the record number of HEI surveys and for working through particularly trying times.

Thanks to our consultants, Daniela Lawton and Rachel Percelay for their invaluable assistance in reviewing HEI surveys.

Thanks to Robert Villaflor for design and printing guidance. Special thanks to the LGBTQ patients and HEI 2020 participants who provided material for this report. The HEI 2020 was designed by Tony Frye Design.

Thanks to GLMA: Health Professionals Advancing LGBT Equity, and endorsing partner of the Healthcare Equality Index

The HEI was funded in part by generous grants from PhRMA and Pfizer, Inc.

HEI 2020 Online – 1,770 Evaluated Facilities

Search our online database to find 1,770 healthcare facilities evaluated on their commitment to LGBTQ equality and inclusion. In addition to the 765 healthcare facilities that actively participated in the HEI 2020, you will find more than 1,000 other hospitals that the HRC Foundation proactively researched or that have previously participated in the survey.

As a service to the LGBTQ community, the HRC Foundation researched the policies at hospitals across the U.S. that did not respond to our invitations to actively participate in the survey. The hospitals we researched were selected based on a variety of criteria related to size and location: the 100 largest hospitals in the U.S.; the largest hospitals in each of the 50 states, District of Columbia and Puerto Rico; and the largest hospitals within a 25-mile radius of the 50 largest metropolitan areas with significant LGBTQ populations.

HRC Foundation staff researched the patient, visitation and employment non-discrimination policies for each of these hospitals. We exhaustively searched these facilities’ public websites for inclusive policies, using search terms such as “non-discrimination,” “visitation,” “EEO,” “bill of rights,” “sexual orientation” and “gender identity.” HRC Foundation staff searched these facilities’ websites much like an internet-savvy potential patient, visitor or applicant would to learn whether a hospital had:

  • An LGBTQ-inclusive patient non-discrimination policy
  • An equal visitation policy
  • An LGBTQ-inclusive employment non-discrimination policy

Search the HEI 2020 Database: hrc.org/hei/search

In addition to our database search where you will find individual report cards for each hospital, you can also search for HEI-evaluated hospitals on our interactive Google map.

Search the HEI 2020 Map: hrc.org/resources/hei-map

How We Obtained Information for the 2020 Report

The HEI criteria was assessed for the 765 healthcare facilities that actively participated in the Healthcare Equality Index. For a facility to actively participate, a facility representative must have completed and submitted the free online HEI survey. The data shown throughout this report was aggregated from these surveys. Invitations for the HEI 2020 survey were emailed in November 2019, and the deadline to submit completed surveys was
February 21, 2020.

The survey aims to highlight and encourage the use of best practices and policies for LGBTQ-inclusive care by providing links to sample policies, requirements from the Centers for Medicaid and Medicare Services, recommendations from The Joint Commission, and other guidance from the HRC website. Throughout the open survey period, HRC Foundation Health & Aging Program staff provided additional assistance and advice to help facility representatives complete the survey. Once submitted, HRC Foundation staff reviewed and verified documentation for appropriate language and consistency with required criteria. If any criteria were not met, the HRC Foundation gave healthcare facilities the opportunity to update the deficiencies and submit the required additional information necessary to meet the criteria.