S.R. NO.



S.D. 1













     WHEREAS, according to the American Medical Association, approximately 1.4 million adults and one hundred fifty thousand youth ages thirteen to seventeen in the United States identify as transgender, meaning those individuals' gender identity and/or expression is different from cultural expectations based on the sex they were assigned at birth, or identify as gender expansive, meaning they identify with neither a traditional binary gender role nor a single gender narrative or experience; and


     WHEREAS, many but not all transgender people experience gender dysphoria, a medical condition defined by the American Medical Association as a "conflict between a person's physical or assigned gender and the gender with which he/she/they identify"; and


     WHEREAS, standards of care and accepted medically necessary services that affirm gender or treat gender dysphoria may include but are not limited to mental health counseling, non-medical social transition, gender-affirming hormone therapy, and gender-affirming surgeries; and


     WHEREAS, every major medical association in the United States recognizes the medical necessity of transition-related care for improving the physical and mental health of transgender people and has called for health insurance coverage for treatment of gender dysphoria; and


     WHEREAS, as a population, transgender individuals are frequently subject to bias and discrimination in many aspects of their lives, including the provision of health care; and


     WHEREAS, the transgender population is less likely to be insured than the lesbian, gay, and bisexual (LGB) and general populations and often faces challenges in accessing needed health care services; and


     WHEREAS, a 2016 report by the National Center for Transgender Equality found that:


     (1)  Twenty-five percent of surveyed respondents experienced a problem with their insurance in the past year related to being transgender, such as being denied coverage for care related to gender transition;


     (2)  Twenty-five percent of those who sought coverage for hormones in the past year were denied;


     (3)  Fifty-five percent of those who sought coverage for transition-related surgery in the past year were denied;


     (4)  Seventy-eight percent of respondents wanted hormone therapy related to gender transition, but only forty-nine percent had ever received it;


     (5)  Forty-two percent reported that insurance covered only some of the surgical care needed for transition; and


     (6)  Twenty-one percent reported that insurance covered transition-related surgery, but had no in-network providers; and


     WHEREAS, according to the American Medical Association, transgender individuals in the United States are three times more likely than the general population to report or be diagnosed with mental health disorders, with as many as 41.5 percent reporting at least one diagnosis of a mental health or substance abuse disorder; and


     WHEREAS, the increased prevalence of these mental health conditions is widely thought to be a consequence of minority stress, which is the chronic stress from coping with societal stigma and discrimination because of one's gender identity and expression; and


     WHEREAS, gender-based discrimination affecting access to services is a strong predictor of suicide risk among transgender persons; and


     WHEREAS, lack of access to gender-affirming care may directly contribute to poor mental health, and individuals with gender dysphoria who have undergone no gender confirmation treatment are twice as likely to experience moderate to severe depression and four times more likely to experience anxiety than their surgically-affirmed peers; and


     WHEREAS, improving access to gender-affirming care is an important means of improving health outcomes for the transgender population; and


     WHEREAS, patients who receive gender-affirming care, including surgical care, feel more congruent in their bodies and report improved mental health; and


     WHEREAS, studies suggest that improved body satisfaction and self-esteem following medical and surgical therapies is protective against poorer mental health and also supports healthy relationships with parents and peers; and


     WHEREAS, positive health effects from gender-affirming care extend to children and adolescents as well, and recent research demonstrates that integrated affirmative models of care for youths, which include access to medications and surgeries, result in fewer mental health concerns than have been historically seen among transgender populations; and


WHEREAS, this body supports health insurance coverage for specific types of health care treatments and services for gender transition, as medically necessary; and


     WHEREAS, section 23-51, Hawaii Revised Statutes, requires that "[b]efore any legislative measure that mandates health insurance coverage for specific health services, specific diseases, or certain providers of health care services as part of individual or group health insurance policies, can be considered, there shall be concurrent resolutions passed requesting the auditor to prepare and submit to the legislature a report that assesses both the social and financial effects of the proposed mandated coverage" and that the concurrent resolutions designate a specific legislative bill that has been introduced identifying certain coverage information; and


     WHEREAS, section 23-52, Hawaii Revised Statutes, further specifies minimum information required for assessing the social and financial impact of the proposed health coverage mandate in the Auditor's report; and


     WHEREAS, S.B. No. 752 has been introduced during the Regular Session of 2021, which prohibits health insurance companies from denying coverage on the basis of gender identity if the policy covers the same treatment for purposes other than gender transition and requires insurance companies to provide certain information about the coverage of gender transition services, including the process for appealing a claim denied on the basis of medical necessity; and


     WHEREAS, S.B. No. 752, requires, in part, that "[a]ll health care services related to gender transition treatments shall be considered medically necessary and not cosmetic"; and


     WHEREAS, the Legislature believes that an analysis of the social and financial impacts of the insurance coverage mandated in S.B. No. 752 is warranted; now, therefore,


     BE IT RESOLVED by the Senate of the Thirty-first Legislature of the State of Hawaii, Regular Session of 2021, that the Auditor is requested to conduct an assessment, pursuant to sections 23-51 and 23-52, Hawaii Revised Statutes, of the social and financial effects of mandating health insurers to provide certain health care services, as provided in S.B. No. 752, Regular Session of 2021; and


     BE IT FURTHER RESOLVED that the Auditor is requested to submit a report of its findings and recommendations, including any proposed legislation, to the Legislature, no later than twenty days prior to the convening of the Regular Session of 2022; and


     BE IT FURTHER RESOLVED that certified copies of this Resolution be transmitted to the Auditor, Director of Health, Director of Commerce and Consumer Affairs, and the Insurance Commissioner, who in turn is requested to transmit copies to each insurer in the State that issues health insurance policies, contracts, plans, or agreements.

Report Title: 

Gender Transition Services; Health Care Insurance Coverage