Blue Cross gender services consultant brings years of work in transgender community to new role

Alex Jackson Nelson never imagined a major health insurance company would create a position called "gender services consultant." But Blue Cross and Blue Shield of Minnesota just did, and they hired the right person for the role: Nelson. A licensed therapist, equity advocate and transgender man, Nelson has long witnessed and worked to remove barriers faced by people who are transgender and nonbinary from blatant discrimination to subtle microaggressions like being called the wrong name in a waiting room. In his new role, he'll answer questions, help people find the right doctor, connect them to benefits and contribute to the broader Gender Care and Services initiative. He shares more below.

Q: How unusual is it for a big company like Blue Cross to create this kind of position? What led to it?

A: Other providers have care coordinators for transgender people, but we're the only ones to do it in this way. It came up because we were hearing from community members experiencing disparities that got in the way of their being served well. A really common theme was the feeling of not fitting in; the wrong pronouns being used when they were spoken to, no place to check on the gender box, or just a general lack of belief in their lived experiences. But preventive care is a worrisome component. This population is less likely to get the care they need unless there's an emergency. Add COVID to that and you have even greater disparities for the LGBTQ community and people of color.

Q: You have more than anecdotal evidence to back up those concerns.

A: We did start to see the data come out that confirmed these disparities, such as a recent American Medical Association brief that showed transgender individuals are frequently subjected to bias and discrimination, are less likely to be insured than both the lesbian, gay and bisexual and general populations and often face challenges in accessing health care services.

Q: While your job title is new, you've been collaborating with Blue Cross for a while. What did your early outreach look like?

A: I initially became involved in this effort in 2017 as an external consultant providing gender identification trainings to Blue Cross associates annually. These trainings are one component of many within the broader Gender Care and Service initiative, which was launched in 2016 by Senior Program Manager Ani Koch. Under Ani's leadership, Blue Cross interviewed trans Minnesotans about their health care experiences, asking them, "What would excellent care look like for you?" It took nearly four years and a lot of people working together to move from that core idea to this position being created.

A: In 2016, Blue Cross committed to understanding the barriers to health experienced by the transgender and non-binary community, and to creating and implementing solutions. This has included creating internal policies around gender identity and restroom and locker room access, increased associate trainings, and designing care coordination efforts. Without that work happening at the outset and continuing now, my new position wouldn't exist or, if it did, it would not be set up to be successful. This policy, systems and culture work is essential to have a real, meaningful impact.

Q: Describe a typical day.

A: I work with Blue Cross case managers, nurses and behavioral health folks. If they have a transgender patient, for example, they can call me and say, "I'm advocating for them about diabetes but they just told me their claim for gender affirmation surgery has been denied. Can you help with that?" What has been amazing is joining case managers via conference call and informing the patient, "I'm here to support you through this process. Let's talk about it." I'll ask members what pronouns they use to be respectful and to gain trust. I think it helps that I'm a part of this community and I've had similar experiences.

Q: What's a myth you'd like to bust right here?

A: That "all these trans people are going to cost our companies so much money for gender affirmation surgeries; that all of our insurance rates will go up." First, many cases don't involve medical intervention at all. And, second, these procedures aren't even a drop in the bucket compared to other health issues, including mental health care and emergency room utilization, which is a downstream impact of not having a primary care provider whom you trust.

A: The reaction that families and friends have when someone comes out as trans has a huge impact on their long-term health. We need to believe them, treat them with respect and be that person for someone. It will literally save lives. If you don't know what to say to your nephew or niece who just came out as trans, for example, just say, "I love you. I'm always going to love you."

Q: What gives you hope?