National Transgender Discrimination Survey Report on health and

N at i o n a l Tr a n s g e n d e r D i s c r i m i n at i o n S u rv e y

R e p o rt o n h e a lt h a n d h e a lt h c a r e

Findings of a Study by the National Center for Transgender Equality and the National Gay and Lesbian Task Force

By Jaime M. Grant, Ph.D., Lisa A. Mottet, J.D., and Justin Tanis, D.Min.

With Jody L. Herman, Ph.D., Jack Harrison, and Mara Keisling

October 2010

Access to health care is a fundamental human right that is regularly denied to transgender and gender non-con-

forming people.

Transgender and gender non-conforming people frequently experience discrimination when accessing health care,

from disrespect and harassment to violence and outright denial of service. Participants in our study reported barri-

ers to care whether seeking preventive medicine, routine and emergency care, or transgender-related services. ese

realities, combined with widespread provider ignorance about the health needs of transgender and gender non-

conforming people, deter them from seeking and receiving quality health care.

Our data consistently show that racial bias presents a signicant, additional risk of discrimination for transgender

and gender non-conforming people of color in virtually every major area of the study, making their health care ac-

cess and outcomes dramatically worse.

K E Y H E A L T H C A R E F I N D I N G S

▪ Survey participants reported very high levels of postponing medical care when sick or injured due to

discrimination (28%) or inability to aord it (48%);

▪ Respondents faced signicant hurdles to accessing health care, including:

• Refusal of care: 19% of our sample reported being refused care due to their transgender or

gender non-conforming status, with even higher numbers among people of color in the survey;

• Harassment and violence in medical settings: 28% of respondents were subjected to

harassment in medical settings and 2% were victims of violence in doctor’s oces;

• Lack of provider knowledge: 50% of the sample reported having to teach their medical

providers about transgender care;

▪ Despite the barriers, the majority of survey participants have accessed some form of transition-

related medical care; the majority reported wanting to have surgery but have not had any surgeries yet;

▪ If medical providers were aware of the patient’s transgender status, the likelihood of that person

experiencing discrimination increased;

▪ Respondents reported over four times the national average of HIV infection, 2.64% in our sample

compared to .6% in the general population, with rates for transgender women at 3.76%, and with those

who are unemployed (4.67%) or who have engaged in sex work (15.32%) even higher;

▪ Over a quarter of the respondents misused drugs or alcohol specically to cope with the

discrimination they faced due to their gender identity or expression;

▪ A staggering 41% of respondents reported attempting suicide compared to 1.6% of the general

population, with unemployment, low income, and sexual and physical assault raising the risk factors

signicantly.

Page 2 | National Transgender Discrimination Survey Report on Health and Health Care

A B O U T T H E S U R V E Y

Every day, transgender and gender non-conforming people bear the brunt of social and economic marginaliza-

tion due to their gender identity. Advocates who work with transgender and gender non-conforming people have

known this for decades as they have worked with clients to nd housing, to obtain health and partnership benets,

or to save jobs terminated due to bias. Too often, policy makers, service providers, the media and society at large

have dismissed or discounted the needs of transgender and gender non-conforming people in their communities,

and a paucity of hard data on the scope of anti-transgender discrimination has hampered the struggle for basic fairness.

In 2008, the National Center for Transgender Equality and the National Gay and Lesbian Task Force formed a

ground-breaking research partnership to address this problem, launching the rst comprehensive national transgen-

der discrimination study. Over eight months, a team of community-based advocates, transgender leaders, research-

ers, lawyers, and LGBT policy experts came together to create an original survey instrument. Over 7,000 people

responded to the 70 question survey, providing data on virtually every signicant aspect of transgender discrimi-

nation—including housing, employment, health and health care, education, public accommodation, family life,

criminal justice, and identity documents.

We present our health ndings here, having just scratched the surface of this vast data source. We encourage

advocates and researchers to consider our ndings with an eye toward much-needed, in-depth future research. We

expect this data set to both answer and provoke many questions for years to come about the discrimination trans-

gender people experience. Please note that in some places, due to rounding, percentages will not add to 100%.

More extensive demographic and methodological information is presented at the end of this report. We present here

some key terms and the ways in which we have used them later in this report.

Visual Non-Conformity

At the outset of our study, the research team hypothesized, based on our anecdotal experience, that those respon-

dents whom others recognized as transgender might be at higher risk for discrimination and violence. us,

we asked whether the respondents believed their presentation matched their gender identity: “People know I am

transgender whether I tell them or not.” e term we developed for the study participants who are perceived to be

transgender primarily because of visual indicators is visual non-conformers.

roughout the report, we note the signicance of visual non-conformity as a risk factor in eliciting anti-transgen-

der bias and its attendant social and economic burdens.

Key H ea l th C are Fin di ng s , 1

Ab ou t t he Su r vey , 2

Vi su a l No n -C on for mi t y, 2

Ou tn e ss , 3

Tran s it io n, 3

Va ri ou s Ter ms r el ate d to o u r tra nsge n de r and

ge nd er no n- co nfo rm in g re s po nd en ts , 4

Ac ce s s to H ea l th C a re, 4

He al t h Ca re S ett i ng s, 4

He al t h Ca re E xp e ri en ces , 5

Postp on em e nt o f Ne ces sa r y an d P rev ent i ve

Me di ca l C are , 7

Ac ce s s to I ns u ran ce , 8

Tra ns it i on -Rel ate d Care , 1 0

Co un s el in g , 1 0

Ho rm o ne T h era py, 1 0

Su rge r y— Ma l e- to -fem al e , 11

Su rge r y— Fe ma le -to- mal e, 1 2

He al t h Vul ne rab i li ti es, 1 3

HI V, 13

Dr ug an d A lcoh ol U s e, 1 4

Sm ok i ng , 1 4

Su ic i de Att em pt s, 1 4

Co nc l us io n a nd Rec om me n dat i on s, 1 6

Me th od o lo gy an d Dem og rap hic s, 1 8

En dn o tes , 2 2

Ac kn o wl ed ge me nt s, 23

C o n t e n t s

National Transgender Discrimination Survey Report on Health and Health Care | Page 3

Never

Occasionally

Sometimes

Always

Most of

the time

“People know I am transgender whether I tell them or not.”

27%

29%

21%

16%

Outness

Along with visual conformity, the research team wondered about outness in the lives of our respondents. Our ques-

tion was: does self-reporting in society that one is transgender or expressing gender non-conformity have a protec-

tive eect against discrimination? In LGBT communities, there is an understanding of the process of coming out as

a path to self-empowerment and public understanding. Some studies among lesbian, gay and bisexual people have

shown positive eects of being out on social and economic outcomes.

Is the same true for transgender and gender

non-conforming people? Multiple questions on levels of outness helped us establish a range of categories from “out

everywhere” to “not out at all” in order to ascertain whether outness has a positive or negative eect in the lives of

transgender and gender non-conforming respondents.

Twenty-eight percent (28%) of respondents said they were out to all their medical providers. Eighteen percent

(18%) said they were out to most, 33% said some or a few, and 21% were out to none.

None

Some

Most

All

None

21%

All

28%

Most

18%

Some

33%

When seeking medical care, how many people know or

believe you are transgender or gender non-conforming:

Transition

Transition is a process that some, but not all, transgender and gender non-conforming people undertake to live as

a gender dierent from the one they were assigned at birth. For some, the journey traveled from birth sex to their

current gender may involve primarily a social change but no medical component; for others, medical procedures are

an essential step toward embodying their gender.

For some gender non-conforming respondents, transition as a framework has no meaning in expressing their

gender—there may be no transition process at all, only recognition of a gender identity that dees convention. For

other gender non-conforming people, transition is a meaningful concept that they do feel applies to their journey

from birth gender to their current identity.

Tra ns it i on -Rel ate d Care , 1 0

Co un s el in g , 1 0

Ho rm o ne T h era py, 1 0

Su rge r y— Ma l e- to -fem al e , 11

Su rge r y— Fe ma le -to- mal e, 1 2

He al t h Vul ne rab i li ti es, 1 3

HI V, 13

Dr ug an d A lcoh ol U s e, 1 4

Sm ok i ng , 1 4

Su ic i de Att em pt s, 1 4

Co nc l us io n a nd Rec om me n dat i on s, 1 6

Me th od o lo gy an d Dem og rap hic s, 1 8

En dn o tes , 2 2

Ac kn o wl ed ge me nt s, 23

Page 4 | National Transgender Discrimination Survey Report on Health and Health Care

Respondents in our sample were asked questions that helped us identify whether or not they had embarked on a

social or medical transition process in achieving embodiment of their gender. We hoped this data would be use-

ful to us and to future researchers in considering the role of transition in (among other things) transgender health,

economic security, experience of bias, and family life.

Two terms that we use throughout this report are medical transition and surgical transition. Here we use surgical

transition to identify those respondents who have had any type of transition-related surgical procedure. Medical

transition includes any surgeries or hormonal treatment.

Various terms related to our transgender and gender non-conforming respondents

As discussed more extensively in the methodology and demographics section at the end of this report, we divided

respondents into three categories for purposes of analysis: male-to-female transgender respondents, also called MTF

or transgender women; female-to-male transgender respondents, also called FTM or transgender men; and gender

non-conforming respondents, who are occasionally further divided into those on the female-to-male and those on

the male-to-female spectrum.

A C C E S S T O H E A L T H C A R E

Health care settings

A majority of study participants sought care (“when you are sick or need advice about your health”) through a

doctor’s oce (60%); however a signicant minority used health centers and clinics (28%). Four percent (4%) of

respondents primarily used emergency rooms for care. Several studies have shown that individuals who use emer-

gency rooms for primary care experience more adverse health outcomes than those who regularly see a primary

physician.

Factors that correlated with increased use of emergency rooms (ERs) were:

▪ Race—17% of African-Americans used ERs as did 8% of Latino/a respondents;

▪ Income—8% of respondents earning under $10,000 per year used ERs;

▪ Employment status—10% of unemployed respondents and 7% of those who had lost their jobs due to

bias used ERs;

▪ Education—13% of those with less than a high-school diploma used ERs.

Visual conformers and those who had identity documents that matched their presentation had the highest rates of

using doctor’s oces for their care.

17%

60%

Free

Clinic

VA ER Alternative

Provider

Health

Center

Doctor’s

Oce

Providers

National Transgender Discrimination Survey Report on Health and Health Care | Page 5

Health Care Experiences

Discrimination by Medical Providers

Denial of health care and multiple barriers to care are commonplace in the lives of trans-

gender and gender non-conforming people. Subjects in our study seeking health care

were denied equal treatment in doctor’s oces and hospitals (24%), emergency rooms

(13%), mental health clinics (11%), by EMTs (5%), and in drug treatment programs

(3%).

Female-to-male respondents reported higher rates of unequal treatment than

male-to-female respondents. Latino/a respondents reported the highest rate of unequal

treatment of any racial category (32% by a doctor or hospital and 19% in both emer-

gency rooms and mental health clinics).

We also asked whether respondents had been denied service altogether by doctors and other providers.

Nineteen

percent (19%) had been refused treatment by a doctor or other provider because of their transgender or gender

non-conforming status.

Twenty-two percent (22%) of MTF respondents reported having been refused treatment altogether, whereas 19%

of FTM respondents did. Respondents who had lost jobs due to bias (36%); those who engaged in sex work, drug

sales or other underground economies for income (30%); those on public insurance (28%); and those living full-

time as their gender identity (25%) experienced high occurrence of refusal to treat.

A doctor or other provider refused to treat me because I am transgender or gender non-conforming:

Refusal of care by race

19%

15%

19%

22%

36%

27%

17%

Total

Sample

Asian Black Hispanic White Multi-

racial

American

Indian

GNC

FTMMTF

Total Sample

Refusal of care by gender identity

19% 19%

22%

36%

27%

19%

of respondents were

refused treatment

Page 6 | National Transgender Discrimination Survey Report on Health and Health Care

Violence and Harassment when Seeking Medical Treatment

Doctors’ oces, hospitals, and other sources of care were often unsafe spaces for study

participants. Over one-quarter of respondents (28%) reported verbal harassment in a

doctor’s oce, emergency room, or other medical setting and 2% of the respondents

reported being physically attacked in a doctor’s oce.

ose particularly vulnerable to physical attack in doctors’ oces and hospitals include

those who have lost their jobs (6%); African-Americans (6%); those that engaged in

sex work, drug sales or other underground economies (6%); those who transitioned before they were 18 (5%); and

those who are undocumented non-citizens (4%). In emergency rooms, those more vulnerable to attack include

those who are undocumented (6%); those who have engaged in sex work, drug sales, or other underground econo-

mies for income (5%); those who lost their jobs (4%); and Asians (4%). Obviously, harassment and physical

attacks have a deterrent eect on patients seeking additional care and impact the wider community as information

about such abuses circulates.

Outness

In accordance with professional standards, doctors can provide more eective care when

they have all medically relevant information about their patients. Unfortunately, our

data shows that doctors’ knowledge of a patient’s transgender status increases the likeli-

hood of discrimination and abuse. Medical professionals’ awareness of their patient’s

transgender status increased experiences of discrimination among study participants

up to eight percentage points depending on the setting:

▪ Denied service altogether: 23% of those who were out or mostly out to

medical providers compared to 15% of those who were not out or partly out

▪ Harassment in ambulance or by EMT: 8% of those who were out or mostly out to medical providers

compared with 5% of those who were not out or partly out

▪ Physically attacked or assaulted in a hospital: 2% of those who were out or mostly out to medical

providers compared with 1% of those who were not out or partly out

Medical Providers’ Lack of Knowledge

When respondents saw medical providers, including doctors, they often encountered ignorance about basic tenets

of transgender health and found themselves required to “teach my provider” to obtain appropriate care. Fully 50%

of study respondents reported having to teach providers about some aspect of their health needs; those who report-

ed “teaching” most often include female-to-male transgender respondents (61%), those who live full-time as their

gender identity (61%), and those on public insurance (56%).

28%

reported being

verbally harassed

in a medical setting

of the respondents

reported b ein g

physically attacked

in a doctor’s oce

National Transgender Discrimination Survey Report on Health and Health Care | Page 7

Postponement of Necessary and Preventive Medical Care

We asked respondents whether they postponed or did not try to get two types

of health care: preventive care “like checkups” and necessary care “when sick or

injured.” We found that many postponed care because they could not aord it and

many postponed care because of discrimination and disrespect from providers.

A signicant number of study participants postponed necessary medical care due to

inability to aord it, whether seeking care when sick or injured (48%), or pursuing

preventive care (50%). Female-to-male transgender respondents report postpon-

ing any care due to inability to aord it at higher rates (55%) than male-to-female

transgender respondents (45%).

Insurance played a signicant factor: those who have private insurance were much

less likely to postpone care because of inability to aord it when sick or injured (37%) than those with public

(46%) or no insurance who postponed care (86%).

In terms of preventive care, those without insurance reported delaying care due to inability to aord it much more

frequently (88%) than those with private insurance (39%) or public insurance (44%). Failing to obtain preventive

care is known to lead to poor long-term health outcomes.

Preventive

Needed

GNC (FTM spectrum)GNC (MTF spectrum)FTMMTF

22%

25%

42%

48%

17%

18%

23%

33%

Postponement due to discrimination by providers

Due to discrimination and disrespect, 28% postponed or avoided medical treatment when they were sick or injured

and 33% delayed or did not try to get preventive health care. Female-to-male transgender respondents reported

postponing care due to discrimination and disrespect at a much higher frequency (42%, sick/injured; 48% preven-

tive) than male-to-female transgender respondents (22%, sick/injured; 25% preventive). ose with the highest

rates of postponement included those who have lost a job due to bias (45%) and those who have done sex work,

sold drugs, or engaged in other underground economies for income (45%). Twenty-nine percent (29%) of re-

spondents who were “out” or “mostly out” to medical providers reported they had delayed care when ill and 33%

postponed or avoided preventive care because of discrimination by providers.

One fourth of

study participants

report delaying

needed care because

of disrespect and

discrimination

from medical

providers.

Page 8 | National Transgender Discrimination Survey Report on Health and Health Care

Access to Insurance

Study participants were less likely than the general population to have health insurance, more likely to be covered

by state programs such as Medicare or Medicaid, and less likely to be insured by an employer.

Nineteen percent (19%) of the sample lacked any health insurance compared to 15% of the general population.

African-American respondents had the worst health insurance coverage of any racial category: 39% reported private

coverage and 30% public. irty-one percent (31%) of Black respondents reported being uninsured; by contrast

66% of white respondents reported private insurance, 17% public insurance and 17% uninsured.

Undocumented non-citizens had very low rates of coverage: 26% reported private insurance, 37% public insurance,

and 36% no insurance. e South was the worst region for coverage where 59% of respondents reported private

insurance, 17% public insurance and 25% no insurance. In terms of gender, MTFs reported private insurance

at 56%, public insurance at 23% and 20% uninsured. FTMs reported private insurance at 69%, public insurance

at 13% and 19% with no insurance. Gender non-conforming respondents were insured at higher rates than their

transgender counterparts, with 73% private insurance, 11% public insurance, and 17% uninsured.

0 5 10 15 20 25 30 35 40

no insurance

Current or former employer

Someone else’s employer

Medicare

Purchased

military health-care

other public health care

student insurance

Other

11%

19%

Medicaid

Student Insurance

Other Public Health Care

Military Health Care

Purchased

Medicare

Someone Else’s Employer

Current or Former Employer

No Insurance

40%

Source of Insurance

National Transgender Discrimination Survey Report on Health and Health Care | Page 9

100

Uninsured

Public insurance

Private insurance

MultiracialAmerican IndianWhiteHispanicBlackAsian

69%

22%

39%

30%

31%

28%

17%

25%

23%

22%

55%

33%

42%

17%

66%

20%

52%

Health Insurance by Race

Page 10 | National Transgender Discrimination Survey Report on Health and Health Care

T R A N S I T I O N - R E L A T E D C A R E

Most survey respondents had sought or accessed some form of transition-related care. Counseling and hormone

treatment were notably more utilized than any surgical procedures, although the majority reported wanting to

“someday” be able to have surgery. e high costs of gender-related surgeries and their exclusion from most health

insurance plans render these life-changing (in some cases, life-saving) and medically necessary procedures inacces-

sible to most transgender people.

roughout this section, we focus primarily on transgender people rather than on gender non-conforming people.

Gender non-conforming people may also desire and sometimes acquire various forms of gender-related medical

care.

e World Professional Association for Transgender Health (WPATH) publishes Standards of Care

which are

guidelines for mental health, medical, and surgical professionals on the current consensus for providing assistance to

patients who seek transition-related care. ey are intended to be exible to assist professionals and their patients in

determining what is appropriate for each individual. e Standards of Care are a useful resource in understanding

the commonly experienced pathways through transition-related care.

Counseling

Counseling often plays an important role in transition. Because of the WPATH Standards of Care, medical provid-

ers often require a letter from a qualied counselor stating that the patient is ready for transition-related medical

care; transgender people may seek out counseling for that purpose. Counseling may also play a role in assisting with

the social aspects of transition, especially in dealing with discrimination and family rejection.

Seventy-ve percent (75%) of respondents received counseling related to their gender identity and an additional

14% hoped to receive it someday. Only 11% of the overall sample did not want it. ose who identied as trans-

gender were signicantly more likely to have had counseling (80%) than those who are gender non-conforming

(48%). Eighty-nine percent (89%) of those who medically transitioned have received counseling along with 91%

of those who had some type of surgery.

Part of counseling can involve receiving a gender-related mental health diagnosis such as “Gender Identity Disor-

der.” Many doctors require this diagnosis before providing hormones or surgical treatment, but the diagnosis itself

is widely criticized as pathologizing naturally occurring gender variance.

Fifty-percent (50%) of study participants

have received a gender-related mental health diagnosis. MTFs reported a higher rate of diagnosis (61%) than

FTMs (53%); and transgender-identied participants had a signicantly higher rate of diagnosis (58%) than gender

non-conforming respondents (11%).

Hormone erapy

Sixty-two percent (62%) of respondents have had hormone therapy, with the likelihood increasing with age; an

additional 23% hope to have it in the future. Transgender-identied respondents accessed hormonal therapy at

much higher rates than their gender non-conforming peers, with those who identied as MTF more likely to have

accessed hormone therapy (71%) than FTM respondents (66%). Almost all respondents who reported undertak-

ing transition-related surgeries also reported receiving hormone therapy (93%).

National Transgender Discrimination Survey Report on Health and Health Care | Page 11

20%

40%

60%

80%

100%

Have had

Want Someday

Do Not Want

65+55-6445-5425-4418-24

Hormone erapy by Age of Respondent

Surgery—Male-to-female

Transgender women may elect to undertake a variety of surgeries, including breast augmentation, removal of testes,

other genital surgeries, and facial feminization surgery. We asked respondents to report on chest surgery, removal

of the testes, and other genital surgery. ree-quarters of transgender women reported that they desired to have sur-

gery at some point in the future or had already done so. However, it is impossible to know how many would desire

or utilize surgery if it were more nancially accessible.

27%

29%

Don't want

Want someday

Have had

18%

Want someday

54%

Don’t want

28%

MTF Chest Surgery

27%

29%

Don't want

Want someday

Have had

21%

Want someday

59%

Don’t

want

20%

MTF Removal of Testes

27%

29%

Don't want

Want someday

Have had

20%

Want someday

60%

Don’t

want

20%

MTF Removal of Penis

and Creation of Vagina

Page 12 | National Transgender Discrimination Survey Report on Health and Health Care

Surgery—Female-to-male

Transgender men may elect to undertake a variety of surgeries, including chest reconstruction, hysterectomy and

other genital surgeries. We asked respondents to report on chest surgery; hysterectomy; metoidioplasty, which

releases the clitoris; surgeries that create testes; and phalloplasty, which surgically creates a penis and testes. e

majority of FTM transgender-identied respondents wanted to have, or have already had, chest surgery and a

hysterectomy. However, when it came to genital surgeries, very few reported having such surgeries; a slim majority

(51%) reported desiring other genital surgery such as metoidoplasty in addition to the 3% that have had it; and

one-quarter (26%) wanted to have a phalloplasty in addition to the 2% who have had it. It is impossible to know

how these rates would change if these surgeries were nancially accessible.

27%

29%

Don't want

Want someday

Have had

41%

Want

someday

51%

Don’t want 8%

FTM Chest Surgery

27%

29%

Don't want

Want someday

Have had

20%

Don’t want

23%

Want someday

57%

FTM Hysterectomy

27%

29%

Don't want

Want someday

Have had

Have had 3%

Don’t want

45%

Want

someday

51%

FTM Metoidoplasty/

Creation of Testes

27%

29%

Don't want

Want someday

Have had

Have had 2%

Don’t want

72%

Want

someday

26%

FTM Phalloplasty

National Transgender Discrimination Survey Report on Health and Health Care | Page 13

H E A L T H V U L N E R A B I L I T I E S

Survey participants reported poorer health outcomes than the general population in a variety of critical health areas.

HIV

Respondents reported an HIV infection rate of 2.64%, over four times the rate of HIV infection in the general

United States adult population (0.6%) as reported by the United Nations Programme on HIV/AIDS and the World

Health Organization.

People of color reported HIV infection at signicantly higher rates: 24.90% of African-

Americans, 10.92% of Latino/as, 7.04% of American Indians, and 3.70% of Asian-Americans in the study reported

being HIV positive. is compares with national rates of 2.4% for African Americans, .08% Latino/as, and .01%

Asian Americans.

Non-U.S. citizens in our sample reported more than twice the rate of HIV infection of U.S.

citizens (2.41%), with documented non-citizens at 7.84% and undocumented at 6.96%.

0.6%

General

Popul-

ation

Survey

Total

Asian

African

American

Latino/

Latina

White

Multi-

racial

American

Indian

2.64%

24.90%

24.9%

10.92%

3.52%

7.04%

3.70%

0.78%

HIV infection by race compared to

U.S. general population

Engaging in sex work for income clearly was a major risk factor for study participants, with 61% of those who

reported HIV infection in our sample having engaged in sex work. To consider this from a dierent angle, of all the

people in our sample who had engaged in sex work, 15.32% reported being HIV positive.

Among survey participants, 91% of those who reported being HIV positive identied as either MTF or gender

non-conforming on the male-to-female spectrum. e reported rate of HIV infection for the MTF transgender re-

spondents was 3.76%. e reported rate of HIV infection for FTM respondents was .48%, lower than the national

average.

Other categories that reported signicantly higher HIV rates than the sample as a whole were:

▪ ose without a high-school diploma (13.49%)

▪ ose with income below $10,000 a year (6.40%)

▪ ose who had lost a job due to bias (4.59%) or reported being unemployed (4.67%)

Eight percent (8%) of our sample reported that they did not know their HIV status.

Page 14 | National Transgender Discrimination Survey Report on Health and Health Care

Drug and Alcohol Use

e National Institutes of Health (NIH) estimate that 7.3% of the general public

abuses or is dependent on alcohol, while 1.7% abuses or is dependent on non-pre-

scription drugs.

Eight percent (8%) of study participants reported currently using al-

cohol or drugs specically to cope with the mistreatment that they received as a result

of being transgender or gender non-conforming, while 18% said they had done so in

the past but do not currently. We did not ask about general use of alcohol and drugs,

only usage which the respondents described as a coping strategy for dealing with the

mistreatment they face as a transgender or gender non-conforming person.

Participation in sex work, drug sales, and other underground economies for income more than doubles the risk of

alcohol or drug use because of mistreatment, with 19% of these respondents currently using alcohol and/or drugs

while 36% reported that they had done so in the past. Also at elevated risk were those who had lost a job due to

discrimination; 12% reported currently using drugs and alcohol, while 28% have done so in the past.

Alcohol and drug use decreased by age among our participants, the same as in studies of the general population,

with those 65 years and above reporting less than half the rate of use (4%) of those who are the 18-44 age range

(9%). is contrasts with studies of LGBT populations that show a less dramatic decrease in use over the life

cycle;

however, because our study only asked about use connected to mistreatment, the comparisons with both

the general population and LGBT studies are not exact.

Smoking

irty percent (30%) of our sample reported smoking daily or occasionally, compared to 20.6% of U.S. adults.

Studies of LGBT adults show similar rates to our study, with elevated rates of 1.1-2.4 times that of the general

population,

and a 2004 California study found a 30.7% smoking rate for transgender people.

In the general

population, men smoke at higher rates than women, but in LGBT studies, women smoke at higher rates than men.

Our sample resembled the LGBT data regarding elevated smoking levels but diered in that more men than women

in our sample smoke, a pattern which is closer to that of the general population. When asked if they would “like to

quit,” 70% of smokers in the study selected yes.

Comparisons

General Population Lesbian and Gay Bisexual Our Sample

Men 23.1% 26.5-30.9% 29.5-38.1% 33%

Women 18.3% 22.3-26% 30.9-39.1% 29%

Suicide Attempts

When asked “have you ever attempted suicide?” 41% of respondents answered yes. According to government

health estimates, ve million, or 1.6%, of currently living Americans have attempted suicide in the course of their

lives.

Our study asked if respondents had ever attempted suicide while most federal studies refer to suicide at-

tempts within the last year; accordingly it is dicult to compare our numbers with other studies. Regardless, our

ndings show a shockingly high rate of suicidality.

e National Institute for Mental Health (NIMH) reports that most suicide attempts are signs of extreme distress,

with risk factors including precipitating events such as job loss, economic crises, and loss of functioning.

Given

that respondents in this study reported loss in nearly every major life area, from employment to housing to family

life, the suicide statistics reported here cry out for further research on the connection between the consequences of

bias in the lives of transgender and gender non-conforming people and suicide attempts.

26% use or have

used alcohol

and drugs to

cope with the

impacts of

discrimination.

National Transgender Discrimination Survey Report on Health and Health Care | Page 15

NIMH also reports that generally African-Americans, Hispanics and Asians have signicantly lower suicide rates

than whites and American Indians; our sample showed a dierent pattern of risk for suicide by race.

White

Asian

Latino/

Latina

African

American

Multi-

racial

American

Indian

Total

Sample

41%

38%

39%

44%

45%

54%

56%

Suicide Attempt by Race

Respondents’ work status had a signicant impact on their likelihood of having attempted suicide:

Employed Unemployed Lost Job

due to Bias

Street

Economy

Total

Sample

41%

37%

51%

55%

60%

Suicide Attempt by Employment

In terms of age cohort risk, the highest rates of suicide attempts in this study were reported among those in the

18-44 age cohort (45%), with only 16% of those over 65 reporting a suicide attempt. ese rates are inverse to the

general population, which shows a higher incidence of attempts among older Americans than youth.

Our data does not show at what age the respondents made suicide attempts and therefore it is dicult to draw

conclusions about the risk of suicide over their life spans. However, there are a number of attributes that correlate

with an increased rate of attempted suicide. High risk cohorts include visual non-conformers (44%); those who are

generally out about their transgender status (44%); and those who have only some of their identity documents in

Page 16 | National Transgender Discrimination Survey Report on Health and Health Care

their preferred gender (46%). ose who have medically transitioned (45%) and surgically transitioned (43%) have

higher rates of attempted suicide than those who have not (34% and 39% respectively).

ose who were bullied, harassed, assaulted, or expelled because they were transgender or gender non-conforming

in school also reported signicantly elevated levels of suicide attempts (51% compared with 41% of our sample as a

whole). Most notably, suicide attempt rates rise dramatically when teachers were the reported perpetrators: 59% for

those harassed or bullied by teachers, 76% among those who were physically assaulted by teachers and 69% among

those who were sexually assaulted by teachers. ese numbers speak to the urgency of ending violence and harass-

ment of transgender students by both their peers and their teachers.

Education and income both correlate with suicide rates, with those earning $10,000 annually or less at extremely

high risk (54%), while those making more than $100,000 are at comparatively lower risk (26%), while still astro-

nomically higher than the general population. ose who have not completed college attempted suicide at higher

rates (48% among those with no high school degree, 49% for those with a high school degree only, and 48% for

those with some college education) while those have completed college (33%) or graduate school (31%) have sig-

nicantly lower rates.

ose who had survived violence perpetrated against them because they were transgender or gender non-conform-

ing were at very high risk; 61% of physical assault survivors reported a suicide attempt, while sexual assault survi-

vors reported an attempt rate of 65%.

C O N C L U S I O N A N D R E C O M M E N D A T I O N S

Respondents in our study reported signicant barriers to health care and outrageous frequencies of anti-transgender

bias in care, from disrespect to refusal of care, from verbal harassment to physical and sexual abuse. Transgender

people of color and low income respondents faced signicantly elevated risk of abuse, refusal of care, and poor

health outcomes than the sample as a whole.

e data gathered here speak to a tremendous need to examine the connection between multiple incidences of

discrimination, harassment, and abuse faced by our respondents in the health care system and the high risk for poor

health outcomes. Additionally, our data suggest that discriminatory events are commonplace in the daily lives of

transgender people and that this has a cumulative impact—from losing a job because of bias to losing health insur-

ance; from experiencing health provider abuse to avoiding health care; from long-term unemployment to turning to

work on the streets. e collective impact of these events exposed our respondents to increased risk for HIV infec-

tion, smoking, drug/alcohol use, and suicide attempts.

It is important to note that the traumatic impact of discrimination also has health care implications. Transgender

people face violence in daily life, compounded by the high rates of physical and sexual assault that transgender

people face while accessing medical care, which leads to additional health care costs, both to treat the immediate

trauma as well as ongoing physical and psychological issues that may be created.

As we have seen across a number of categories in the survey, the ability to work signicantly impacts transgender

health. In particular, those who have been red due to anti-transgender bias and those who have engaged in sex

work, drug sales, or other underground economies for income are much more likely to experience health risks that

are shown to lead to poorer health outcomes.

Discrimination in the health care system presents major barriers to care for transgender people and yet a majority

of our survey participants were able to access some transition-related care, with 75% receiving counseling and 62%

obtaining hormones. Genital surgery, on the other hand, remains out of reach for a large majority, despite being

desired by most respondents. is is one signicant reason why legal rights for transgender people must never be

determined by surgical status.

National Transgender Discrimination Survey Report on Health and Health Care | Page 17

Recommendations

¾ Anti-transgender bias in the medical profession and U.S. health care system has catastrophic consequences

for transgender and gender non-conforming people. is study is a call to action for the medical profession;

▪ e medical establishment must fully integrate transgender-sensitive care into its professional standards,

and this must be part of a broader commitment to cultural competency around race, class, and age;

▪ Doctors and other health care providers who harass, assault, or discriminate against transgender and

gender non-conforming patients should be disciplined and held accountable according to the standards

of their professions.

¾ Public and private insurance systems must cover transgender-related care; it is urgently needed and is

essential to basic health care for transgender people.

¾ Ending violence against transgender people must be a public health priority, because of the direct and

indirect negative eect it has on both victims and on the health care system that must treat them.

¾ Medical providers and policy makers should never base equal and respectful treatment and the attainment of

government-issued identity documents on:

▪ Whether an individual has obtained surgery, given that surgeries are nancially inaccessible for large

majorities of transgender people because they are rarely covered by either public or private insurance;

▪ Whether an individual is able to aord or attain proof of citizenship or legal residency.

¾ Rates of HIV infection, attempted suicide, drug and alcohol abuse, and smoking among transgender and

gender non-conforming people speak to the overwhelming need for:

▪ Transgender-sensitive health education, health care, and recovery programs;

▪ Transgender-specic prevention programs.

¾ Additional data about the health outcomes of transgender and gender non-conforming people is urgently

needed;

▪ Health studies and other surveys need to include transgender as a demographic category;

▪ Information about health risks, outcomes and needs must be sought specically about transgender

populations;

▪ Transgender people should not be put in categories such as “men who have sex with men” (MSM) as

transgender women consistently are and transgender men sometimes are. Separate categories should be

created for transgender women and transgender men so HIV rates and other sexual health issues can be

accurately tracked and researched.

Page 18 | National Transgender Discrimination Survey Report on Health and Health Care

M E T H O D O L O G Y

e National Transgender Discrimination Survey is the most extensive survey of transgender discrimination ever

undertaken. Over four months, our research team elded its 70 question survey through direct contacts with more

than 800 transgender-led or transgender-serving community-based organizations throughout the United States. We

also contacted possible participants through 150 active online community listservs. e vast majority of respon-

dents took the survey on-line, through a URL established at Pennsylvania State University.

Additionally, we distributed 2,000 paper surveys to organizations serving hard-to-reach populations – including

rural, homeless, and low-income transgender and gender non-conforming people –conducting phone follow-ups

over three months. With only $3,000 in dedicated funding for outreach, we paid stipends to workers in home-

less shelters, legal aid clinics, mobile health clinics, and other service settings to host “survey parties” to encourage

respondents whose economic vulnerability, housing insecurity, or literacy level might pose particular barriers to

participation. is eort resulted in the inclusion of 500 paper surveys in the nal sample.

While over 7,000 people completed online and paper surveys, the nal study sample includes 6,450 valid respon-

dents from all 50 states, the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands. Our geograph-

ic distribution mirrors that of the general U.S. population.

1 Dot: 100,000 People

1 Dot: 1 Person

National Transgender Discrimination Survey Report on Health and Health Care | Page 19

21%

18%

21%

17%

15%

New England

(ME, NH,

VT, MA,

RI, CT)

Mid-Atlantic

(NY, NJ,

DE, PA,

MD, DC

VA, WV)

South

(NC, SC,

GA, FL,

AL, MS,

LA, TX,

OK, AR,

TN, KY

Mid-West

(OH, MI,

IN, IL,

WI, MN,

IA, MO,

KS, NE,

SD, ND)

West

(NM, AZ,

CO, WY,

UT, NV,

MY, ID,

WA, OR,

AK, HI)

California

(CA)

Respondents by Region

Demographics.

We asked participants questions to help us create categories by which we could consider their reported experiences.

Any attempt to create such constructs is limited and constraining. We did so in the interest of analyzing conditions

and situations that are more harmful or less harmful and more empowering or more threatening to the well-being

of our respondents.

Gender Identity

Respondents identied across a broad spectrum of gender identities.

We asked several questions to establish the gender identity of our respondents, including: sex assigned at birth; cur-

rent gender identity; and a list of terms that describe various gender identities including MTF, FTM, genderqueer,

androgynous, two-spirited, etc. We asked respondents to indicate where they rested along a spectrum of identica-

tion with the many terms on our list, from “strongly” to “not at all.” From this set of responses, we created criteria

for several gender categories that, though limited, provide a framework from which to analyze strengths, resiliencies,

and exposure to prejudice and abuse.

In this report on health, we generally commented on the experiences of respondents who—via the choices described

above—identify as male-to-female transgender (MTF), also referred to as transgender women, and female-to-male

transgender (FTM), also referred to as transgender men. Fully 88% of all respondents fall into one of these two

categories.

We also discussed the experiences of the 12% of the sample to whom we refer as “gender non-conforming,” which

includes those who identied as gender queer or as gender non-conforming. ree percent (3%) of our sample

self-reported identifying as gender non-conforming along a male-to female spectrum of gender identity and 9%

describe themselves as gender non-conforming along a female-to-male spectrum of gender identity.

While the research team understands gender identity and expression to be more complex and layered than the col-

lapsed categories presented here, for the purposes of this study, these constructs created useful “containers” in which

to organize and analyze respondents’ experiences of anti-transgender bias and its impacts.

Page 20 | National Transgender Discrimination Survey Report on Health and Health Care

Race

Along the same lines as our questions on gender, the research team used standard but simplied racial categories for

the purposes of analysis and to avoid statistically insignicant sample sizes. e persistence of racism in the U.S.

creates observable negative outcomes in terms of present-day realities for our transgender respondents. Our nd-

ings conrm what is obvious in American society today: structural racism—and its signicant consequences—persists.

With a “check all that apply” instruction, respondents chose from a limited list of race signiers. While our choices

do not mirror Census demographic categories on race, which are more extensive, our sample’s racial and ethnic

breakdown resembles the national portrait of race and ethnicity.

White

76%

Latino/Latina 5%

American Indian/

Alaska Native 1%

Multiracial 11%

Black 5%

Asian 2%

Race of Respondents

Age

e sample includes participants from 18 to 89 years of age. In nearly every age category, this is the largest sample

of transgender experiences of discrimination ever collected.

19%

52%

17%

11%

2% 65+ years old

18-24 years old

25-44

years old

45-54

years old

55-64 years old

Age of Respondents

National Transgender Discrimination Survey Report on Health and Health Care | Page 21

Sexual Orientation

e sexual orientation of the sample demonstrates the diverse spectrum of sexual orientations among transgender

and gender non-conforming people. Among respondents, 23% reported a lesbian, gay, or same-gender attracted

sexual orientation; 24% identied as bisexual; 23% reported a queer/pansexual orientation; 23% reported a hetero-

sexual sexual orientation; 4% describe themselves as asexual; and 2% wrote in other answers.

23%

24%

23%

Other 2%

Gay, lesbian

or same gender

Bisexual

Queer/

Pansexual

Heterosexual

Asexual 4%

Sexual Orientation of Respondents

is chart illustrates the range of sexual orientations in the transgender community. ose who assume all trans-

gender people are straight after transition are as incorrect as those who would assume them all to be gay, lesbian, or

bisexual. ese assumptions create additional barriers even in supposedly transgender-friendly spaces.

e common assumption that gender identity and sexual orientation form the basis for two distinct communities

obscures the reality, documented here, that the majority of transgender people are lesbian, gay, bisexual, or queer-

identied. While debate in the LGBT community often draws clear lines of demarcation between the LGBs and

the Ts, our ndings suggest that there is signicant overlap.

Page 22 | National Transgender Discrimination Survey Report on Health and Health Care

E N D N O T E S

Some researchers have found that coming out to family members and others may have some positive inuence

on identity formation and social and intimate relationships for lesbians and gay men. Savin-Williams, R. (1989).

“Coming Out to Parents and Self-Esteem Among Gay and Lesbian Youths,” Journal of Homosexuality 18(1-2); Mey-

er, Ilan. (2003). “Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual

Issues and Research Evidence,” Psychol Bull 129(5); Eliason, M. (1996). “Identity Formation for Lesbian, Bisexual,

and Gay Persons,” Journal of Homosexuality 30(3).

See for example Foraselli, P., DeAngelis, C., & Kaszuba, A. (1985). Compliance with follow-up appointments

generated in a pediatric emergency room. Am J Prev Med, 1(3), Pediatr Emerg Care. Chande, V.T., Krug, S.E., &

Warm, E.F. (1996). Pediatric emergency department utilization habits: a consumer survey. Pediatr Emerg Care,

12(1).

ese results were based on our question 30, which was prefaced by: “Based on being transgender/gender non-con-

forming, please check whether you have experienced any of the following in these public spaces,” and asked respon-

dents to indicate whether they had been “denied equal treatment or service” for each of the various locations.

ese results were based on our question 43, which was prefaced by: “Because you are transgender/gender non-

conforming, have you had any of the following experiences?” and asked respondents to indicate whether “a doctor

or other provider refused to treat me because I am transgender/gender nonconforming.”

DeNavas-Walt, C., Proctor, B., Smith, J., & U.S. Census Bureau. (2009). Current Population Reports, Income,

Poverty, and Health Insurance Coverage in the United States: 2008. Retrieved September 22, 2010, from http://

www.census.gov/prod/2009pubs/p60-236.pdf

World Professional Association of Transgender Health. (2001). Standards of Care for Gender Identity Disorders,

Sixth Version. Retrieved September 21, 2010, from http://www.wpath.org/documents2/socv6.pdf

e National Gay and Lesbian Task Force’s statement on reform of the American Psychiatric Association’s Diagnos-

tic and Statistical Manual (DSM) can be accessed at http://www.transgenderlaw.org/medicalhealthcare/NGLTF_

DSM_Statement.pdf . e National Center for Transgender Equality’s position may be found at http://transgende-

requality.wordpress.com/wp-admin/post.php?post=264&action=edit .

United Nations Programme on HIV/AIDS (UNAIDS), & World Health Organization (WHO). (2007). 07 AIDS

Epidemic Update. Retrieved September 14, 2010, from http://data.unaids.org/pub/EPISlides/2007/2007_epiup-

date_en.pdf

Henry J. Kaiser Family Foundation. (2007). e HIV-AIDS Epidemic in the United States. Retrieved September

14, 2010, from http://www.k.org/hivaids/upload/3029-071.pdf

Substance Abuse and Mental Health Services Administration. (2009). Results from the 2008 National Survey

on Drug Use and Health: National Findings. Retrieved September, 14, 2010, from http://www.oas.samhsa.gov/

nsduh/2k8nsduh/2k8Results.pdf

Substance Abuse and Mental Health Services Administration. (2010). Results from the 2009 National Survey on

Drug Use and Health: Volume I. Summary of National Findings. Oce of Applied Studies, NSDUH Series H-

38A, HHS Publication No. SMA 10-4586Findings. In particular, see p. 30, chart 3.1.

National Institute on Alcohol and Alcoholism. (2005). Sexual Orientation and Alcohol Use Disorders. Retrieved

September 24, 2010, from http://pubs.niaaa.nih.gov/publications/social/Module10GSexualOrientation/Modu-

le10G.html.

American Lung Association. (2010). Smoking Out a Deadly reat: Tobacco Use in the LGBT Community.

Retrieved September 14, 2010, from http://www.lungusa.org/assets/documents/publications/lung-disease-data/lgbt-

report.pdf

National Transgender Discrimination Survey Report on Health and Health Care | Page 23

Review of literature aggregated in American Lung Association. (2010). Smoking Out A Deadly reat: Tobacco

Use in the LGBT Community. Retrieved September 14, 2010, from http://www.lungusa.org/assets/documents/

publications/lung-disease-data/lgbt-report.pdf.

Bye, L., Gruskin, E., Greenwood, G., Albright, V., & Krotki, K. (2005). California Lesbians, Gays, Bisexuals, and

Transgender (LGBT) Tobacco Use Survey – 2004. California Department of Health Services. Retrieved September

14, 2010, from http://www.cdph.ca.gov/programs/tobacco/Documents/CTCP-LGBTTobaccoStudy.pdf

e general population, lesbian and gay, and bisexual data in this table is from Bye, L., Gruskin, E., Greenwood,

G., Albright, V.,& Krotki, K. (2005). California Lesbians, Gays, Bisexuals, and Transgender (LGBT) Tobacco Use

Survey – 2004. California Department of Health Services. Retrieved September 14, 2010, from http://www.cdph.

ca.gov/programs/tobacco/Documents/CTCP-LGBTTobaccoStudy.pdf. e data on transgender persons is ours.

“U.S.A. Suicide: 2002 Ocial Final Data,” prepared for the American Association of Suicidology by John L. Mc-

Intosh, Ph.D. Ocial data source: Kochanek, K.D., Murphy, S.L., Anderson, R.N., & Scott, C. (2004). Deaths:

Final data for 2002. National Vital Statistics Reports, 53 (5). Hyattsville, MD: National Center for Health Statistics

DHHS Publication No. (PHS) 2005-1120. Population gures source: table I, p.108. of the National Center for

Health Statistics (Kochanek et al., 2004), see http://www.sprc.org/library/event_kit/2002datapgv1.pdf

National Institute of Mental Health. (2010). Suicide in the U.S.: Statistics and Prevention. Retrieved September

22, 2010, from http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention/index.

shtml

American Foundation for Suicide Prevention. (2010). Risk Factors for Suicide. Retrieved September 22, 2010,

from http://www.afsp.org/index.cfm?fuseaction=home.viewPage&page_id=05147440-E24E-E376-BDF4BF-

8BA6444E76. According to the Substance Abuse and Mental Health Services Administration, adults who have had

a major depressive episode—the leading risk factor for suicide—in the previous twelve months had an attempt rate

of 10.4%.

National Institute of Mental Health. (2010). Suicide in the U.S.: Statistics and Prevention. Retrieved September

22, 2010, from http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention/index.

shtml

e National Transgender Discrimination Survey met the standards established by Pennsylvania State University’s

Institutional Review Board (IRB) to ensure the condentiality and humane treatment of our survey participants.

We are grateful to Dr. Susan Rankin, a nationally recognized LGBT researcher, for hosting our study through Penn-

sylvania State University’s Consortium on Higher Education.

We are grateful to the LGBT Tobacco Control Network for this funding, which undoubtedly improved access to

the study and allowed us to explore levels of tobacco use among transgender people.

We use terms in this study that have dierent meanings across nations, cultures, and regions. For the purposes of

analyzing information reported in this study, we necessarily had to develop working denitions that may dier in

other contexts.

A C K N O W L E D G E M E N T S

We are grateful for the supplemental funding for this study provided by the LGBT Tobacco Control Network.

We would like to thank the other members of the original team for their invaluable contributions: Susan (Sue)

Rankin, Ph.D, Steve Aurand, and especially Somjen Frazer. We also extend our gratitude to Scout, Ph.D, Moon-

hawk River Stone, Tey Meadow, Stephen Wiseman, Robert Valadéz, Chloe A. Mirzayi, Amanda Harris, Morgan

Goode, and Nick Ray.

1325 Massachusetts Avenue NW, Suite 700

Washington, DC 20005

202.903.0112

www.TransEquality.org

1325 Massachusetts Avenue NW, Suite 600

Washington, DC 20005

202.393.5177