The State of Our Health

( – promoted by buhdydharma )

On NCOD, the National Center for Transgender Equality and the National Gay and Lesbian Task Force released the National Transgender Discrimination Survey:  Report on health and health care (warning = pdf:  I read the pdfs so you don’t have to).  Being as how it was during the week and that week was midterm exam time, I just got around to reading it.  I know others have reported on the findings, such as David Mixner, but I would like to share what it looks like through my eyes.

I’m a doctor, but not a medical doctor, but I thought I recalled some words from somewhere:

First, do no harm

The National Transgender Discrimination Survey is the most extensive survey of transgender discrimination ever undertaken.  Over four months, our research team fielded 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.  The vast majority of respondents took the survey on-line, through a URL established at Pennsylvania State University.

An additional 2000 paper surveys were distributed to organizations serving homeless, rural, and low-income trans and gender non-conforming people.  500 of those surveys were returned.

In the end there were 6450 valid responses, representing all 50 states, the District of Columbia, Puerto Rico, Guam, and the US Virgin Islands.  Geographic distribution generally mirrored the distribution of the general population, except for clear high density pockets in the Willamette Valley and the Seattle-Olympia corridor.

88% of respondents identified as either transwomen or transmen.  The other 12% identified as gender queer or gender-nonconforming.  Those were sometimes divided into 3% who were gender non-conforming on the mtf spectrum and 9% who were gender non-conforming on the ftm spectrum.

76% of respondents were white, 11% multiracial, 5% black, 5% Latino/a, 2% Asian, and 1% American Indian/Alaska Native (which I shall categorize as Native American, when useful).

19% of respondents were 18-24 years old, 52% were 25-44, 17% 45-54, 11% 55-64 and 2% 65+.

Sexual orientation:  lesbian/gay/same gender = 23%, bisexual = 24%, queer/pansexual = 23%, heterosexual = 23%, asexual = 4%, other = 2%.

Those who assume all transgender people are straight after transition are as incorrect as those who would assume them all to be gay, lesbian, or bisexual.  These assumptions create additional barriers even in supposedly transgender-friendly spaces.

The 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-identified.   While debate in the LGBT community often draws clear lines of demarcation between the LGBs and the Ts, our findings suggest that there is significant overlap.

The results:

Survey participants reported very high levels of postponing medical care when sick or injured due to discrimination (28%) or inability to afford it (48%).

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.

28% of respondents were subjected to harassment in medical settings and 2% were victims of violence in doctor’s offices.

50% of the sample reported having to teach their medical providers about transgender care

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 significantly.

Every day, transgender and gender non-conforming people bear the brunt of social and economic marginalization 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 find housing, to obtain health and partnership benefits, 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.

visual non-conformers –> People know I am transgender whether I tell them or not.

Always = 6%

Most of the time = 16%

Sometimes = 27%

Occasionally = 29%

Never = 21%

When seeking medical care, how many people know or believe you are transgender or gender non-conforming:

All = 28%

Most = 18%

Some = 33%

None = 21%

60% sought care “when you are sick or need advice about your health” from a doctor’s office, 28% from health centers and clinics (including VA = 4%), 4% hospital emergency rooms.

Factors that correlated with emergency room use:  17% of African-Americans used ERs as did 8% of Latino/a respondents; 10% of  unemployed respondents and 7% of those who had lost their jobs due to bias used ERs; and 13% of those without 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 offices for their care.

Denial of equal treatment in medical situations is commonplace for transfolk, so much so that we can ask where and get reasonable data:

Doctor’s offices and hospitals = 24%

ERs = 13%

Mental health clinics = 11%

EMTs = 5%

Drug treatment programs = 3%

Transmen reported unequal treatment more often than transwomen.

Latinos/as reported unequal treatment rates of 32% for doctor or hospital and 19% in both ERs and mental health clinics.

19% of respondents had at least one instance of being refused treatment by a medical provider (22% of transwomen, 19% of transmen, 6% of gender non-conforming).

Refusal to treat:

Respondents who had lost their jobs due to bias = 36%

Those who engaged in sex work, drug sales or other underground economies = 30%

Those on public insurance = 28%

Those living full-time in their gender identity = 25%

Refusal to treat by race:

Native American = 36%

Multiracial = 27%

Hispanic = 22%

Black = 19%

White = 17%

Asian = 15%

28% of survey respondents reported verbal harassment in a medical setting.  2% reported having been physically attacked.

Those being physically attacked in doctors offices and hospitals:

Those who have lost their jobs = 6%

African-Americans = 6%

Underground economies = 6%

Transitioned before age 18 = 5%

Undocumented non-citizens = 4%

Physically attacked in ERs:

Undocumented = 6%

Underground economies = 5%

Those who have lost their jobs = 4%

Asians = 4%

In accordance with professional standards, doctors can provide more effective 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 likelihood 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 open to medical providers about their status and 15% of those who were either not out or only partly out.

Harassment in ambulance or by EMT:  8% of those out, 5% of those not.

Physically attacked or assaulted in a hospital:  2% of those out, 1% of those not.

When respondents actually got to see medical professionals, 50% of them reported having to teach their providers how to give appropriate care (transmen = 61%, those living full-time = 61%, those on public assistance = 56%).

A significant portion of respondents postponed necessary medical care because they could not afford it (48% who were sick or injured and 50% of those in need of preventative care). (Transmen = 55%; transwomen = 45%)

Sick or injured: (Insured = 37%; Public insurance = 46%; Uninsured = 86%)

Preventative: (Insured = 39%; Public insurance 44%; Uninsured = 88%)

But money wasn’t the only reason for postponing care.

Postponement due to discrimination by providers:

Transwomen = 22% needed; 25% preventative

Transmen = 42% needed; 48% preventative

Gender non-conforming (mtf spectrum): 17% needed; 18% preventative

Gender non-conforming (ftm spectrum): 23% needed; 33% preventative

Due to discrimination and disrespect, overall 28% postponed or avoided medical treatment when they were sick or injured and 33% delayed or did not attempt to get preventative health care.  Highest rates of postponement for this reason:  lost a job due to bias = 45%, underground economies = 45%.

Study participants were less likely to have insurance than the general population (probably because insurance companies refuse to provide us meaningful coverage), more likely to to be covered by medicaid or medicare and less likely to be insured by an employer (because we are less likely to be employed).

31% of black respondents were uninsured, as opposed to 17% of white respondents, 28% of hispanics, 22% or Asians, 25% of Native Americans and 23% or multiracial people.

Undocumented non-citizens were uninsured at a rate of 36%.  Those who lived in the South were uninsured 25% of the time.

19% of the aggregate were uninsured, as compared to 15% for the general population.

About Transition-related services

Gender non-conforming people are not included in some parts of the data to come.

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.  The 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 inaccessible to most transgender people.

75% received counseling related to their gender identity and another 14% hoped to begin that “someday”.  The other 11% did not desire counseling.  89% of those who medically transitioned have been in counseling as well as 91% or people who have had gender-related surgery.  50% of survey respondents had received a gender-related health diagnosis (transwomen = 61%; transmen = 53%…transgender =58%, gender-nonconforming = 11%).

62% of respondents have had hormone therapy (which increases with age)  (transwomen = 71%; transmen = 66%).  An additional 23% hope to have it in the future.

Three-quarters of transwomen have either had gender-related surgery or wish to do so at some point.

chest surgery: 18% have had, 54% desire

orchiectomy:  21% have had, 59% desire

penectomy and vaginoplasty:  20% have had, 60% want someday

Personally, I imagine that quite a few of the pre-operative transwomen respondents do not understand how much power the hormones can have in growing your own breasts.

Surgery for transmen has more associated problems and so is less popular.

Chest surgery:  41% have had, 51% want someday

Hysterectomy:  20% have had, 57% want someday

metoidoplasty/creation of testes:  3% have had, 51% want someday

phalloplasty:  2% have had, 26% want someday

HIV/AIDS:

The HIV infection rate of the respondents was 2.64%, as opposed by the US rate (as reported by the UN) of 0.6%.  For people of color, it was much worse:

African Americans = 24.90%  (national rate = 2.4%)

Latinos/as = 10.92%  (national rate = .08%)

Native Americans = 7.04%  (national rate not reported)

Asian-Americans = 3.70%  (national rate = .01%)

Documented non-citizens = 7.84%

Undocumented non-citizens = 6.96%

61% of those who reported HIV infection had engaged in sex work.  15.32% of those who had engaged in sex work were HIV+.

91% of the HIV+ were either transwomen or gender-nonconforming on the mtf spectrum.  3.76% of transwomen were HIV+.  The reported rate for transmen was 0.48%.  Those without a high school diploma had an HIV rate of 13.49%, those with an income below $10000 were at 6.40% and those who had lost a job due to bias or reported being unemployed were at 4.59%.

8% of survey respondents did not know their HIV status.

Drug and Alcohol Abuse:  8% of respondents reported current use of alcohol or drugs in order to cope with the treatment of mainstream society.  7.3% of the general public abuses or is dependent on alcohol and 1.7% abuses or is dependent on non-prescription drugs, so we actually are doing well with this.

Of course, the underground economies people did not do so well with 19% currently using alcohol and/or drugs and 36% reporting past usage.

Alcohol and drug usage decreased with age (editors note: it gets harder to find drugs).

Smoking:  30% of respondents smoked daily or occasionally, compared to the national rate of 20.6% of adults.

Suicide:  Have you ever attempted suicide?  Yes= 41%.  According to the government health authorities, 1.6% of currently living Americans have attempted suicide during the course of their lives.  There is a slight differentiation in methodology, but if the data is true, transpeople are over 25 times as likely to attempt suicide than your general run-of-the-mill normal person.  And that’s not counting the successful suicides.

The really regretful thing about it is that statistics like this are used against us:  we don’t need or deserve legal protections because we are obviously nuts.  Here’s the proof.

The 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.

There is a breakdown of suicide attempts by race and SES, but it is very depressing for me.  They are all too high.

Native American = 56%

Multiracial = 54%

African American = 45%

Latino/a = 44%

Asian = 39%

White = 38%

Employed = 37%

Unemployed = 51%

Lost job due to bias = 55%

Street economy = 60%

18-44 = 45%

65+ = 16%

Those who were bullied, harassed, assaulted, or expelled because they were transgender or gender non-conforming in school reported elevated levels of suicide attempts (51%).  Rates for those who were the harassed or bullied by a teacher had a suicide attempt rate of 59%.  Those who were physically assaulted by a teacher had a suicide attempt rate of 76%.  69% of those who were sexually assaulted by teachers attempted suicide.

Recommendations:

1.  Anti-transgender bias in the medical profession and U.S. health care system has catastrophic consequences for transgender and gender non-conforming people. This study is a call to action for the medical profession;

• The 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.

2.  Public and private insurance systems must cover transgender-related care;  it is urgently needed and is essential to basic health care for transgender people.

3.  Ending violence against transgender people must be a public health priority, because of the direct and indirect negative effect it has on both victims and on the health care system that must treat them.

4.  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 financially inaccessible for large majorities of transgender people because they are rarely covered by either public or private insurance;
• Whether an individual is able to afford or attain proof of citizenship or legal residency.

5.  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-specific prevention programs.

6.  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 specifically 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.