Discrimination, violence, and stigma, along with other social determinants of health,1 significantly affect the physical, mental, and behavioral health of transgender adults.2 Compared with the general population, evidence reveals that transgender people suffer from more chronic health conditions and experience higher rates of health problems related to HIV/AIDS, substance use, mental illness, and sexual and physical violence, as well as higher prevalence and earlier onset of disabilities that can also lead to health issues.3 In addition to these health disparities, transgender people also face unique challenges in their ability to access health insurance and receive adequate care.4 It is essential to understand these inequities in health outcomes and barriers to care through the lenses of minority stress,5 institutional medical system hostility, and social determinants of health. This is particularly true for transgender people of color who experience multiple dimensions of individual and systemic discrimination.
In a recent report,6 the Center for American Progress examined a range of issues pertaining to the health challenges that transgender adults experience, including disparate health outcomes, discrimination in health care, inadequate provision of care, and barriers with respect to cost and insurance.
Disparities in health outcomes
Compared with cisgender adults, transgender adults experience higher rates of adverse mental, physical, and behavioral health outcomes. According to a CAP analysis of 2019 Behavioral Risk Factor Surveillance System data:7
- Transgender adults report higher rates of smoking tobacco some days or every day compared with cisgender adults, at 59 percent and 39 percent, respectively.
- 22 percent of transgender adults report being informed they have asthma compared with 14 percent of cisgender adults.
- 60 percent of transgender adults report having poor mental health at least one day in the past month compared with 37 percent of cisgender adults.
- 54 percent of transgender adults report having had poor physical health at least one day in the past month compared with 36 percent of cisgender adults.
Additionally, according to TransPop8 data from the Williams Institute, transgender respondents were more likely than cisgender heterosexual respondents to be informed by a doctor that they had a sexually transmitted infection, at 7 percent and 2 percent, respectively. 81 percent of transgender respondents reported having contemplated suicide during their lifetime compared with 30 percent of cisgender heterosexual adults; 25 percent of transgender respondents reported using drugs other than alcohol at least twice per month compared with 10 percent of cisgender heterosexual adults; and 48 percent of transgender adults reported that they had been physically attacked or sexually assaulted at least once since the age of 18 compared with 36 percent of cisgender heterosexual adults.
Discrimination and mistreatment in health care
In addition to being more likely to experience poor health outcomes, transgender adults also face high rates of discrimination and mistreatment when interacting with health care systems and providers.9 These experiences manifest in a variety of ways, from providers declining to see transgender patients and refusing to provide general or gender-affirming care due to an individual’s gender identity, to engaging in abusive behavior, to lacking the training and knowledge about how to provide affirming care to transgender patients. These negative experiences can lead transgender people to engage in avoidance behaviors to circumvent discrimination and mistreatment in health care settings.
Key data points from CAP’s nationally representative survey of LGBTQI+ adults conducted in 202010 include the following findings, which are also displayed in Figure 1:
- 28 percent of transgender respondents reported postponing or avoiding necessary medical care in the year prior to CAP’s survey for fear of experiencing discrimination, including 22 percent of transgender respondents of color.
- 40 percent of transgender respondents reported postponing or avoiding getting preventive screenings in the year prior to CAP’s survey due to discrimination, including 54 percent of transgender people of color.
- Nearly 1 in 2 transgender respondents, including 68 percent of transgender respondents of color, reported experiencing some form of discrimination or mistreatment at the hands of a health provider in the year prior to CAP’s survey, including care refusal, misgendering, and verbal or physical abuse.
- One in 3 transgender respondents reported having to teach their doctor about transgender people in order to receive appropriate care in the year prior to CAP’s survey.
Financial barriers to accessing care
Cost barriers present a significant obstacle to accessing care for transgender adults. Compared with cisgender adults, transgender adults experience greater financial insecurities11 and economic hardships12 such as higher rates of poverty and unemployment, workforce discrimination, and housing instability. While these disparities predate the pandemic, they have also been intensified by it.13 CAP’s survey data found:
- 40 percent of transgender respondents reported postponing or avoiding preventive screenings in the year prior to CAP’s survey due to cost, including 31 percent of transgender respondents of color.
- More than half of transgender respondents, including 60 percent of transgender respondents of color, reported postponing or avoiding necessary medical care in the year prior to CAP’s survey because they could not afford it.
Challenges with public and private insurers
In addition to having lower rates of insurance14 compared with cisgender people, transgender individuals encounter challenges15 with public and private insurers that deny coverage for gender-affirming care, leaving patients with large out-of-pocket costs:
- 46 percent of transgender respondents reported having a health insurer deny them gender-affirming care in the year prior to CAP’s survey, including 56 percent of transgender respondents of color.
- In the year prior to CAP’s survey, 48 percent of transgender respondents—including 54 percent of transgender respondents of color—reported that their insurance company only partially covered gender-affirming care or had no providers in network.
- In the year prior to CAP’s survey, 34 percent of transgender respondents—including 39 percent of transgender respondents of color—reported that a health insurance company refused to change their records to reflect their current name or gender.
In order to improve health disparities and reduce barriers to care for transgender patients, federal, state, and local governments must adopt both robust nondiscrimination laws, targeted funding, and in-practice policies that are affirming, inclusive, and culturally competent throughout the U.S. health care system. Policymakers should also pursue significant investments in programs that provide direct health and support services to transgender communities. Adopting these policies will be critical for improving health outcomes and the daily lives of the estimated 1.4 million adults16 who identify as transgender in the United States.
Caroline Medina is a policy analyst for the LGBTQ Research and Communications Project at the Center for American Progress.
- Social determinants of health are the conditions in which people are “born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” See U.S. Department of Health and Human Services Office of Disease prevention and Health Promotion, “Social Determinants of Health,” available at https://health.gov/healthypeople/objectives-and-data/social-determinants-health (last accessed August 2021). ↩
- National Academies of Sciences, Engineering, and Medicine, Understanding the Well-Being of LGBTQI+ Populations (Washington: The National Academies Press, 2020), available at https://www.nap.edu/read/25877/chapter/1. ↩
- Sari L. Reisner and others, “Global Health Burden and Needs of Transgender Populations: A Review,” The Lancet Global Health 388 (10042) (2016): 412–436, available at https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00684-X/fulltext; Sari Reisner, “Meeting the Health Care Needs of Transgender People,” The Fenway Institute, available at https://www.lgbtqiahealtheducation.org/wp-content/uploads/Sari-slides_final1.pdf (last accessed June 2021); Asa E. Radix, “Addressing Needs of Transgender Patients: The Role of Family Physicians,” The Journal of the American Board of Family Medicine 33 (2) (2020): 314–321, available at https://www.jabfm.org/content/33/2/314/tab-article-info; Wyatt Koma and others, “Demographics, Insurance Coverage, and Access to Care Among Transgender Adults” (San Francisco: Kaiser Family Foundation, 2020), available at https://www.kff.org/health-reform/issue-brief/demographics-insurance-coverage-and-access-to-care-among-transgender-adults/; Linda M. Wesp and others, “Intersectionality Research for Transgender Health Justice: A Theory-Driven Conceptual Framework for Structural Analysis of Transgender Health Inequities,” Transgender Health 4 (1) (2019): 287–296, available at https://www.liebertpub.com/doi/pdf/10.1089/trgh.2019.0039 ↩
- Ibid. ↩
- A “minority stress” model is a well-supported theory that for minorities within a society, stigma, prejudice, and discrimination create a hostile and stressful social environment that can contribute to mental health problems such as depression and anxiety and drive higher prevalence of unhealthy or high-risk behaviors. See Ilan H. Meyer, “Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence,” Psychology Bulletin 129 (5) (2003): 674–697, available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2072932/; National Academies of Sciences, Engineering, and Medicine, Understanding the Well-Being of LGBTQI+ Populations. ↩
- Caroline Medina and others, “Protecting and Advancing Health Care for Transgender Adult Communities“ (Washington: Center for American Progress, 2021), available at https://www.americanprogress.org/issues/lgbtq-rights/reports/2021/08/18/502181/protecting-advancing-health-care-transgender-adult-communities/. ↩
- See U.S. Centers for Disease Control and Prevention, “Behavioral Risk Factor Surveillance System,” available at https://www.cdc.gov/brfss/annual_data/annual_2019.html (last accessed August 2021). Of the 50 states represented by BRFSS data, 31 states and territories include an optional module asking individuals about their sexual orientation and gender identity, providing a total sample of 955 transgender individuals and 230,459 cisgender individuals. All percentages included that create a comparison between transgender and cisgender respondents are significant at the 0.01 level. ↩
- For more information about TransPop data methodology and access to the data, see Evan A. Krueger and others, “Methodology and Technical Notes” (Lost Angeles: TransPop, 2020), available at http://www.transpop.org/methods. All comparisons between transgender and cisgender heterosexual individuals from TransPop are significant at the 0.1 level. For more information on how TransPop data are used here, please see Appendix A in Medina and others, “Protecting and Advancing Health Care for Transgender Adult Communities.“ ↩
- See S.E. James and others, “The Report of the 2015 U.S. Transgender Survey” (Washington: National Center for Transgender Equality, 2016), available at https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf. ↩
- Data are from a nationally representative survey of 1,528 LGBTQI+-identifying individuals, jointly conducted in June 2020 by the Center for American Progress and NORC at the University of Chicago. Survey results are on file with the authors. Unless otherwise indicated, all statistics on transgender individuals differ significantly from those of cisgender LGBTQ respondents at the 0.05 level. For more information, see Appendix A in Medina and others, “Protecting and Advancing Health Care for Transgender Adult Communities.“ ↩
- M.V. Lee Badgett, Soon Kyu Choi, and Bianca D.M. Wilson, “LGBT Poverty in the United States: A study of differences between sexual orientation and gender identity groups” (Los Angeles: The Williams Institute, 2019), available at https://williamsinstitute.law.ucla.edu/wp-content/uploads/National-LGBT-Poverty-Oct-2019.pdf. ↩
- Ilan H. Meyer, Bianca D.M. Wilson, and Kathryn O’Neill, “LGBTQ People in the US: Select Findings from the Generations and TransPop Studies” (Los Angeles: The Williams Institute, 2021), available at https://williamsinstitute.law.ucla.edu/wp-content/uploads/Generations-TransPop-Toplines-Jun-2021.pdf. ↩
- Human Rights Campaign, “The Economic Impact of COVID-19 Intensifies for Transgender and LGBTQ Communities of Color,” available at https://www.hrc.org/resources/the-economic-impact-of-covid-19-intensifies-for-transgender-and-lgbtq-commu (last accessed August 2021). ↩
- Wyatt Koma and others, “Demographics, Insurance Coverage, and Access to Care Among Transgender Adults.” ↩
- National Center for Transgender Equality, “Know Your Rights: Health Care,” available at https://transequality.org/know-your-rights/health-care (last accessed August 2021). ↩
- The Williams Institute, “How Many Adults Identify as Transgender in the United States?” (Los Angeles: University of California Los Angeles, 2016), available at https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/. ↩