Patient Care

Leadership Initiatives in Patient-Centered Transgender Care

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About 700,000, or 0.3%, of the adult population in the U.S. identify themselves as transgender, and an estimated 134,300 identify as transgender veterans.6,12 The transgender population in the U.S. is estimated to be 55% white, 16% African American, 21% Hispanic, and 8% other races.13 The U.S. census data noted that the transgender population was geographically located across the nation. Transgender persons are more likely to be single, never married, divorced, and more educated but with significantly less household income.2 Data to provide an accurate reflection of the number of transgender people in the U.S. are lacking. Some transgender individuals also may identify as lesbian, gay, or bisexual, making population-based estimation even more challenging and difficult.

Transgender persons who have transitioned may not have changed their names or changed their identified sex on official Social Security records, which the Social Security Administration allows only if there is evidence that genital sexual reassignment surgery was performed.14 The number of transgender adults requesting treatment continues to rise.10

Social and Health Challenges

Transgender people face many challenges because of their gender identity. Surveys assessing the living conditions of transgender people have found that 43% to 60% report high levels of physical violence.15 By comparison, the National Intimate Partner and Sexual Violence Survey found that interpersonal violence and sexual violence were reported by lesbian and gay individuals at equal or higher levels than that reported by heterosexuals. Forty-four percent of lesbian women, 35% of heterosexual women, 29% of heterosexual men, and 26% of gay men reported experiencing rape or physical violence.16 A study in Spain reported 59% of transgender people experienced patterns of harassment, and in Canada, 34% of transgender people lived below the poverty level.17,18

In the U.S., the National Transgender Discrimination Survey of 6,450 transgender and nonconforming participants provided extensive data on challenges experienced by transgender people.6 Discrimination was frequently experienced in accessing health care. Due to transgender status, 19% were denied care, and 28% postponed care due to perceived harassment and violence within a health care setting.6 The same study also reported that as many as 41% live in extreme poverty with incomes of less than $10,000 per year reported. Twenty-six percent were physically assaulted, and 10% experienced sexual violence. More than 25% of the transgender population misused drugs or alcohol to cope with mistreatment.6

In the U.S., HIV infection rates for transgender individuals were more than 4 times (2.64%) the rate of the general population (0.6%).6 Internationally, there is a high prevalence of HIV in transgender women. The prevalence rate of HIV in U.S. transgender women was 21.74% of the estimated U.S. adult transgender population of about 700,000.19 One in 4 people living with HIV in the U.S. are women.20

Suicide attempt rates are extremely high among transgender people. A suicide rate of 22% to 43% has been reported across Europe, Canada, and the U.S.21 Depression and anxiety were commonly noted as a result of discrimination and social stigma. In the U.S., transgender persons reported high rates of depression, with 41% reporting attempted suicide compared with 1.6% of the general population.6 Access to health care services, such as mental health, psychosocial support, and stress management are critical for this vulnerable population.22

Health Policies

Since 1994, the UK has instituted legal employment protections for the transgender population. In the UK, transgender persons, including military and prisoners, have health care coverage that includes sexual reassignment surgery as part of the UK's National Health Service.23

In the U.S., the federal policy of "Don't Ask, Don't Tell" barring transgender persons from serving openly in the military was repealed in June 2016. This policy historically has had a silencing effect on perpetuating institutionalized biases.24 This remains problematic even after veterans have transitioned from military service to the VA for civilian care.

Between 2006 and 2013, the reported prevalence and incidence of transgender-related diagnoses in the VA have steadily increased with 40% of new diagnoses occurring since 2011.25 In fiscal year 2013, there were 32.9 per 100,000 veterans with transgender-related diagnoses.25 Health care staff, in particular health care providers (HCPs), can play a critical role in reducing health disparities and unequal treatment.26

With the passage of the U.S. Affordable Care Act (ACA), health insurance coverage for transgender persons is now guaranteed by law, and health disparities within the transgender population can begin to be properly addressed. The ACA offers the ability to purchase health insurance, possibly qualify for Medicaid, or obtain subsidies to purchase health insurance. Insurance coverage is accessible without regard to discrimination or preexisting conditions.27 As of May 2014, the Medicare program covered medically necessary hormone therapy and sex reassignment surgery.13 While VA benefits cover hormone therapy for transgender veterans, sex reassignment surgery is not currently a covered benefit.28 The ACA now increases access to primary care, preventative care, mental health services, and community health programs not previously available in the transgender community.


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