The Health of the Transgender Community: Out, Proud, and Coming Into Their Own

When the riots happened at and around the Stonewall Inn in Greenwich Village, New York, in 1969, the rioters included many gender diverse members of the nascent gay (now LGBTQ [lesbian, gay, bisexual, transgender, and questioning]) community. Little did anyone know then, including those drag queens and butch lesbians, that they would get their own letter—“T” for transgender—within the evolving gay rights movement. Evolving queer theory has identified separate concepts of sexual orientation and gender identity, the former focused on the gender of the individual one is attracted to versus the latter focused on having an internalized and outwardly expressed gender identity different from the sex one was assigned at birth.

In 2001, AJPH published a theme issue on Lesbian, Gay, Bisexual, and Transgender Health, making it among the first, and possibly the first, mainstream scientific health journal with such a focus. Within that issue, Lombardi’s commentary “Enhancing Transgender Health Care” (reprinted in part in this issue on p 230) identified a new health care concern—training health care providers to provide competent and appropriate care to transgender people—which today remains unaddressed to a large degree. In this issue, dickey’s editorial (p 222) revisits this topic with a clarion call for competent clinical care and how such care can impact not only physical health, but emotional and mental health and well-being as well.

One factor limiting the ability to address transgender health, as well as other sexual minority health issues, was the lack of population-based data. While convenience surveys and anecdotal data indicated that the LGBTQ community experienced health disparities, the findings from such studies were limited in their scientific validity. In a classic chicken-and-egg dilemma, advocates for LGBTQ health argued that if population-based surveys, primarily administered by government agencies, did not add questions about sexual orientation or gender identity, valid data could not be produced. Government officials responded with concerns about the lack of validated measures to assess either sexual orientation or gender identity.

Two crucial efforts to address the lack of validated measures provided the necessary support to various expert panels deliberating on how to ask valid questions on these surveys about sexual orientation¹ and gender identity.² As of 2016, many state and federal health and nonhealth (such as the General Social Survey) surveys now include measures of sexual orientation, and a growing number are also adding measures of gender identity. Thus, through science and advocacy, population-based data on gender identity or transgender status have become increasingly available in the past five or so years.

These population-based data provide an opportunity, for the first time, to assess the size of the transgender population within a larger swath of the US population, as Crissman et al. do in this issue (p 213) by using Behavioral Risk Factor Survey System data across multiple states. These findings, published here for the first time in a peer-reviewed journal, echo those reported by the Williams Institute, a national leader on LGBTQ issues. Next, a systematic review by Meerwijk and Sevelius (p 216) reviews data on prevalence of transgender persons among college-age individuals, incarcerated persons, and the general population. Using the two analyses found in this journal, data converge around a lower estimate of 0.4 and an upper estimate of 0.53 of the adult US population. The adult population in the United States was estimated by the US Census Bureau at 242 470 820 in 2013. Using the two estimates results is an estimated population size of transgender adults in the United States between 969 883 and 1 285 095 or roughly between 1 and 1.3 million. With more population-specific data on transgender persons, more accurate information regarding their health, mental health, and social services needs and strengths can be identified. These data can in turn be used to support the development of evidence-informed information and training programs for professionals in each of these fields, and, ultimately, improved health status and well-being for the transgender population.

A limited number of population-based studies as well as surveys using convenience samples have identified significant health-related disparities in transgender individuals. For example, transgender individuals experience disproportionately higher rates of HIV infection, suicidality, and unemployment compared with the general population. One of the first population-based studies of transgender health, by Conron et. al., identified higher rates of unemployment and smoking for transgender persons compared with the general population in Massachusetts.³ With respect to HIV infection, systematic reviews have explored the disproportionate burden of HIV infection on transgender person both in the United States⁴ and across the globe.⁵ In 2010, a national study of the transgender population in the United States, with a large convenience sample (n = 6450), was conducted by the National LGBTQ Task Force and the National Center for Transgender Equality (NCTE). That study found that 41% of transgender respondents had reported attempting suicide, compared with 1.6% of the general US population.⁶ The NCTE has announced that its follow-up study, with approximately 28 000 respondents, will be released on December 8, 2016, with findings announced via a Web-based broadcast from the National Press Club.⁷

In response to these health disparities, and specifically to address the serious HIV epidemic among transgender women of color, the Health Resources and Services Administration has launched an effort to identify and study the effectiveness of HIV programs for this population. Rebchook et al., from the Center of Excellence in Transgender Health, describe the programs being studied and the effort to evaluate their effectiveness in the article, “The Transgender Women of Color Initiative: Implementing and Evaluating Innovative Interventions to Enhance Engagement and Retention in HIV Care” (p 224).

The past few years have seen an explosion of media coverage of transgender persons with Laverne Cox appearing on the cover of Time magazine and Caitlyn Jenner winning an ESPY award in 2015. With the public more aware than ever of the transgender population, now is a time for public health and health care professionals to understand and address their issues. While training programs on transgender health are necessary to improve medical care and health outcomes, other issues affecting the transgender population must be addressed as well. Violence against transgender persons is disproportionately higher, and the greater likelihood of negative health outcomes is directly related to stress from fear of violence or trauma associated with being a victim of violence. Respect for the transgender population includes rational policies that allow for changes of identity documents including birth certificates and driving licenses. And while asking for and using the preferred pronoun of an individual, regardless of what pronoun the speaker thinks should apply, may seem unimportant to some of us, doing so is a common courtesy and shows the respect due to out and proud transgender people.