Abstract
The purpose of this exploratory study was to examine the effects of legal name change on socioeconomic factors, general and transgender-related healthcare access and utilization, and transgender-related victimization in a sample of young transgender women (transwomen) of color. A cross-sectional group comparison approach was used to assess the potential effects of legal name change. A convenience sample of young transwomen enrolled in a no-cost legal name change clinic were recruited to complete a 30-minute interviewer-guided telephone survey including sociodemographic and socioeconomic factors, health and well-being, health care utilization, transgender transition-related health care, and transgender-related victimization. Sixty-five transgender women of color (37 = pre-name change group; 28 = post-name change group) completed the survey. Results indicated that the transwomen in the post-name change group were significantly older than the pre-name change group. In age-adjusted analyses, the post-name change group was significantly more likely to have a higher monthly income and stable housing than the pre-name change group. No significant differences were observed for general healthcare utilization; however, a significantly greater percentage of transwomen in the pre-name change group reported postponing medical care due to their gender identity. In addition, a significantly larger proportion of transwomen in the pre-name change group reported using non-prescribed hormones injected by friends and experiencing verbal harassment by family and friends compared to transwomen in the post-name change group. Findings suggest that legal name change may be an important structural intervention for low-income transwomen of color, providing increased socioeconomic stability and improved access to primary and transition-related health care.
Keywords: transgender, transgender health, transgender rights, transition-related health care, transgender victimization
A growing body of evidence shows that transwomen of color carry a disproportionately high burden of adverse social and economic outcomes, including high rates of unemployment, homelessness, limited access to health care, stigma, discrimination, victimization, homicide, and difficulty accessing gender-affirming medical services (e.g., transition-related counseling and hormone therapies) (Bauer, Scheim, Deutsch, & Massarella, 2014; Conron, Scott, Stowell, & Landers, 2012; Institute of Medicine (IOM), 2011; Clements-Nolle, Marx, & Katz, 2006). Additionally, transwomen have difficulty securing legal name and/or sex marker change on institutional identification documents (Strousma, 2014; Bockting, Miner, Romine, Hamilton, & Coleman, 2013; IOM, 2011). Although multimodal interventions are needed to address these challenges, there also is a need to examine the potential effectiveness of structural- and policy-level interventions that may have downstream effects on the overall health and well-being of transgender people (Crosby, Salazar, & Hill, 2016). The objective of this exploratory study was to examine the potential associations between legal name change and socioeconomic factors, general and transgender-related healthcare access, and experiences of transgender-related victimization among young transwomen of color.
In the United States (U.S.), state and federal identification documents are required to access jobs, housing, health care services, and public health benefits (Haas, Eliason, & Mays, 2010; Garofalo, Deleon, Osmer, Doll, & Harper, 2006). As a result, people who lack identification documents concordant with their gender identity may avoid seeking jobs, health care services and benefits for fear of being “outed” as transgender, which could expose them to discrimination and victimization (Brown & Herman, 2016; Transgender Legal Defense and Education Fund, 2014; Bradford, Reisner, Honnold & Xavier, 2013). Conversely, possessing identification documents concordant with one’s gender identity and preferred name and gender marker may enable transgender people to access employment, safe housing or shelter, public health benefits and health care services with less fear of discrimination and victimization (Crosby et al., 2016). Although transgender women experience harassment, discrimination, and violence in multiple ecological contexts (Reisner, White, Bradford, & Mimiaga, 2014; Bradford et al., 2013; Nadal, Skolnik, & Wong, 2012), legal identification with name concordance is a potentially important structural intervention that could foster better access to a range of health promotive structures (Couch, Pitts, Croy, Mulcare, & Mitchell, 2008).
Structural-level interventions foster individual agency, allowing individuals to act in their own best interest, and have been positively associated with behavior change as well as the promotion of health-enabling environments (Auerbach, Parkhurst, & Caceres, 2011). In the area of sexual health structural interventions such as comprehensive sex education (Santelli et al., 2006), condom availability (Card, Lessard, & Benner, 2007), clean syringe exchange (Centers for Disease Control (CDC), 2002), housing assistance programs (Wolitski et al., 2010), and increased healthcare coverage (DeNavas-Walt, Proctor, & Smith, 2013) have significantly reduced the incidence of poor health outcomes including HIV infection (Adimora & Auerbach, 2010). Although the impact of structural-level interventions on health outcomes may not be immediately evident, changing the legal, political, economic, and cultural conditions that drive poor health among marginalized populations may have a long-term impact on overall health and the amelioration of health inequities and disparities (Auerbach et al., 2011). To date, few structural interventions for transwomen exist, and we know of no study that has explicitly examined the potential role of legal name change status on state and federal identification documents on social and health outcomes among transwomen of color. The present study thus addresses this important gap in the extant literature.
Current Study
Two groups of transwomen of color were recruited to explore legal name change as a structural intervention: 1) transwomen who had not completed a legal name change, but were initiating their legal name change (pre-name change group) and 2) those who completed a legal name change at least nine months prior to study participation (post-name change group). We hypothesized that legal name change on identification documents would have downstream effects on socioeconomic stability, healthcare access and utilization, and experiences of victimization. More specifically, we hypothesized that transwomen of color in the post-legal name change group would have 1) improved economic stability, e.g., higher rates of employment, higher income, increased housing stability, and decreased economic hardship; 2) increased access and utilization of general and transition-related health care; and 3) decreased experiences of transgender-related victimization, compared to the group who have not yet changed their legal name (pre-legal name change).
Methods
Recruitment
As both practical and ethical considerations preclude randomly assigning transwomen to legal name change conditions, a cross-sectional group comparison approach was used. Data from a convenience sample of transwomen of color using a no-cost legal clinic were used to assess the potential effects of legal name change. Transwomen of color were recruited through the Transgender Legal Defense & Education Fund, Inc. Name Change Project based in New York, New York (TLDEF-NCP) (TLDEF, 2014). All participants were clients who were currently enrolled in the TLDEF-NCP or had completed their legal name change with the program nine months prior to participation in the current study. TLDEF staff recruited eligible participants and former clients through their database to participate in the study via phone and/or email, and participants interested in the study scheduled a phone appointment with TLDEF staff to complete the interview survey.
Procedure
Participants completed a confidential 30-minute interviewer-guided telephone survey with trained TLDEF staff immediately inputting participant responses into a password-secured electronic survey. Survey data were collected from March 2015 to October 2015. Inclusion criteria were based on the ages and race/ethnicities of transgender people most impacted by poor health outcomes, including disproportionately high rates of STI and HIV infection, i.e., younger transgender women of color (Bradford et al., 2013; Garofalo et al., 2006; IOM, 2011). Inclusion criteria included 1) identifying as a transgender woman, transwoman, transgender female, or male-to-female (MTF) transgender/transsexual person; 2) self-identifying as a person of color, Black/African American, Latina/Hispanic, and/or Asian/Pacific Islander; 3) being age 18–35 years, inclusive; and 4) either inquiring about or initiating a legal name change with the TLDEF-NCP (pre-name change group), or having completed a legal name change with the TLDEF-NCP at least nine months prior (post-name change group). At the beginning of each survey, participants confirmed whether they had or had not undergone a legal name change. Additionally, TLDEF staff cross-checked database records to ensure that participant group assignments were matched. This approach allowed the university research team to be blind to participant contact and legal information and to acquire anonymous data through the partnership with the TLDEF. All participants provided verbal informed consent prior to participation and received a $20 pre-paid VISA debit card for participation. All procedures were approved by the university’s Institutional Review Board.
Measures
Sociodemographic characteristics
Participants reported their age, race/ethnicity, highest level of educational attainment, and health insurance status.
Socioeconomic factors
Participants reported their current employment status, range of monthly income, and current housing arrangement. A five-item scale assessed economic hardship in the past six months, including 1) having experienced homelessness, 2) receiving food stamps, 3) receiving governmental financial assistance, 4) having had to borrow money to “get by,” and 5) having missed meals or lacked food due to lack of money. Response options were 0=no, 1=yes.
General health
Two items assessed self-reported current mental and physical health on a 10-point scale (1=poor to 10=excellent): “How would you rate your current PHYSICAL health?” and “How would you rate your current MENTAL health?”
Depression and anxiety
Two six-item subscales from the Brief Symptom Inventory (BSI) were used to assess the presence of depressive (α = 0.85) and anxiety (α = 0.89) symptoms over the past seven days (Derogatis, 1983), with responses assessed on a five-point 1=not at all to 5=extremely scale.
Self-esteem
The ten-item Rosenberg Self-Esteem Scale assessed self-worth and positive and negative feelings about the self (Rosenberg, 1965). Responses were rated on a 1=strongly disagree to 4=strongly agree scale, with higher scores indicating higher self-esteem (α = 0.83).
Health care utilization
Seven items measured health care utilization over the past six months, including 1) having visited an emergency room or medical center, 2) having been a patient in the hospital overnight, 3) experiencing barriers to accessing services due to gender identity or presentation, 4) looking for health information on the Internet, 5) postponing care when needed, 6) postponing medical care due to cost, and 7) postponing care due to gender identity or presentation. Response options were 0=no, 1=yes.
Transgender transition-related care
Four items assessed whether participants had received formal medical or informal non-medical interventions related to transgender transition-related care in the past six months. Two items assessing formal medical care asked transwomen to report if they had 1) transition-related hormones prescribed by a medical professional and 2) visited a mental health profession for gender-transition services. Two additional items asked participants about informal and non-medically based interventions related to 1) having received transition-related hormones injected by a friend or non-medical professional and 2) having silicone injected by a friend or non-medical professional. Response options for all items were 0=no, 1=yes.
Transgender-related victimization
Six items assessed verbal and physical victimization over the past six months including having been victimized by 1) a stranger in public, 2) a family member or friend, and/or 3) a romantic or sexual partner (0=no, 1=yes) (Clements-Nolle et al., 2006).
Data Analysis
Descriptive statistics analyzed the proportions and central tendencies for all variables used to describe the sample and outcome variables. Group comparisons were conducted using Chi-square and Fisher’s exact tests for binary/categorical variables and t-tests and Mann-Whitney U tests for continuous variables. Because of the exploratory nature of this study, we detected initial bivariate group differences at a significance level of p < .10 (McClelland & Judd, 1993). Additionally, Cramer’s V coefficient, a statistical test of association that gauges the strength of a relationship and accounts for variations in sample sizes with values ranging from 0 (no association) to 1 (perfect association) (Agresti, 1996; Liebetrau, 1983), was calculated for all group comparisons. Binary logistic regression models were used to control for age for all significant group differences reaching p < .10. Adjusted odds ratios controlling for age are reported for all significant differences. All data were analyzed in SPSS 23.0.
Results
Participants
Table 1 details the sociodemographic characteristics of the sample. A total of 65 transwomen of color completed the survey, with 37 who met criteria for the pre-legal name change group and 28 who met criteria for the post-legal name change group. All participants self-identified as a transgender woman/female, transwoman, or male-to-female transgender/transsexual. The majority of participants identified as Black/African American (52.3%) or Hispanic/Latina (46.2%). Transwomen in the post-name change group were significantly older than those in the pre-name change group (see Table 1). There were no significant differences by group for incarceration history, race/ethnicity, educational background, sexual attraction, or HIV-status.
Table 1.
Group sociodemographic characteristics of transwomen of color enrolled in a no-cost transgender legal services agency (N=65)
| Variable | Total Sample (N=65) |
Pre-Name Change Group (n=37) |
Post-Name Change Group (n=28) |
|---|---|---|---|
| Mean (SD) | Mean (SD) | Mean (SD) | |
| AgeA | 26.1 (4.74) | 24.5 (4.60) | 28.2 (4.10) |
| Number of times incarcerated | 1.69 (1.58) | 1.78 (1.67) | 1.57 (1.48) |
| % Yes (n) | % Yes (n) | % Yes (n) | |
| Race/Ethnicity | |||
| Black/African American | 52.3 (34) | 48.6 (18) | 57.1 (16) |
| Pacific Islander | 7.7 (5) | 5.4 (2) | 10.7 (3) |
| Hispanic/Latino | 46.2 (30) | 45.9 (17) | 46.4 (13) |
| Education | |||
| Less than high school | 13.8 (9) | 16.2 (6) | 10.7 (3) |
| Currently in high school | 3.1 (2) | 5.4 (2) | 0.0 |
| High school graduate | 43.1 (28) | 43.2 (16) | 42.9 (12) |
| Some or Currently enrolled in college | 26.2 (17) | 24.3 (9) | 28.6 (8) |
| College degree | 13.8 (9) | 10.8 (4) | 17.9 (5) |
| Sexual attraction | |||
| Men only | 67.2 (43) | 66.7 (24) | 67.9 (19) |
| Mostly men | 17.2 (11) | 19.4 (7) | 14.3 (4) |
| Both men and women equally | 9.4 (6) | 13.9 (5) | 3.6 (1) |
| Mostly women | 4.7 (3) | - | 10.7 (3) |
| Women only | 1.6 (1) | - | 3.6 (1) |
| HIV-status | |||
| Positive | 20.3 (13) | 13.9 (5) | 28.6 (8) |
| Negative | 76.6 (49) | 80.6 (29) | 71.4 (20) |
| Unknown | 3.41 (2) | 5.6 (2) | - |
Notes:
Significantly different at p < .05.
Socioeconomic factors
Table 2 presents comparison data on socioeconomic factors for transwomen in each group. Overall, 29.7% of participants were currently employed, with transwomen in the pre-name change group significantly less likely to be employed than the post-name change group, however this did not remain significant after controlling for age differences (adjusted odds ratio (AOR)=0.30 [95% CI=0.09–1.01]). Overall socioeconomic status in the sample was low, with 44.6% reporting a monthly income below $500. However, compared to the pre-name change group, women in the post-name change group were five times more likely to report an income higher than $1,000 a month controlling for age (AOR=5.36 [1.50–19.13]). Additionally, transwomen in the post-name change group were three times more likely to report owning or renting a house or apartment in the past year controlling for age (AOR=3.35 [1.09–10.35]) than were transwomen in the pre-name change group. Although there were no significant differences in economic hardship, the overall sample reported high levels of economic hardship in the past 6 months: 20.6% reported homelessness, 33.3% received food stamps, 25% received government financial assistance, 48.4% needed to borrow money in order to “get by,” and 29.7% had missed a meal/lacked food due to limited financial resources. The three significant differences for the socioeconomic comparisons had medium effect sizes (Cramer’s V=0.25–0.41, p<.05).
Table 2.
Comparisons of income, housing, and economic hardship experienced transwomen of color enrolled in a no-cost transgender legal services agency (N=65)
| Variable | Total Sample (n=65) |
Pre-Name Change Group (n=37) |
Post-Name Change Group (n=28) |
Adjusted Odds Ratio (OR) [95% confidence interval]B |
|---|---|---|---|---|
| % Yes (n) | % Yes (n) | % Yes (n) | ||
| EmploymentA | 29.7 (19) | 19.4 (7) | 42.9 (12) | 0.30 [0.09–1.01] |
| IncomeA | 5.36 [1.50–19.13] | |||
| Less than $1,000 a month | 63.1 (41) | 75.7 (28) | 46.4 (13) | |
| More than $1,000 a month | 36.9 (24) | 24.3 (9) | 53.5 (15) | |
| Housing (past year)A | ||||
| House or Apartment (owned or rent) | 43.1 (28) | 27.0 (10) | 64.3(18) | 3.35 [1.09–10.35] |
| Motel, hotel, or boarding house | 9.2 (6) | 13.5 (5) | 3.6 (1) | |
| A car, on the street, or homeless shelter | 10.8 (7) | 10.8 (4) | 10.7 (3) | |
| Rehabilitation or treatment facility | 7.7 (5) | 5.4 (2) | 10.7 (3) | |
| Economic Hardship (past 6 months) | ||||
| Homelessness | 20.6 (13) | 19.4 (7) | 22.2 (6) | |
| Received food stamps | 33.3 (21) | 34.3 (12) | 32.1 (9) | |
| Received government financial assistance | 25.0 (16) | 27.8 (10) | 21.4 (6) | |
| Borrowed money to “get by” | 48.4 (31) | 52.8 (19) | 42.9 (12) | |
| Missed meals or lacked food due to | 29.7 (19) | 33.3 (12) | 25.0 (7) |
Notes:
Significantly different at p < .05;
Adjusted for age differences.
General health and well-being
Table 3 details the health and well-being of the sample. Overall, transwomen in both groups rated their current physical (mean (M)=8.11, standard deviation (SD)=1.84) and mental (M=7.24, SD=2.32) health relatively high. Self-esteem also was high for both groups (M=30.64; SD=5.58). Global indices for depressive (M=15.19, SD=6.43) and anxiety (M=14.23, SD=7.15) symptoms were relatively low. There were no significant differences by group for physical and mental health, self-esteem, depressive or anxiety symptoms.
Table 3.
Comparisons of health and well-being, transition-related care, victimization, and sexual risk among transwomen of color enrolled in a no-cost transgender legal services agency (N=65)
| Variable | Total Sample (n=65) |
Pre-Name Change Group (n=37) |
Post-Name Change Group (n=28) |
Adjusted OR [95% confidence interval]B |
|---|---|---|---|---|
| General Health and Well-Being | Mean (SD) | Mean (SD) | Mean (SD) | |
| Current Physical Health Rating (1 = poor, 10 = excellent) | 8.11 (1.84) | 7.89 (1.76) | 8.39 (1.93) | |
| Current Mental Health Rating (1 = poor, 10 = excellent) | 7.24 (2.32) | 7.14 (2.16) | 7.36 (2.54) | |
| Self-esteem | 30.64 (5.58) | 30.44 (5.43) | 30.89 (5.87) | |
| Depressive symptoms | 15.19 (6.43) | 15.39 (6.09) | 14.93 (6.96) | |
| Anxiety symptoms | 14.23 (7.15) | 14.56 (7.35) | 13.82 ±7.00) | |
| % Yes (n) | % Yes (n) | % Yes (n) | ||
| Health insurance | 92.1 (58) | 94.3 (33) | 89.3 (25) | |
| Health Care Utilization (past 6 months) | ||||
| Visited the emergency room or medical center | 43.8 (28) | 42.9 (12) | 44.4 (16) | |
| Was a patient in the hospital overnight | 22.2 (14) | 28.6 (10) | 14.3 (4) | |
| Barriers to accessing services due to gender identity or presentation | 15.6 (10) | 16.7 (6) | 14.3 (4) | |
| Looked for health information on the Internet | 58.7 (37) | 65.7 (23) | 50.0 (14) | |
| Postponed medical care when needed | 39.1 (25) | 36.1 (13) | 42.9 (12) | |
| Postponed medical care due to cost | 14.1 (9) | 11.1 (4) | 17.9 (5) | |
| Postponed medical care due to gender identity or presentation | 18.0 (11) | 25.7 (9) | 7.7 (2) | 5.88 [1.03–33.40] |
| Transgender Transition-Related Health Care (past 6 months) | ||||
| Transition-related hormones prescribed by a medical professional | 84.1 (53) | 82.9 (29) | 85.7 (24) | |
| Visited a mental health professional for gender-transition services | 62.5 (40) | 69.4 (25) | 53.6 (15) | |
| Transition-related hormones injected by a friend A | 42.2 (27) | 55.6 (20) | 25.0 (7) | 4.12 [1.28–13.31] |
| Silicone injected by a friend | 4.8 (3) | 5.7 (2) | 3.6 (1) | |
| Transgender-Related Victimization | ||||
| Verbally abused or harassed by a… (past 6 months) | ||||
| Stranger in public | 53.1 (34) | 55.6 (20) | 50. (14) | |
| Family member or friendA | 22.2 (14) | 31.4 (11) | 10.7 (3) | 4.86 [1.08–21.89] |
| Romantic or sexual partner | 17.2 (11) | 11.1 (4) | 25.0 (7) | |
| Physically abused or assaulted by a… (past 6 months) | ||||
| Stranger in public | 10.9 (7) | 13.9 (5) | 7.1 (2) | |
| Family member or friend | 6.3 (4) | 8.6 (3) | 3.6 (1) | |
| Romantic or sexual partner | 6.3 (4) | 5.6 (2) | 7.1 (2) |
Notes:
Significantly different at p < .05;
Adjusted for age differences.
Health care utilization
There were no significant differences for health care utilization between groups. However, one notable difference in postponement of medical care due to gender identity or presentation was observed, with transwomen in the pre-name change group being significantly more likely to report postponing medical care than were transwomen in the post-name change group when controlling for age (AOR=5.88 [1.03–33.40]), with a small-medium effect size (Cramer’s V=0.23).
Transgender transition-related health care
Overall, 84.1% of participants reported using transition-related hormones prescribed by a medical professional and 62.5% had visited a mental health professional for gender-transition services in the past six months. No group differences were observed for transgender transition-related health care, with the exception that transwomen in the pre-name change group were four times more likely to report having transition-related hormones injected by a friend (AOR=4.12 [1.28–13.31]) than were transwomen in the post-name change group, with a medium effect size (Cramer’s V=0.31), even when controlling for age.
Transgender-related victimization
Roughly one half of the sample had experienced verbal abuse or harassment by strangers in the past six months (see Table 3). Fewer reported verbal abuse or harassment by family or friends and romantic or sexual partners. There were no significant between group differences for verbal abuse or harassment. However, when we control for age transwomen in the pre-name change group were nearly five times more likely to report verbal abuse or harassment by family or friends in the past six months than were transwomen in the post-name change group (AOR=4.86 [1.08–21.89]), with a small-medium effect size (Cramer’s V=.25).
Discussion
We hypothesized that legal name change would act as a structural intervention for transwomen of color and have downstream effects on: socioeconomic factors (Hypothesis 1), access to and utilization of general and transgender transition-related health care (Hypothesis 2), and transgender-related victimization (Hypothesis 3). Findings supported Hypothesis 1 in that significantly more transwomen in the post-name change group were employed, reported higher monthly incomes, and held stable housing over the past year with medium effect sizes for differences. These findings suggest that legal name change is a potential structural intervention for establishing economic stability for transwomen of color. Prior research has found that fears of being “outed” as transgender and discriminated against prevent some transgender individuals from interacting with public-facing institutions or jobs (e.g., public services) (Couch et al., 2008). Legal name change may be particularly instrumental in workplaces and employment searches, given the central role that identification documents play in hiring processes. Our data indicate that having legal documents befitting one’s gender identity may increase transwomen’s success on the job market. Because secure employment is critical to other life outcomes (e.g., financial stability, health and well-being), decreasing structural and policy level barriers to legal name change may be particularly important for employment, with the potential to improve transwomen’s lives in myriad ways.
Group comparisons for access and utilization of general and transgender transition-related health care did not fully support Hypothesis 2; however, after adjusting for age differences, transwomen in the pre-name change group were five times more likely than transwomen in the post-name change group to report postponing medical care due to gender identity or presentation. Additionally, a significant group difference was observed in non-medically prescribed injectable hormone use, with more transwomen in the pre-name change group reporting use of transition-related hormones injected by friends or non-medical professionals compared to transwomen in the post-name change group. Taken together, these findings have direct implications for transgender health. First, postponement of medical care due to gender identity and presentation may exacerbate health problems experienced by transwomen of color (Bauer et al., 2014; Sanchez, Sanchez, & Danoff, 2009). Second, the use of transition-related hormones injected by a friend or non-medical professional significantly increases the potential for infections, including HIV (Jordan, Edwards, & Reynolds, 2007; Namaste, 1999). The potential for legal name change to mitigate these health risks should be considered in subsequent studies and incorporated as a structural intervention aimed at addressing disparities in transgender health, including HIV/AIDS. Prior research has demonstrated that significant barriers to adequate health care exist for transgender individuals, such that even transgender individuals who have a primary care provider are not necessarily “out” to them and may be uncomfortable talking about transgender-related health care with their providers (Rood, Reisner, Surace, & Puckett, 2016). Thus, the link between legal name change and culturally sensitive and supportive interactions with health care providers warrants further investigation.
Our findings did not fully support Hypothesis 3, that legal name change would have an effect on transgender-related victimization. However, after adjusting for age differences, transwomen in the pre-name change group were nearly five times more likely to report experiencing verbal abuse or harassment from family members or friends in the past six months. This finding may indicate that legal name change helps to legitimate transgender individuals’ identities in the eyes of family and friends, a finding that should be further investigated in future research (Bradford et al., 2013). Notably, experiences of verbal abuse and harassment by strangers in public in the past six months were high for both groups, which may indicate a ceiling effect for the potential for legal name change to minimize experiences of victimization unrelated to legal identification. Thus, additional structural and policy level interventions that provide transwomen and other transgender and gender non-conforming people with legal protections from violence and victimization are needed to fully realize transgender rights, health, and well-being.
In addition, several positive and transgender-related health findings warrant discussion. First, self-reported self-esteem and physical and mental health were relatively high among both groups. These results mirror prior studies that have found a significant relationship between self-acceptance of transgender identity and lowered odds of depressive symptoms (Su et al., 2016). Furthermore, nearly all transwomen reported having health insurance and having accessed transition-related health care and/or mental health care in the past six months. Independent from legal name change, these findings underscore that the transwomen of color in our sample were successfully accessing and receiving transgender-related health care. However, this finding may reflect that both groups comprise transwomen of color who were actively engaged with a transgender advocacy agency (i.e., TLDEF). Thus, the transwomen in this sample may be particularly proactive about their social and medical transitions.
Conversely, study findings also indicate that transwomen of color continue to experience social determinants that are known correlates of poor health and well-being. First, in contrast to the high number of transwomen reporting having health insurance, nearly half of the sample had visited an emergency room or immediate medical care center within the past six months. This finding suggests that transwomen may use emergency care as a primary resource for health care or may be experiencing acute health problems that increase the likelihood of utilizing emergency medical care, reflecting prior research demonstrating that transgender people may avoid health care interactions because of fear of discrimination (Bauer et al., 2014; Rood et al., 2016). Second, close to half of the sample reported using transition-related hormones injected by a friend or non-medical professional, thereby comprising a significant risk factor for blood-borne infections, including HIV and Hepatitis C (Jordan et al., 2007; Namaste, 1999). Taken together, these findings may indicate that transwomen in our sample were avoidant of interactions with medical providers despite high reports of having insurance and recently receiving transition-related health care. Future research should take into account these findings when further examining the reasons transwomen seek or forego healthcare, their interactions with healthcare providers, and how to support routine access to primary healthcare services.
Notably, many transwomen in the sample reported experiencing socioeconomic hardship in the past year, suggesting that additional interventions are needed to support their economic well-being, particularly as employment was significantly higher among the post-name change group. A large body of research has found that unemployment is linked to multiple poor health outcomes (e.g., self-rated health, mortality, and mental illness), and that job instability is linked to similarly damaging health effects (Kim & von dem Knesebeck, 2015). Thus, interventions that promote stable employment for transwomen, while important, are likely insufficient to address the multiple social, economic, and health concerns that affect transgender women of color. Multicomponent interventions, of which legal name change is one component, are necessary to achieve multiple positive impacts on transwomen’s health and well-being.
Limitations
One challenge in researching transwomen of color is that they represent a small and relatively hard-to-reach population. In partnership with the TLDEF, this study was able to reach a relatively comparative sample of transwomen of color initiating legal name change as well as those who had changed their legal name through this no-cost legal advocacy clinic. However, the data are comprised of a convenience sample recruited through an advocacy organization, which likely impacts the results (such as the high percentage of the sample with health insurance). Thus, our data are not representative of all transwomen of color and are not generalizable to the transgender population as a whole, and selection bias may influence the results. Further, this research used a retrospective group design rather than a prospective design that would have allowed for more definitive inferences relative to cause and effect. Additionally, although both groups were homogenous with respect to demographic characteristics, additional factors including length of time identifying as transgender and level of transgender “outness” were not assessed in this study and may modify the potential benefits of legal name change on socioeconomic status and health. Also, since we recruited from an existing pool of transwomen, we were unable to create a case-matched control or experimental design, contributing to a significant difference in age between groups, which required statistical control for age on all significant group differences. Thus, prospective case-matched control and/or longitudinal studies examining the potential effects of legal name change on the socioeconomic status and health outcomes of transgender people are needed.
Conclusion
To the best of our knowledge, this is the first study to quantitatively explore the potential socioeconomic and health benefits of transgender legal name change. Our findings suggest that legal name change may serve as an important structural intervention for low-income transwomen of color. In particular, our findings suggest that legal name change has potential downstream effects on socioeconomic factors frequently associated with health, e.g., employment, income, stable housing. Furthermore, we found that legal name change is associated with decreased use of non-medically prescribed transgender transition-related health care (e.g., hormones injected by a friend of non-medical professional), the potential to decrease postponement of medical care due to gender identity or presentation, and the potential to decrease transgender-related verbal abuse or harassment by family members or friends among transwomen of color. Taken as a whole, our findings support that legal name change represents a structural level factor that contributes to the milieu of positive benefits experienced by transgender women of color through social-transition, gender affirmation, and legal legitimacy, and ultimately contributes to improved transgender health (Sevelius et al., 2014; Nuttbrock, Rosenblum, & Blumenstein, 2002). Given the potential influence of legal name change on socioeconomic factors and health, state and federal policies limiting or preventing access to legal name change for transgender people may contribute to persistent health disparities and poor health outcomes among transgender people. Apart from state and federal policies, supportive community organizations and health care providers should increase transgender clients’ access to legal name change services. Community organizations should pursue integrating legal name change consultations into existing service portfolios, and health care providers should provide referrals to such services to help increase the amount of transgender individuals benefiting from legal name change. Thus, public policies improving access and reducing costs associated with legal name change may play a critical role in mitigating health disparities and ultimately improve transgender health.
Acknowledgments
We would like to acknowledge and thank all of our participants and the staff at the Transgender Legal Defense & Education Fund, Inc. for their dedicated support.
Funding: This research was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health, grant number UL1-TR000430 and The University of Chicago, Medicine and Biological Sciences Office of Diversity and Inclusion, B.J. Hill & M. Silverman (PIs). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or The University of Chicago Office of Diversity and Inclusion.
Footnotes
Compliance and Ethical Standards.
Ethical Approval
All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Conflict of Interest: All authors declare no conflict of interests.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
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