General Articles

Trans*forming Healthcare: Increasing Visibility Around Trans*-Specific Health Risks

By Greg Tartaglione, SIECUS Program Research Intern

Karen I. Fredriksen-Goldsen, Loree Cook-Daniels, Hyun-Jun Kim, Elena A. Erosheva, Charles A. Emlet, Charles P. Hoy-Ellis, Jayn Goldsen, and Anna Muraco, “Physical and Mental Health of Transgender Older Adults: An At-Risk and Underserved Population,” The Gerontologist (March 2013).

This article in The Gerontologist uses the term “transgender” as an umbrella for any persons who have “gender identities, expressions, or behaviors not traditionally associated with their birth sex”[1] including intersex and fully-transitioned transsexual participants who are specifically mentioned in the analysis as not identifying as transgender. SIECUS uses “trans*” in the title of this Research Update to be inclusive of these and other gender identities and expressions, but will otherwise use the term “transgender” to be congruent with the source material

In 2010, researchers conducted a survey of more than 2,500 lesbian, gay, bisexual and transgender (LGBT) Americans over the age of 50 to better understand the long term physical and mental health effects of social stigma and identity concealment on marginalized sexual and gender identity groups. The current analysis focuses on the reports of transgender adults (7% of surveyed respondents), whose specific medical needs are frequently unmet by medical professionals and who experience unique fears and boundaries related to health care access.

According to the authors, transgender people face the highest societal rates of violence and abuse and often are marginalized even by their lesbian, gay, and bisexual peers.[2] In a previous survey, more than one in four transgender adults reported having “experienced discrimination by a physician or have been denied enrollment in a health insurance due to their gender identity.”[3]

While most studies typically group LGBT adults together, this study demonstrates the importance of taking into account “modifiable risk factors” that uniquely influence the lifetime health of transgender adults in comparison to that of lesbian, gay, and bisexual adults.

Through 2,200 printed and 300 electronic surveys, authors observed the indirect effects of gender identity (transgender v. non-transgender) on reported rates of risk factors (lifetime victimization, internalized stigma, tendency toward minority identity concealment) in relation to protective factors (social support, social network size, religious activity) as well as health indicators (access to healthcare, fear of accessing health service, smoking, physical activity) to better understand long term health outcomes (perceived physical health and mental stress, physical or mental disability, and depression).

Key Findings:

  • Transgender adults age 50 and older were more likely to be “non-Hispanic white,” have lower household incomes, have children, have served in the military, and less likely to live alone than non-transgender respondents. Though transgender adults reported larger social networks, they cited lower levels of social support; their social networks consisted of fewer biological family members.
  • 22% of transgender adults reported having faced financial barriers to health services vs. 6.5% of non-transgender adults. 40% of transgender adults reported fear of accessing health services that did not cater to LGBT needs vs. 13% of non-transgender adults.
  • Transgender adults reported twice as many incidents of lifetime discrimination and victimization including (in order of prevalence) verbal insults, threat of physical violence, not being hired for a job, being denied health care, and being hassled by the police.
  • Concealment of gender identity was significantly associated with higher degrees of perceived depression and stress. Social support and positive feelings of “LGBT community belonging” were associated with better overall physical health, and lower likelihood of disability, depression, and stress.

Including gender identity in policy surrounding access to health care , hate crimes, and non-discrimination in the workplace is crucial to begin to address the distinct needs of an increasingly more visible and aging trans* population. For example, the study noted higher rates of military service among older transgender participants compared to older LBG study participants. Despite the fact that trans* people cannot serve openly during their service, the Department of Veterans Affairs and Veterans Health Administration stated in 2013 that “medically necessary care is provided to enrolled or otherwise eligible intersex and transgender Veterans, including hormonal therapy, mental health care, preoperative evaluation, and medically necessary post-operative and long-term care following sex reassignment surgery” though they will not perform or fund what they refer to as the “cosmetic” surgery itself.[4]

Though concealing gender and sexual identity is strongly linked with stress and depression in the study, there is always the risk that disclosing gender identity could lead to discrimination in medical settings where providers lack knowledge on trans* issues— either due to a lack of training or lack of exposure to openly trans* patients. The authors compare this to the beginning of the AIDS epidemic when persons diagnosed with HIV/AIDS experienced a similar fear of seeking necessary care and treatment due to the stigma which surrounded it due medical practitioner’s lack of basic knowledge.

Sexuality educators can advance the quality of physical and mental health care for trans* people by providing information to patients and their medical providers; this can help to reduce stigma and prevent victimization. Fostering individual and community support and understanding of transgender issues is a key factor which the study suggests is important to reduce long-term physical and mental health risks for transgender people.

[1]Fredriksen KI, Cook-Daniels L, Kim HJ, Erosheva EA, Emlet CA, Hoy-Ellis CP, Goldsen J, Muraco A (2013). Physical and Mental Health of Transgender Older Adults: An At-Risk and Underserved Population. The Gerontologist. 54(3): 488-500. Accessed July 10, 2014 at


[3]Bradford J, Reisner SL, Honnold JA, Xavier J (2013). Experiences of transgender-related discrimination and implications for health: Results from the Virginia transgender health initiative study. American Journal of Public Health. October: 103(10): 1820-29. Accessed July 10, 2014 at

[4]Department of Veterans Affairs & Veterans Health Administration (2013). Providing healthcare for transgender and intersex veterans. Accessed July 3, 2014 at