The Cost of Discrimination Against Transgender People

transgender discriminationAt the end of last year, Rolling Stone declared 2014 “The Biggest Year in Transgender History,” noting increased representation of trans characters and actors on TV (think: Orange Is the New Black’s Laverne Cox, Amazon’s Transparent). Prominent women’s colleges like Mills College and Mount Holyoke began to accept transgender women as applicants, and the United States made legislative strides toward more inclusive health care.

2015 arguably saw a trans woman in the brightest spotlight yet: Caitlyn Jenner’s Vanity Fair cover and subsequent press tour broadcast a high-profile trans woman into homes across America. But new visibility should not be mistaken for progress; transgender Americans endure significant adversity and financial penalties.

While the Affordable Care Act (ACA) was touted as revolutionizing trans-specific health care by eliminating the discrimination often faced by trans people when it comes to health coverage, the changes weren’t nearly as sweeping as they were made out to be. And while Caitlyn Jenner is a valuable advocate for transgender rights, her extraordinary resources and profound privileges are not reflective of the community as a whole.

The economic reality for most trans people is a starker one.

Jobs, What Jobs?
The most severe case of economic discrimination faced by the trans population is employment, says Finn Brigham, director of care coordination at the Callen-Lorde Community Health Center in New York City. Trans people are already more likely than their cisgender counterparts to face homelessness, and according to the Movement Advancement Project are nearly four times more likely as the cisgender population to earn a yearly income below $10,000 (“cisgender,” or simply “cis,” describes people whose gender identity lines up with the sex assigned to them at birth).

That number escalates for trans people of color; Asian American/Pacific Islander and Latino trans people are nearly six times more likely to live in poverty than cisgender Asian American/Pacific Islander and Latino people.

"It is legal in 32 states to fire somebody simply because of their gender identity."  

Overcoming poverty is hard enough for anyone, but trans people are “often set up from a very young age to not be able to obtain gainful employment,” Brigham says. Many trans people are kicked out of their homes and are unable to finish high school, making college unlikely. This makes finding work that pays a living wage exceptionally difficult.

If a trans person does manage to overcome these obstacles, the onboarding process at a new job presents a challenge, Brigham says. Even with all legal documents changed to reflect the correct gender identity (which is a herculean task — here are some resources to help navigate it), most jobs will require some sort of background check and a list of any names you have gone by in the past.

At this point, it becomes nearly impossible not to disclose that a person is trans (if they haven’t already, and some trans people choose not to disclose), which presents a shocking problem: It is legal in 32 states to fire somebody simply because of their gender identity. This means that a perfectly competent, qualified, hired person can lose their chance at employment when an employer chooses to discriminate — and it’s legal.

Unfortunately this isn’t rare: According to a survey by the National Center for Transgender Equality and the National Gay and Lesbian Task Force, 26 percent reported losing a job due to their gender identity, while 47 percent reported being fired, denied promotions, or not being hired at all. If they did gain employment, 90 percent reported harassment, mistreatment, or discrimination in the workplace.

The results of this bias are staggering. According to the survey, “respondents experienced unemployment at twice the rate of the general population at the time of the survey, with rates for people of color up to four times the national unemployment rate.” Sixteen percent of respondents were left with no choice but to work in the “underground economy,” taking up illegal occupations like selling drugs or engaging in sex work.

It gets worse. Those who had lost a job due to gender identify bias reported “ruinous consequences”; four times the rate of homelessness, more than double the HIV infection rate, and 70 percent more drinking or drug use as compared to the wider population not fired due to discrimination. All these statistics go hand-in-hand with the 85 percent increase in the likelihood of incarceration.

Unfortunately, unemployment isn’t the only way trans people find themselves predisposed to being homeless.

Propensity for Homelessness
A Blueprint for Equality: Federal Agenda for Transgender People, a report by the National Center for Transgender Equality, notes that “shelter is a basic human right, yet trans people face severe discrimination and hardship in many ways as we pursue suitable housing.” According to a report by the National Transgender Discrimination Survey, 19 percent of American trans people have been refused a home or apartment when trying to rent or buy, and 11 percent have been evicted based on their gender identity. One in five trans people have experienced homelessness, either due to discrimination or because their families rejected them.

Help is hard to come by: More than half of homeless trans Americans who have sought out homeless shelters have been harassed by staff or other residents. Twenty-nine percent of respondents have been turned away at shelters because of being trans, and 22 percent reported sexual assault from staff or other residents. In a system where “help” is either denied to trans people or dangerous, it’s no wonder that so many trans people are relegated to a life of poverty.

The Cost of Trans Health
Health care is another hurdle. Brigham says that “across the board, the vast majority of insurances do not cover [trans-specific] care,” referring to hormones and surgery. While the ACA was hailed as extending health care to trans people, the ACA’s website clarifies that transgender-specific care is no longer subject to “blanket exclusions.” Saying that something will not be routinely denied is hardly the same thing as mandating care, and there is no law explicitly protecting transgender people from health-care discrimination.

"One in five trans people have experienced homelessness, either due to discrimination or because their families rejected them."  

Numerous medical organizations — including the American Medical Association — have concluded that the procedures involved in transitioning are medically necessary and non-elective, but this critical medical treatment is not always covered by health insurance. The various surgeries associated with transitioning can cost anywhere between $5,000 and $30,000, says Masen Davis, executive director of the Transgender Law Center.

Anecdotally, trans people report that prolonged gender dysphoria, the feeling that your gender does not align with your physical sex, can lead to suicidal thoughts and self-mutilation. A 2011 study of 500 people with gender dysphoria found that 72 percent experienced suicidal ideation over their lifetimes. Treatment is certainly necessary and timely.

While surgeries are each a one-time expense (barring complications that could result in emergency-room visits or additional medical treatment), some trans people take hormones over the course of their lives. (According to the National Center for Transgender Equality, some insurance companies cover hormone therapy.) For reference, hormone replacement therapy can cost approximately $30 per month, and mandatory therapy visits can cost more than $100 per session.

While New York State now mandates that trans-specific care must be covered by insurance companies, Brigham remembers what it was like for the trans population who used Callen-Lorde’s services before that decision was enacted in 2014. Each case “came down to an individual situation, an individual health insurance company, sometimes even an individual representative from the health insurance company that you were working with.”

If you were denied coverage, you could attempt to mount a legal case, but you’d have to find an attorney who would work within your price range and be knowledgeable about this area of law. As you might guess, this type of lawyer isn’t particularly easy to find.

The effects of providing access to trans-specific care go far beyond transitioning. “If people are able to get this type of care covered, they’re more likely to engage with a primary physician, which means they’re more likely to get preventative screenings and have better health indicators in general,’’ Brigham says. However, “a lot of folks feel like if they can’t get their trans-related care covered, then what’s the point of engaging with a provider?” says Brigham. That means they aren’t getting mammograms or colonoscopies, which could mean they are missing early detection on very expensive illnesses.

However, even if your care is covered, there’s another battle: finding knowledgeable doctors. According to Brigham, medicals schools may have “training on LGBT health, but not a lot of focus particularly on the ‘T.’”

The Association of American Medical Colleges found that doctors are not given nearly enough training in LGBT health, although student-led efforts may be driving a change. For now, this means trans people may have to travel extensively for care.

“There are virtually no surgeons in New York State that are performing genital-specific transition-related surgeries,” Brigham says. “So even if you could get it paid for, there’s no surgeons to go to.” So in addition to the overwhelming cost of care, trans people are looking at lost wages and travel costs just to receive care by a doctor who knows what they’re doing.

The Real Cost
Discrimination comes at a cost beyond dollars and cents: A Williams Institute study found a link between discrimination and the shocking rate of suicide attempts in the trans population. Harassment, the inability to find a home or adequate health care, and rejection by families “may contribute to elevated prevalence of suicide attempts among transgender people,” according to the study.

"Transgender people are seven times more likely to 'experience physical violence when interacting with the police."  

In addition to employment, housing, and health-care discrimination, the trans population faces an outsize risk of violence, which is much higher for trans people of color: According to a National Coalition of Anti-Violence Programs report, transgender women constituted 55 percent of reported hate crimes — which are on the rise. Fifty percent of those victims were transgender women of color, primarily black transgender women.

Of the 21 transgender women who were killed this year, the HRC notes that “the murders are typically gruesome and have gone mostly unsolved.”

Help often doesn’t help: A 2013 report by the same organization noted that transgender people are seven times more likely to “experience physical violence when interacting with the police” compared to cisgender victims. And compared to white cisgender victims, transgender people of color are six times “more likely to experience physical violence from the police.”

Raffi Freedman-Gurspan, a policy advisor for the National Center on Transgender Equity, called transphobia-related crime “a national crisis."

Is There a Solution?
Sweeping changes are needed.

Employment discrimination comes with an obvious solution: a federal law making it illegal to discriminate based on gender identity. While the Equal Employment Opportunity Commission included gender identity in its definition of gender discrimination in 2012, there is no explicit law regarding the transgender population, meaning that firings based on bias are settled on a case-by-case basis. More specific legislation is needed in order to give trans people full protection, and awareness by employers and enforcement of the law is critical.

Similarly, health insurance should no longer be able to deny coverage for trans-specific care; it is necessary medical treatment. Brigham points to the need for more education for doctors about trans-specific care (like how to safely prescribe hormones and perform trans-specific surgeries), which medical schools should require — in addition to cultural competency courses on how to deal with LGBT patients.

The U.S. Department of Housing and Urban Development has stated that discrimination against trans tenants may constitute sex discrimination under the Fair Housing Act, but gender identity is not written into housing law on a national level. Like employment discrimination, explicit federal legislation is needed.

Some progress has been made. In October of this year, New York Governor Andrew Cuomo issued an executive action laying out the first-ever statewide regulations to protect New York’s trans population from discrimination in housing, employment, schools, hospitals, and restaurants, as well as when it comes to applying for financial services like mortgages and credit cards. Trans people are also given recourse to file complaints against discrimination and set up to receive compensatory damages if it's ruled that discrimination did occur.

Remember that New York State already mandates that health insurers cover trans-specific care. So far, this makes New York the most progressive state in the country when it comes to transgender civil rights — although this big step forward simply means extending basic human rights to Americans.

The tipping point for trans visibility may have arrived, but it was not accompanied by enough progress to improve the basic rights of the trans population in America. In an age in which trans people are being discriminated against, beaten, killed, and driven to suicide, we need changes — fast.

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