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Discrimination Beyond the Bathroom: Health Disparities among Transgender People in the U.S.

By Jamie Linnea Luckhaus, Lund University


As Danica Roem makes history as the first openly transgender US state legislator, replacing Virginia’s “chief homophobe,” as Del. Robert G. Marshall referred to himself, we find ourselves at a point of reflection.(1) Although this historical election may have many feeling hopeful, what is the current trans situation? Especially within the more conservative southern states, transgender people face many disadvantages in health quality and access.

Sixteen states—Alabama, Arkansas, Illinois, Kansas, Kentucky, Minnesota, Missouri, Montana, New York, South Carolina, South Dakota, Tennessee, Texas, Virginia, Washington and Wyoming—have proposed legislation that would restrict access to multi-user sex-segregated facilities such as restrooms and changing rooms, on the bases of “biological sex.” North Carolina is the only state to pass such legislation (House Bill 2) known as the “Bathroom Bill,” which has now been repealed after bringing the state economic and social devastation.(2)  To give an example, under such legislation, a transgender female, who looks, sounds, and acts according to society’s expectations and definition of a female, would be required to enter a restroom designated for men, because that is the sex listed on her birth certificate.

Comic addressing the “Bathroom-Bill”, which was passed in North Carolina (Credit: Jacob Winkleman and Rhiannon Bauer )

The justification for such bills is to protect citizens, especially women, from assault by a transgender person in a bathroom or other public space. According to TED Talk speaker Jackson Bird, “more US congressmen have been convicted of assaulting someone in a public bathroom than trans people have.”(3) Further research has shown transgender people are often the ones in danger, with 64%  experiencing sexual assault at some point in their lives.(4) Even if these claims were unjustified and without evidence, the mindset such legislation creates among the public has very real effects on the trans community. A 2015 national survey found a higher rate of urinary tract infections (UTIs) among transgender people, with 8% of trans individuals having faced a UTI within the last year from fear of using either restroom.(4)

Alexander Iman, a transgender master’s student in North Carolina, has shared some of his experiences navigating the U.S. system. “The healthcare system is a nightmare for trans people. It’s literally set up against you,” he shares, “…basically there’s a MILLION loopholes you have to jump through to get any type of coverage.” Alexander was dropped from his insurance twice due to “gender mismatch” and had to pay for his testosterone prescriptions out-of-pocket, with a 9-week supply costing around $120.

Many trans individuals decide to undergo hormone replacement therapy (HRT) so that their bodies more closely match their identity.(5) If one wants a gender reassignment surgery, which is extremely expensive, most insurance companies require 12 months of HRP and 12 months of psychological therapy before considering covering surgery.

While taking hormones and attending therapy, Alexander’s first therapist left that practice. Alexander then finished his year with a therapist at his university before discovering that the university does not write letters to insurance companies. After switching to a third therapist, attending for 12 consecutive months and undergoing a second year of HRT, Alexander’s insurance agreed to cover 30% of the surgery, which is more generous than some companies.

Unfortunately, Alexander’s case is more common that one may think. The National Center for Transgender Equality found that one in four (25%) respondents across the nation reported having problems in the past year with their health insurance related to being transgender.(4)

Many transgender people face problems with their health insurance regarding the coverage of HRT and surgeries (Picture Source: Human Rights Campaign)

According to a report in Massachusetts by The Fenway Institute and the Massachusetts Transgender Political Coalition, 65% of transgender people reported having experienced discrimination in one or more public accommodation settings over the past year, with 24% experiencing discrimination in health care settings specifically.(6)

Many health services viewed as gender- specific such as PAP-smears, cervical cancer screenings, and prostate exams are commonly denied to transgender people.(4) However, it is illegal for a Marketplace insurer to limit recommended sex-specific exams based on one’s sex assigned at birth, gender identity, or recorded gender. For example, a transgender man who has residual breast tissue or an intact cervix should have access to a mammogram or pap smear.(7)

The discrimination and restricted access to common services goes beyond healthcare. After his health insurance failed him, Alexander later was involved in a car accident in December 2016, for which his car insurance refused to cover. “My car insurance rejected me … because my voice on the phone did not match the name they had in their system.” Alexander, a student already paying for prescriptions out-of-pocket, ended up with a bill of nearly $4k, despite having car insurance.

There is a well-documented association between discrimination and poorer overall self-reported physical and mental wellbeing. A survey found that 39% of transgender people were currently experiencing serious psychological distress, which is almost eight times the rate of the overall U.S. population (5%).(4)

The discrimination is something Alexander and many others are forced to live with. At the time of the incident, Alexander had to present the police with his old identification with his old name and photo. He had tried to change the gender on his driver’s license multiple times, but at each attempt the Division of Motor Vehicles (DMV) told him he needed another document. Returning with his Social Security card, then a proof of surgery, and then an updated birth certificate, Alexander still received a flat “no.” “I don’t buy alcohol or go to many events where I know I’ll get carded,” Alexander shares, “just because it’s a hassle.”



  1. Olivo A. Danica Roem of Virginia to be first openly transgender person elected, seated in a U.S. statehouse The Washington Post: The Washington Post; 2017 [
  2. National Conference of Stae Legislatures. “BATHROOM BILL” LEGISLATIVE TRACKING: National Conference of Stae Legislatures; 2017 [Available from:
  3. Bird J. How to talk (and listen) to transgender people [Internet]. TED: TED; 2017. Podcast. Available from:
  4. Equality NCfT. The Report of the 2015 U.S. Transgender Survey. 2015.
  5. American Medical Student Association. Tansgender Health American Medical Student Association: American Medical Student Association; 2017 [Available from:
  6. Reisner SL WJ, Dunham EE, Heflin K, Begenyi J, Cahill S, the Project Voice Team,. Discrimination and Health in Massachusettes: a Statewide Survey of Transgender and Gender Non-comforming Adults: The Fenway Institute and the Massachusetts Transgender Political Coalition; 2013 [
  7. Services USCfMM. Transgender health care  [Available from:

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