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Published and Approved USTS Projects
This page contains information about projects for which use of the 2015 U.S. Transgender Survey dataset has been approved. Please check back here for the most current information about approved projects prior to submitting a data request. In order to ensure that USTS data is used to support a valuable and diverse body of research on a range of important issues, researchers submitting data requests for projects that substantially overlap with projects that have already been approved may be asked to revise their abstracts.
As a note, researcher names and affiliations for approved projects in progress are not listed for privacy reasons. If you are interested in connecting with a researcher about a project listed below, please submit your inquiry to email@example.com, and we will connect you with the researcher if possible.
Published PROJECTS
A Closer Look: Bisexual Transgender People - An analysis of bisexual USTS respondents by Movement Advancement Project, NCTE, BiNet USA, Bisexual Organizing Project, and Bisexual Resource Center
Approved Projects in Progress
Intersection of Gender, Ethnoracial, and Class Stigma and HIV Testing Patterns among Transgender Women of Color
The disparate rates of individual and structural discrimination faced by transgender women of color is embedded in misogyny, transphobia, racism, and classism. There is scant research examining the interconnected processes of gender, race/ethnicity, and class discrimination towards transgender women of color. This study will explore the social processes—forms of oppression producing health disparities—of discrimination based on gender, race/ethnicity and class targeting transgender women of color aware and unaware of their HIV status. Moreover, it will examine the relationship between intersecting processes of discrimination and HIV testing patterns. Addressing the link between discrimination and reasons to not get tested for HIV is necessary to improve awareness of HIV status and subsequent engagement in care and/or engagement in prevention efforts.
Adherence to HIV care and medication among trans men, women and nonbinary individuals: Findings from the US Trans Survey
Adherence to antiretroviral therapy (ART) can improve health outcomes, extend the lives of people living with HIV, and decrease or eliminate HIV transmission. Achieving an undetectable viral load requires that people living with HIV fully engage in the HIV continuum of care by learning their HIV status, linking to care, and adhering to treatment and ART. Transgender people, especially trans women, are at high risk for contracting HIV and less likely to adhere to HIV care and medication. Existing research on HIV care and adherence is limited by small numbers of trans people, little research on trans men, and virtually no research on people who identify as non-binary. However, understanding how HIV medication adherence is related to transgender specific barriers and facilitators is important for improving healthcare for transgender persons living with HIV. The US Trans Survey offers a unique dataset, with a large enough sample, to explore medication adherence patterns among trans people living with HIV. The purpose of this analysis is to examine the relationship between outness, hormone therapy, provider discrimination, social support and adherence to care and medication among trans people living with HIV. These relationships will be tested separately across men, women, and non-binary to see if these factors differentially affect medication adherence across gender. Follow up analyses will examine race/ethnicity and geographic region. This analysis will provide important information about variables influencing care and adherence among trans populations that can be used to tailor intervention strategies to these groups.
Experiences of Health Care Discrimination Among Transgender People of Color in the USTS
Although prior studies have noted the negative experiences within health care settings transgender and gender non-conforming (TGNC) individuals may encounter, there is still a paucity of research on the unique experiences of TGNC people of color (POC) in the health care system. Specifically, within-group differences in experiences of health care discrimination among TGNC POC are rarely examined. This study seeks to use latent class analysis to identify mutually exclusive subgroups of individuals based on their responses to observed binary variables, including: having to teach one's doctor or other health care provider about trans people to receive appropriate care, being refused trans-related care, being refused other health care, having a doctor use harsh or abusive language when being treated, having a doctor be physically rough or abusive when treated, being verbally harassed in a health care setting, being physically attacked in a health care setting, or experiencing unwanted sexual contact in a health care setting. We also plan to examine the association of demographic and health indicators including being "out" in health care settings, health insurance status, and undergoing transition-related procedures with latent class membership.
The Effect of Discriminatory Health Care Encounters, Forgone Care, and Informal Care Networks on Mental Health Outcomes among U.S. Transgender Care-Seekers
Transgender individuals are at increased risk for experiencing depression compared to their cisgender counterparts due to chronic exposure to stressors, such as discrimination. These elevated rates of depression render access to effective treatment as imperative; however, transgender communities often remain under-served in health care environments and report unmet mental health (MH) needs. Proposed are two interrelated studies that will assess the influence of health care access on MH outcomes among transgender individuals. Study 1 will use Latent Class Analysis (LCA) to examine discriminatory health care encounters among transgender help-seekers. LCA can help elucidate population heterogeneity within observed data through the identification of underlying subgroups of individuals. Study 1 will: 1a) Identify clusters of discriminatory events that respondents confront in health care environments; 1b) Use multinomial logistic regression to investigate demographic predictors of class membership, and 1c) Employ multinomial logistic regression to assess the association between latent class membership and MH outcomes, including depressive symptoms and suicidal ideation. Given barriers to care, Study 2 will examine if transgender respondents of the 2015 U.S. Transgender Survey who experience depressive symptoms can attain wellness through the reliance on informal care networks when they do not seek care for reasons when needed (e.g., for reasons related to cost or anticipated discrimination). Study 2 will: 2a) Identify respondents who have meaningful levels of depressive symptoms; 2b) Compare suicide outcomes (e.g., thoughts, plans, attempts) between respondents who do and do not receive care, and; 2b) Examine access to a supportive network as a potential protective influence against the deleterious effects of forgone care on suicide outcomes.
The Healthcare Experiences of Transmasculine Adults: Differences by Sociodemographic Characteristics and the Importance of Access to a Transgender-Competent Healthcare Provider
This project will focus on the healthcare experiences of transmasculine respondents of the USTS. First, this project would explore which transmasculine adults are at highest risk for not having access to a trans-competent healthcare provider or for experiencing mistreatment in healthcare settings (discrimination, blatant abuse/harassment/assault); specifically, differences would be examined by factors such as a person's geographic region, distance traveled to a doctor, race/ethnicity, income, education, sexual orientation, disability, and mental health (depression, suicidality). Secondly, this project would examine whether having access to a transgender-competent healthcare provider (either routine or trans-specific) will mediate the relationship between mistreatment in a healthcare setting and mental health (depression, suicidality) and delaying needed medical care due to anticipated stigma. Thirdly, this project would investigate whether the mediating role of having access to a transgender-competent provider differs based on a transmasculine person's geographic region (e.g., Northeast, Southeast, etc.), distance traveled to a healthcare provider, and household income. Knowledge gathered through this project could help inform future efforts to improve healthcare for transmasculine adults, including information about the importance of access to trans-competent healthcare providers and the differing experiences in healthcare based on geography and sociodemographic characteristics.
When Health Care Isn't Actually Care: An Intersectional Look at Discrimination and Barriers to Trans Affirming Health Care
Transgender and non-binary (trans/NB) individuals experiences higher rates of discrimination, harassment, and barriers to culturally responsive care than their cisgender counterparts, with those who have multiple marginalized identities having even increased differential rates of challenges to trans affirming health care. This study aims to look at how these barriers to care (such as cost, fear of discrimination, and lack of an available trans inclusive provider) and actually experiences of discrimination have changed in the trans/NB community since the passing and incremental roll out of the Affordable Care Act (ACA) in the United States. Specifically, using an intersectional lens as coined by Black feminist scholar Kimberle Crenshaw, we aim to explore how various socioeconomic identities and factors (disability, race/ethnicity, age, income, education, gender identity, sexual orientation, and being insured) may further affect some of the post vulnerable members of the trans/NB community. We will use these findings to push for the requirement of information about transgender/non-binary communities to be included in medical trainings for providers, and to move forward the effort to facilitate more accessible, trans affirming care for all members of the trans/NB community.
Barriers and Facilitators to Health Care Utilization Among Transgender People Living in the U.S.
The goal of this study is to understand the impact of gender conformance, demographic factors (education, race/ethnicity, age, income), psychological distress, physical distance to see a health care provider (HCP), health insurance status, health care costs, HCP knowledge, and perceived HCP behavior on whether transgender individuals utilize health care in a large, ethnically diverse, national sample of U.S. transgender individuals. This proposed study will use structural equation modeling (SEM) to test the relationships among several potential factors that may impact whether transgender people decide to participate in the health care system. Mediation and moderation analyses will provide understanding into how environmental factors, perceived HCP behavior, and educating HCPs are potentially important for utilization of health care. The advantages of using SEM are to enable multiple indicators of the constructs to be measured; to allow for multiple ways to test the overall goodness of fit for the conceptual model; and to take into account measurement error in the conceptual model.
Health Care Access Among Transgender Older Adults
Background: Current research indicates that aging gender minority people suffer health disparities that can be linked to exposure to social stigma, discrimination, and health care inequity (dickey, Budge, Katz-Wise, & Garza, 2016; Institute of Medicine, 2011; Stanton, Ali, & Chaudhuri, 2017; Zelle & Arms, 2015). Access to health insurance and interactions with health care providers and insurers have been found to involve instances of discrimination or inspire fear of discrimination are attributed with impacting treatment choices (Gonzales & Henning-Smith, 2017; Kattari & Hasche, 2016; Padula & Baker, 2017; Seelman, Colón-Diaz, LeCroix, Xavier-Brier, & Kattari, 2017).
Objective: Identify the relationship between health care quality (provider knowledge and treatment of the individual), barriers to insurance access and utilization (distance to reach a health care provider, lack of insurance, and insurance rejection and communication), outness to providers, and physical and mental health in gender minority people over age 65. Poor health care quality and greater barriers to insurance access and utilization are expected to be associated with poorer mental and physical health in gender minority people over 65.
Method: Through a secondary data analysis of the 2015 U.S. Transgender Survey, 803 respondents over the age of 65 will be evaluated for responses regarding insurance coverage, experience with insurers, experience with health care providers, provider knowledge, and outness to providers. These will be analyzed through ordinal & linear regression for their relationship with respondent overall health and psychological stress responses while controlling for income and housing status.
Implications: Greater knowledge of the health outcomes in relationship to institutionalized and stigma relate barriers among aging gender minority people can help inform improved education for health providers and illuminate gaps in quality of care delivery. The establishment of a relationship between health status and utilization can also inform policy decisions to improve financial access to care.
Examining the Impact of Rurality on Healthcare Resource Access, Healthcare Utilization, Mental Health and Global Well-Being in Transgender Adults: A Comparison Study
The purpose of this study is to examine the ways in which residing in a rural location impacts the mental health and global well-being of individuals identifying as transgender. Residing in a rural location, for anyone, often presents a set of unique factors with which to navigate, due to lack of resources, limited access to healthcare and counseling services, and inexperienced healthcare provider competency. While there is insufficient research examining the specific experiences of transgender people living in rural areas, research that does exist suggests that they face unique barriers not shared by non-transgender people in rural areas or by many transgender people living in urban areas. The goal of this research study is to explore the impact rurality has on the mental health of transgender individuals when compared to those residing in large, metropolitan cities. In particular, the study seeks to explore the experiences of this population in accessing healthcare resources and the subsequent outcomes of these interactions for transgender people living in rural locations within the United States. The results of this research will work to inform healthcare providers and practitioners in rural communities on the best practices and approaches in working with this distinct population.
Insurance Coverage and Access to Care: A Comparison of Trans and Cisgender People
The 2008 National Transgender Discrimination Study results were compared to the National Health Interview Survey (NHIS) in an article published in 2016. The article, published in Psychology of Sexual Orientation and Gender Diversity (dickey, Budge, Katz-Wise, & Garcia, 2016), reported the results of a study that explored the differences in trans and cis people with regard to access to health care and insurance coverage. Clear health disparities were seen in the results. Trans people were less likely to be insured, less likely to have a primary care physician, and were more likely to use the emergency department (ED) for care than were cisgender people. In this study we plan to follow-up on the original study to determine how and if the atmosphere in health care has changed. We will compare the USTS data to the NHIS data to determine if there are any changes in the health arena. It is notable that the USTS data was collected after the Affordable Care Act (ACA) was implemented. We would expect to see less difference in the numbers of trans people who have insurance coverage. This may not change whether a person has a primary care provider as there continues to be a shortage of providers in the United States. The results of this study can be used to inform policy about the need to ensure that people have access to affordable insurance, that there are sufficient primary care providers who can work with trans patients (e.g., providers need to have cultural and clinical competence), and the need for training of ED staff to ensure culturally competent care.
Health Care Access among Transgender People in the U.S.: An Examination of Risks and Protections
The transgender population experience pervasive interpersonal and structural discrimination within the health care system which impact their ability to access appropriate and inclusive health care. Their invisibility is sustained by a cultural milieu of cisgenderism and cisnormativity, whereby non-trans identities are privileged and an assumption is made that all people are cisgender. The transgender population consists of a diverse spectrum of gender and other intersecting identities. Yet, there is a paucity of research about how each subgroup experiences discrimination, especially if they belong to more than one marginalized community. More specifically, transmen have been underrepresented in research and little is known about the factors which can increase their risk of experiencing health care discrimination or potentiates their ability to access care. Informed by intersectionality theory, the aims of this study are to (a) compare barriers to health care access between transmen versus other gender identity subgroups; (b) examine the interaction of gender identity with possible risk factors which may influence health care access; and (c) examine the interaction of gender identity with possible protective factors which may potentiate health care access. It is hypothesized that transmen are more likely to experience barriers to health care access than trans women and gender non-conforming people. Transmen who identify with other marginalized communities will experience greater disadvantage in accessing health care than transmen who do not. Logistic regression analyses will be conducted with the 2015 USTS (N = 27,715). The results of the study can used to inform gender affirming care, illuminate the intragroup differences within the transgender population in their ability to access health care, and to extend the current knowledge base about the plight of transmen. Practitioners need to increase their understanding about the complexities and multiplicities of gender, and to develop cultural competency in serving the transgender population.
The Effect of Gender Transition-Related Health Care Utilization on Suicidal Thoughts and Behaviors: Findings from the 2015 U.S. Transgender Survey
Prior research suggests a higher prevalence of suicidal thoughts and behaviors among transgender people compared to the U.S. general population. There is an urgent need to identify effective interventions to improve mental health outcomes for trans people. Meta analyses and clinical research suggests that hormone therapy and surgical care are effective in alleviating gender dysphoria. Prior research has also found that hormone therapy, along with surgical care for transition, has resulted in significant improvements in suicidal thoughts and behaviors. This study will examine the effects of medical gender affirmation (hormones and/or surgery) for gender transition on risk of suicidal thoughts and behaviors using a large, non-clinical sample of trans people. The study uses USTS data on lifetime and past-year suicidal thoughts and behaviors, including age at onset and recurrence of suicidal behaviors, as well as age at onset of hormone therapy, and age at first receipt of surgical care for transition. Findings have implications for public health and health policy, including delivery of transition-related health care and future intervention research to mitigate trans mental health disparities.
Childhood & Adolescent Experiences with Gender-related Medical Care and Depressive Symptomatology in Adulthood
The field of pediatric gender identity has evolved substantially over the past several years. New research suggests that cross-gender identification is prevalent (approximately 1% of youth). These young people suffer disproportionately high rates of anxiety, depression, and suicidality. These internalizing mental health conditions are thought to be secondary to rejection by family and peers, minority stress, and dysphoria related to one's body developing in an incongruent fashion to one's gender identity. Emerging data have shown that affirmative medical treatment protocols may improve the high rates of mental health difficulties seen among these youths. These affirmative protocols, as outlined by the World Professional Association for Transgender Health and the Endocrine Society include consideration of pubertal blockade with gonadotropin-releasing hormone analogs at the onset of puberty and gender-affirmative hormone therapy with estrogen or testosterone as early as age fourteen. Family and peer support is vital throughout this process, and emerging data shows that transgender youth who experience family and peer rejection suffer worse mental health outcomes. This study aims to examine recalled experiences in childhood and adolescence among adults who identify as transgender. The first project will examine if access to gender-affirming hormonal interventions in adolescence is correlated with lower rates of suicidality and depressive symptomatology among transgender adults. The second will examine if childhood exposure to conversion/reparative therapy is correlated with higher rates of suicidality and depressive symptomatology among transgender adults. The final study will examine the correlations between parent and peer rejection in childhood and depressive symptomatology and suicidality in adulthood.
Contrasting preferences for gender transition procedures between transgender and gender non-binary individuals: An analysis of the 2015 USTS database
Procedures for gender transition remain in a binary framework, despite our recognition of a wide spectrum for gender identity and sexual orientation. The expectation that a linear set of procedures can treat all variants of gender dysphoria may be inappropriate and potentially detrimental. This study seeks to analyze the USTS database for any difference in preferences among transgender and gender non-binary individuals when choosing procedures for gender transition. Other variables to be included in the analysis are sexual orientation, history of hormone therapy, and history of sexual contact. Information obtained from this study will serve as a basis for further studies to refine surgical indications and technique to maximize postoperative outcomes in gender dysphoria and sexual well-being.
Predictors and Effects of Specific Transition-Related Surgical Procedures on Transgender Patients
There is an expanding body of clinical research within surgical literature describing the psychosocial benefits of transition-related procedures on transgender individuals. While the results are consistently positive, the data comprises primarily case reports and case series of single surgeon, single institution experiences. The purpose of this study is to evaluate both the predictors and outcomes of specific gender transition related surgical procedures through two separate projects. The first project will examine the correlation between specific surgical procedures and depressive symptomatology, suicidal thoughts and behaviors, adherence to HIV medication regimens, and substance abuse. The second project will evaluate the predictors of undergoing specific surgical procedures, including insurance status, socioeconomic status, income, education, access to providers, family support, prior experience of violence, and discriminatory health care encounters. Through an analysis of a large nationally-represented dataset, we hope to provide surgeons with information on both access to the impact of transition-related procedures on transgender patients.
Older Transgender Medicare Recipients and Access To Gender-Affirming Care
AARP seeks to investigate the relationship between older transgender recipient of Medicare benefits and access to gender-affirming care, as well as other healthcare access. According to the USTS, transgender people who have Medicare are denied coverage for cross-sex hormone treatment and gender-affirming surgeries less often than those without Medicare. As of 2014, Medicare covers hormone treatments and reassignment surgeries that are deemed medically necessary, which might explain this phenomenon. Research highlights the fact that transgender individuals experience discrimination when trying to access both gender-affirming care and routine medical care, and as a result, may not utilize access to medical care even when they have insurance. AARP will explore the data to understand the barriers to care that transgender Medicare recipients encounter and how this affects their health. AARP will examine subgroups differences among age cohorts, those with disabilities and multicultural populations. Findings will be highlighted in research reports, professional conferences and publications.
Clinical and socio-economic determinants of surgical transition: an analysis of the 2015 U.S. Transgender Survey
Even minor surgical procedures can profoundly improve a transgender (TG) individuals' self-esteem and functioning. However, despite receiving medical and hormonal therapy, certain individuals choose not to obtain gender affirming surgery. Several social factors such as race, sexual orientation, socio-economic status (including income, education), family/social support and mental health are postulated to negatively and positively affect rates of transitioning. Most literature has evaluated these factors singularly; there have not been studies that have evaluated the interaction of the factors and the resultant effects on surgical transitioning. Our study proposes to elucidate the impact of various socio-economic factors using a mixed effects model. We will utilize geographical and time-sensitive intercepts to account for the clustering of data. Additionally, we will utilize cluster analysis and structural equation models to identify confounding factors. The results of this study will be important from a surgical and public health perspective; identifying modifiable social and economic factors will enable policy makers to intervene, channeling resources to bring about effective change. From a surgical standpoint, identifying patient cohorts that are most and least likely to desire surgery, stratified by the type of surgery will help improve the clinical care that is offered.
Patterns of Suicide Risk in Transgender Adults: a Latent Class Analysis
Previous studies of transgender and other gender minority individuals have linked suicidal behavior to a wide range of personal characteristics, behaviors, and stressful life experiences, notably gender identity-related rejection, discrimination, and victimization. Although suicide risk is a complex multidimensional phenomenon, research in this area has largely focused on identifying the association of single risk factors to suicide-related outcomes, rather than examining patterns of simultaneously-occurring factors that can likely explain these outcomes in a more comprehensive and holistic manner. This study uses USTS data to identify and describe distinct groups of respondents who evidence common patterns of suicide risk. Specifically, the study aims to identify "latent classes" of survey respondents, describe these classes using distributions of demographic/personal characteristics, and examine how class membership is associated with past-year suicidality.
Suicide Thoughts and Attempts among Transgender Adults
This study seeks to increase understanding of suicidal thoughts and behaviors among transgender people through an analysis that aims to identify key characteristics and experiences that are correlated with suicide thoughts and attempts in the USTS sample as a whole, and to examine how suicide thoughts and attempts vary among different groups of transgender people, based on both demographics and experiences. This includes examination of factors that are known risks for suicide thoughts and attempts among the general population, such as certain demographic profiles, substance use, experiences of interpersonal trauma, and psychological distress, to understand how these known risk factors correlate with suicide thoughts and attempts among USTS respondents. The study also assesses risk factors that uniquely impact transgender populations, including experiences related to minority stress, such as discrimination, victimization, and lack of access to transition-related health care.
The Influence of Psychological Distress and Substance Use on Suicide Ideation Among Transgender People Over Four Age Cohorts
Guided by theories of minority stress and transgender-related stigma and using an intersecting identities lens, this study investigates the constructs of psychological distress and substance use as risk factors for suicide ideation among four age cohorts of transgender people. The study examines which demographic characteristics are associated with suicidal ideation and how psychological distress and substance use are associated with suicide ideation. The study methodology employs SEM analysis to determine the unique effect of various demographic characteristics on projected outcomes mediated by the construct of psychological distress and substance use.
Associations of Prejudice and Health Among Gender Minority Youth with Binary and Non-Binary Gender Identities
Compared to binary individuals, non-binary individuals may be at increased risk for substance use and adverse mental health due to stigma related to being non-binary. The proposed research integrates Minority Stress Theory and Intersectionality Theory to propose that non-binary gender minority (GM) individuals, particularly those with other minority identities, may experience prejudice across different settings, which may adversely affect their health. Examining associations between prejudice and health among binary and non-binary GM youth is critical to identifying protective factors that moderate the adverse effects of prejudice on substance use and mental health. These associations will be examined via secondary analysis of quantitative data from binary and non-binary GM young adults, age 18-25 years, from the 2015 U.S. Transgender Survey (N=27,715). The aims of this proposal are to: 1) Compare the prevalence of prejudice experienced in three settings between binary and non-binary GM young adults, and examine differences in exposure to prejudice at the intersections of gender identity and sex assigned at birth, race/ethnicity, and sexual orientation. We hypothesize that non-binary GM young adults will experience more prejudice in each setting than binary GM young adults (H1), and that GM youth who hold other minority statuses will experience more prejudice than GM youth who do not hold other minority statuses (H2). 2) Investigate the impact of minority stressors on substance use and mental health outcomes, and examine protective factors as moderators among binary and non-binary GM young adults. We hypothesize that minority stressors will be associated with increased substance use and adverse mental health (H3), and that protective factors will moderate the adverse effects of minority stressors on substance use and mental health (H4). Findings from this study will inform interventions to reduce adverse effects of prejudice on health among binary and non-binary GM youth to better ensure development into healthy adulthood.
Suicide Prediction in Transgender Adults: A Machine Learning Approach
Suicide attempts occur at alarmingly high rates in transgender individuals in comparison to the general population. Suicide, in the words of Antoine Leenars, is a "multidimensional malaise" of "biological, psychological, intrapsychic, interpersonal, social, cultural, and philosophical elements." Standard probabilistic techniques are prone to overfitting high dimensionality data in the attempt to capture its full complexity. Machine learning (ML), however, imposes no assumptions or constraints, actively learning from the data. This study will train a ML classifier with the USTS dataset which produces a set of predictive algorithms for suicide attempt in the last 12 months and lifetime. The algorithms rank and weigh each variable's global influence on suicide risk, revealing the strongest universal predictors for suicide attempt across a highly heterogeneous population. The predictive accuracy of the algorithm can be directly measured, a powerful feature of this type of analysis. Furthermore, the estimated rate of new suicide attempts in the next 12 months or thereafter can also be calculated from the dataset. The same methodology will be applied to the 2008 USTS dataset to determine the stability of predictive factors across time and changing sociopolitical climate. Our findings have direct clinical impact, including the development of a transgender-specific suicide risk calculator to facilitate routine screening in a variety of healthcare settings and improve early intervention.
Syndemic Dynamics: Modeling Mental Health and Substance Use Risks and Resiliencies in a Large U.S. National Non-Probability Sample of Gender Minority Adults
In the U.S., mental health distress and substance use behaviors cause significant mortality and morbidity and have been shown to disproportionately burden gender minorities (transgender, non-binary, other gender non-conforming people; herein trans) compared to cisgender populations. Epidemiological studies are urgently needed to identify those factors which increase vulnerability to adverse mental health and substance use outcomes for trans people, especially early-life experiences which shape life-long health trajectories. Factors affecting mental health and substance use often co-occur and synergistically interact to exacerbate risk of poor outcomes. It is critical to identify these synergistic epidemics to design effective and responsive targeted interventions and programs to improve trans health. In addition, alongside risks, there is a need to characterize salutogenic, health-promoting factors which can be leveraged for future public health efforts to enhance the resiliency and wellbeing of trans people. This study aims to conduct a secondary analysis of U.S. Transgender Survey data (N=27,715) to: 1) characterize the prevalence and distribution of mental health distress (e.g., depression), substance use (e.g., alcohol and drug use), and their co-morbidity among trans adults in the U.S., 2) identify and model syndemic vulnerabilities that increase risk (e.g., violence victimization, discrimination) and resiliencies (e.g., family support, community connection) that decrease risk for mental health and substance use outcomes. A key methodological challenge for epidemiology is how to best model risks and protective factors simultaneously. This research will test several analytic methods to address this challenge, including latent class analysis, cluster analysis, additive and multiplicative effect modification, and causal inference models. The study will contribute to increased methodological rigor of trans health research and provide "best practices" for understanding syndemics generally, and in trans populations specifically. Findings will inform future public health and clinical care research, programming, education, interventions, and advocacy to improve trans mental health and wellbeing.
Affirmation, Mental Health, and Physical Health Among Non-Binary and Genderqueer Individuals: Findings from the 2015 USTS Survey
Non-binary and genderqueer people make up over one-third of the population of individuals whose gender is different than assumed at birth. However, little is known about unique gender-based stressors which impact the group's wellbeing. While non-binary and genderqueer individuals' experiences of victimization are comparable to binary transgender individuals experiences, knowledge regarding forms of non-binary invalidation is sparse. Given the disproportionate rates of violence experienced by transgender individuals broadly, specific acts of mistreatment, including forms of invalidation that apply specifically to non-binary and genderqueer individuals, and their effects on health must be examined. This knowledge will help to inform practitioners and policy makers better understand community needs and advance non-binary affirming practices and policies. Therefore, this study will examine the effects of interpersonal and structural non-affirmation on the mental and physical health as well as the role of support among non-binary and genderqueer individuals.
The Asian American experience as transgender in the U.S.: A Mixed Method Analysis
Despite indications of substantial health disparities, violence, poverty, and other challenges faced by transgender Asian Americans, there lacks significant understanding about their experiences. The purpose of this study is to conduct mixed-methods analyses using explanatory sequential protocol. The first part of the study will use USTS data to understand the intersectionality of how key areas of social determinants, such as poverty, homelessness, insurance status and coverage, comfort with speaking to health care professionals, family dynamics, and exposure to violence (including at workplace and by family), impact health outcomes of transgender Asian Americans; data will be further disaggregated by available sub-ethnic groups. This analysis will be conducted by multivariable logistic regression as well as structural equation modeling to evaluate the interplay between each variable. The next phase of the study will involve conducting focus groups in order to further explore barriers this population faces, with emphasis on the social determinants identified in part 1. The primary research questions to be addressed are as follows:
1. What is the impact of exposure to violence on mental health status (suicidal ideation and serious psychological distress) among transgender Asian Americans, after accounting for sociodemographic characteristics?
2. What is the impact of communication and experiences with health providers on health outcomes (HIV status, suicidal ideation, psychological distress) among transgender Asian Americans, after adjusting for sociodemographic characteristics?
3. Are there differences between these relationships among transgender women as compared to transgender men in the Asian American population? Does family support mediate this relationship?
Relationship Experiences, Minority Stress, and Health Outcomes among Transgender and Gender Non-conforming Adults
Though health disparities facing the transgender and gender non-conforming (TGNC) community have been increasingly recognized and studied, little knowledge exists about the impact of relational experiences on the health outcomes of TGNC individuals. Though romantic relationships can increase well-being and serve a protective function in health, they may be less supportive for TGNC individuals depending upon levels of rejection and/or transphobia exhibited by one's partner(s). Existing research is minimal, though some suggests that romantic partners of TGNC adults can contribute in significant ways to experiences of hostility, prejudice, and discrimination. For example, the USTS dataset contains important information related to relational minority stressors (e.g., whether romantic partners have been physically, emotionally, verbally, and/or sexually violent; whether romantic partners have interfered with gender transition-related care). Analysis of this large and robust secondary dataset will provide important new information about the role of romantic relationships in the health and well-being of TGNC adults. This study aims to examine the frequency and impact of minority stress experiences within romantic/sexual relationships of TGNC adults, as well as the role that relationship status plays in health outcomes for this community. The overall objective of this study is to identify how, within romantic relationships, gender-based support and/or minority stressors influence the health of TGNC adults. Identifying the role that romantic relationships may play in minority stress experiences of TGNC adults is critical to the development of future health prevention and intervention strategies.
Mental health, HIV, and exposure to violence among trans and non-binary people who have participated in sex work or exchange sex
Research suggests that transgender and non-binary people (TNBP) participate in sex work at higher rates than the general population. Those who participate in sex work are at elevated risk for poor mental health, HIV, and exposure to violence. Race, ethnicity, and poverty often further compound these risks. We approach this work via the framework of syndemics - the concentration of two or more co-existing conditions that interact to exacerbate the outcome of each condition. Existing research on trans sex work is limited by examining mental health, HIV, or exposure to violence bilaterally, primarily among transgender women, and not distinguishing paid sex work from exchange sex. Existing syndemic research often does not test for the critical disease interaction component because of small sample sizes. The USTS offers a large sample size of TNBP who have participated in sex work to examine interactions between these factors within one sample. We hypothesize that the co-existence of poor mental health, HIV, and violence interact in a way that exacerbates the severity of the outcomes for the other factors among TNBP who have participated in sex work and/or exchange sex compared to those who have not. We will first explore the rates of these health outcomes across TNBP who participate in sex work or exchange sex to discern differential risk factors. Then, we will examine the interactions between these factors among people who have engaged in sex work and/or exchange sex. This research will identify health risks and relationships in order to tailor interventions for TNBP who have, or currently are, engaging in sex work. If syndemic interactions between conditions exist, this work could advocate for a holistic approach to care and treatment for TNBP among health and social service providers.
Discrimination and Suicide Risk among Transgender Adults: Testing Minority-Stress and Social-Ecological Models of Suicide
Transgender adults demonstrate consistent patterns of elevated risk for experiences of discrimination and suicide. Data is requested to examine the link between discrimination experiences (e.g., in counseling and conversion therapy; unequal treatment, harassment, and physical assault) and suicide-related behavior in a nationally representative sample of Transgender and Gender Non-Conforming adults. Consistent with a Minority Stress (Herek, 2016, Meyer, 2013) perspective, we will test the moderating effects of coping (e.g., family and peer support; substance use) on the discrimination-suicide link. From a Social-Ecological (Cramer & Kapusta, 2017) view, we will examine additional multi-level influences such as interpersonal (e.g., experiences in the workplace), community (e.g., military status) and societal (e.g., geographic region) factors. Analyses will result in scholarly publications, and inform further primary data collection and grant development efforts. Consistent with Minority Stress Theory, we specifically treat social support and coping as moderators of the discrimination-suicide/mental health link. In contrast, other approved proposals examine social support from clustering approaches in relation to other outcomes (e.g., trauma) or among specific subgroups (e.g., military) unrelated to suicide.
Interactions between blending and identity concealment: Effects on Non-Binary people's distress, suicidality, and experiences of victimization
Identity concealment (whether or not a person is open with others about their transgender status) and passing/blending (how much a transgender person can, or chooses to, blend into the binary social environment) have been shown to impact transgender people's experiences in various ways, but few studies examine these constructs in the lives of Non-Binary transgender individuals. Living in a binary-gendered world may impact people with a Non-Binary gender identity in unique ways, creating unique stressors for this population. Also, little research to date examines Non-Binary transgender people's mental health and victimization experiences, which could be related to blending and identity concealment. This study will use the Non-Binary subset of the sample from the United States Transgender Survey data to examine the interactive effects of blending/passing and identity concealment on distress, suicidality, and victimization. Blending will be operationalized as how others perceive Non-Binary participants in public ("for people in your life who don't know that you're non-binary/genderqueer, what gender do they usually think you are?"). Identity concealment will refer to how often the respondents correct binary gender assumptions placed on them ("when people in our life assume you are something other than non-binary/genderqueer, how do you respond?").
Predictors of Non-Medical Prescription Drug Use Among Transgender and Gender Nonconforming Adults: Findings from the 2015 U.S. Transgender Survey
In light of the current opioid use epidemic, we propose to examine non-medical prescription drug use among the USTS sample. Based on current knowledge about the predictors of non-medical prescription drug use among the general population, we will test whether such drug use is related to physical health, lack of housing stability, race/ethnicity, and socioeconomic status. In addition, we will test a number of predictors particularly relevant to the TGNC population, such as stigma, gender affirmation (both social and medical), and participation in sex work.
Tobacco Use Associations Among Transgender People Living in the U.S.
Tobacco use is the leading cause of preventable death in the US. Little research to date has investigated the risk factors of tobacco use among transgender communities. This study seeks to increase understanding of tobacco use among transgender persons through analyses to identify key characteristics associated with tobacco use in the 2015 USTS sample and to examine how tobacco use varies among different groups of transgender people, based on demographics and gender transition. Data from the 2015 US Transgender Survey (USTS) indicate that tobacco use differs by age, race, and income generating activities (e.g., underground economy). Transgender persons who are interested in hormone treatment and/or gender transition surgery are generally advised to stop tobacco use. One study of 156 transgender patients reported transgender women who receive hormone therapy are more likely to quit smoking. Guided by Minority Stress Theory and Intersectionality Theory, this study aims to 1) examine how risk factors for tobacco identified among the general and LGB population correlate with tobacco use among USTS respondents, 2) assess risk factors that uniquely impact transgender communities (e.g., discrimination, lack of adequate care), and 3) examine the association between gender transition and tobacco use.
Family Matters: Trauma and Resilience in Trans Communities
The majority of trauma exposure in the United States is chronic, and takes place in the context of compromised caregiving. Moreover, transgender/gender non-conforming (TGNC) status is significantly associated with elevated exposure to early life trauma. One possible mechanism is that withdrawal of family support exposes TGNC youth to risk of maltreatment from individuals outside the family. The proposed study would utilize cluster analysis to identify clusters of community support the 2015 U.S. Transgender Survey data. This cluster analysis would identify various forms of social support (e.g., family, community, significant other) in the sample population. These clusters would then be used to predict exposure to traumatic stressors through group-based regression analysis. Past evidence with sexual minority populations suggest that the sample will vary significantly by cluster. Moreover, past data suggest that the primary predictor of elevated exposure to traumatic stressors will be low family support, even in a cluster with low family and high "other" support. However, this pattern has not been explored in a sample of TGNC individuals. Additionally, factors of intersectional identity have not been included in past analyses. This study proposes modeling race, ethnicity, age cohort, religious background, and socio-economic status as integral components of the model.
Examining Risk Factors and Health Consequences of Intimate Partner Violence among Transgender People: Findings from the 2015 U.S. Transgender Survey
Studies on transgender people's experiences of violence report high levels of partner-related acts of physical, sexual, emotional, or financial harm known as intimate partner violence (IPV). Data from the 2015 U.S. Transgender Survey (USTS) indicates that transgender respondents, particular those of color, are more likely than the U.S. population to experience IPV. IPV is a major public health concern given its numerous risk factors and its resulting negative health outcomes, including HIV and other sexually transmitted infections, depression, suicidal behavior, and even death. However, little research to date have investigated the risk factors and health consequences of IPV among transgender populations. Using the 2015 USTS data, this study aims: (1) to examine the risk factors like substance and alcohol use, gender norms, history of childhood victimization, and history of sex work that may predict experiences of IPV, and (2) to analyze how IPV may relate to acquisition of HIV/STI and negative mental health outcomes like psychological distress, depression, and suicidal attempts among this racially diverse sample of transgender respondents. Public health implications from the findings include developing intervention strategies to reduce experiences of IPV, acquisition of HIV/STI, and negative mental health outcomes.
Transgender Intimate Partner Violence in a National U.S. Sample
Intimate partner violence (IPV) among transgender individuals is under-studied. Transgender IPV (T-IPV) research to date has been limited to small youth samples (e.g., transgender N < 30; Dank et al., 2014; Zweig et al., 2013), small adult samples (e.g., transgender N < 10; Turell, 2000), highly unique sub-populations (e.g., only sex workers, see Nemoto et al., 2011; only those contacting IPV agencies, see Waters, 2017), or non-U.S.-based samples (e.g., Australia, see Pitts et al., 2006; Scotland, see Roch, Ritchie, & Morton, 2010). Beyond T-IPV prevalence analyses of the U.S. Transgender Survey (James et al., 2016), no publication has ever examined statistically significant risk factors and outcomes of T-IPV with a representative U.S. sample of transgender individuals. The proposed paper will fill this gap in the literature by examining covariations between lifetime IPV victimization (intimate partner physical, sexual, and coercive controlling abuse, as well as being pressured by an intimate partner to de-transition) and the following: (1) demographic factors (gender identity, gender identity relative to gender assignment at birth, transition status, number of years since transitioning, sexual orientation, age, race-ethnicity, U.S. citizenship status, personal income, poverty, employment status, homelessness, having children), (2) potential risk factors associated with cisgender IPV that remain largely untested for T-IPV, including family violence victimization, non-IPV sexual violence victimization, and discrimination-related factors (frequency of being perceived as a transgender person by others, outness, absence of supportive family behaviors, and experiencing negative treatment both generally as well as in regard to school, work, housing, and public accommodations), and (3) potential outcomes that remain untested in T-IPV research, including substance use, health (general health rating, serious psychological distress, suicidal ideation or attempted suicide, HIV status), and seeking IPV victim services (seeking help from victim services in the past year). Implications for future research, services, and policy will be discussed.
Intimate Partner Violence in Transgender Population; Identity, Risk, and Health Impact
Emerging evidence suggests intimate partner violence (IPV) is as prevalent or more prevalent against transgender individuals as compared to cisgender individuals. Trans individuals may be more vulnerable to IPV as they may face discrimination in accessing domestic violence shelters or rape crisis centers, and abusers may be able to leverage societal transphobia to control their partner (e.g. threatening to "out" their partner as blackmail). Little is known about IPV disparities within the trans community and which segments of the community may be most vulnerable to IPV. The USTS report had some analysis of how IPV prevalence varied by race, but further analyses examining how IPV prevalence varies by different intersectional identities is needed. We propose to examine how physical and sexual IPV prevalence vary by different factors such as trans masculine or trans feminine spectrum, genderqueer/non-binary or binary identities, age, disability, and race. Using USTS data, we hope to look at associations of IPV with health outcomes included in the survey, including alcohol and drug use, HIV testing behavior, and suicidality.
Rates of Polyvictimization Among Non-Binary Individuals: A Comparison of Individuals Assigned Male and Assigned Female at Birth
Despite the increase in knowledge and public awareness of binary transgender experiences, there remains a dearth of research literature on non-binary and genderqueer people. Given that over one-third of the population of individuals whose gender is different than assumed at birth are non-binary or genderqueer, it is important to gain a deeper understanding of multiple forms of victimization faced by this population. Forms of victimization include harassment, physical assault, and unwanted sexual contact. This research seeks to fill knowledge gaps regarding similarities and differences between individuals assigned male at birth (AMAB) and assigned female at birth (AFAB) who are non-binary or genderqueer. Therefore, this study will examine the rates of polyvictimization and the effect of these victimization experiences on mental health among non-binary AMAB and AFAB individuals.
Understanding factors of post-traumatic growth (PTG) in transgender adults: an analysis of risk and protective influences
This research team seeks to understand and identify factors of post-traumatic growth by conducting secondary analysis from the USTS. Our research identifies the following hypotheses:
1) The following factors will play a role in the presence of higher levels of resilience, improved behavioral and physical health outcomes and more markers of post-traumatic growth: a. the farther along the identified stage of social or medical transition; b. the more supportive/inclusive faith communities; c. involvement of trans-affirmative medical providers.
2) The following factors will contribute to higher risk factors and the less significant presence of factors of PTG: a. Less involved family of origin/lack of family of choice; b. Less identified social support; c. High frequency of more marginalized/less visible sexual identities including bisexuality, asexuality and polyamory.
3) Trans-oppressive/non-affirming medical providers can perpetuate and facilitate traumatic events contributing to the presence or absence of PTG, which can lead to negative physical and behavioral health outcomes.
The research team has extensive work in quantitative secondary data analysis from the AddHealth study, mixed methods research and qualitative analysis, particularly in 20th century feminist theory, queer theory and thematic narrative analysis.
We hope to publish two papers – the first focusing on mitigating risk factors in order to facilitate post-traumatic growth within the trans community directed at medical and nursing professional, particularly for those who provide post-surgical support during medical affirmation surgery. We seek to publish this paper in medical/nursing journals The second paper will be dedicated to behavioral health professionals to build trans affirmative treatment practices to facilitate the five pillars of post-traumatic growth: spiritual changes, new possibilities, appreciation of life, relating to others and personal strength. This second publication is aimed at behavioral health and queer journals.
Trauma and Mental Health Among Disabled Trans and Gender Nonconforming Emerging Adults in the U.S.
Existing research on the impact of violent and traumatic experiences (i.e. bias incidents, hate violence, sexual assault, employment discrimination, etc.) on disabled transgender and gender nonconforming (TGNC) emerging adults is nearly non-existent. However, some existing research indicates that disabled and neurodivergent individuals, trans individuals, and emerging adults are all, separately, more likely to experience most forms of violence and also more likely to report decreased wellbeing and overall mental health. This project will complete a series of chi-square analyses and advanced binomial regression tests to assess not only the baseline disparities in mental health outcomes for disabled TGNC emerging adults, but also some of the factors that impact those outcomes--including but not limited to experiences of violence and trauma; other demographic variables such as race ethnicity, sexuality, educational attainment, employment status, etc.; and access to and utilization of comprehensive and competent mental health care services. Findings will be published in 2-3 peer reviewed LGBTQIA+ and/or health journals.
Victimization and Health Outcomes for TGNC Individuals in Women's Prisons
This study examines the prevalence of victimization and quality of transitional health care provided to transgender and gender non-conforming (TGNC) individuals formerly incarcerated in women's prisons. Current research indicates significant disparities in terms of health outcomes and experiences of violence for transgender individuals broadly, and transfeminine individuals while incarcerated more specifically; yet, it is still largely unknown to what extent these experiences compare amongst incarcerated transmasculine and non-binary individuals. This study seeks to address this glaring gap in the literature through a quantitative analysis of experiences and outcomes for transgender and other gender non-conforming formerly incarcerated individuals. Specifically, this study seeks to address the following aims: 1) to explore the prevalence of experiences of violence for TGNC individuals previously incarcerated in women's prisons (for the purposes of this study, "violence" refers to physical and sexual assault, by both other inmates and correctional staff); 2) to examine the relationship between transgender identity and the nature of treatment by law enforcement and prison staff; and 3) to explore the quality and extent of healthcare for TGNC individuals in women's prisons, specifically with regard to the availability of hormone replacement therapy and other forms of care related to gender transition. This study uses USTS data regarding the experiences of transmasculine and non-binary individuals (assigned female at birth) who were previously incarcerated, held in immigration-related detention, or have had encounters with law enforcement to explore the extent to which these individuals experience violence and health disparities in relation to their interactions with the criminal justice system, and to theorize what factors affect these complex health experiences and outcomes.
The Role of Identity, Discrimination, and Safety in the Political Attitudes and Behavior of the Transgender Population
In recent years, the debate over the rights of transgender people has become a dominant issue in political discourse with an impact in the legislative, executive, and judicial branches of government at the state and federal levels. This undoubtedly has an effect on the political behavior of transgender people. Given the salience of issues impacting transgender people, it is important to gain an understanding of factors that influence the political attitudes and behavior of transgender people. This research seeks to fill gaps in the literature and provide vital information about the political attitudes and behavior of transgender people by examining several forms of political participation among transgender people as assessed in the USTS. Measures of political attitudes and behavior include political efficacy, voting, and other forms of political participation. The study examines factors that may impact political attitudes and behavior, including identity and discrimination. The study explores various aspects of transgender identity to determine how identity impacts political attitudes and behavior. Additionally, through the development of a discrimination scale and the analysis of several variables related to an individual's sense of safety, this research examines how discrimination affects the political attitudes and behavior of transgender people. This study will provide an in-depth analysis of factors that impact the political attitudes and behavior of transgender people and much-needed information about political participation in the transgender population.
Performative Partisanship: Investigating the Partisan Gender Gap in the Transgender Community
One of the more fundamental findings in the gender and politics literature is the existence of a "gender gap" in terms of partisan affiliation: that is, women have been consistently found to be more likely to identify as Democrats than are men. Our project intends to investigate whether or not this pattern exists within the transgender community. Although this sort of research, due to limited individual-level data, has been difficult to conduct in the past, we have been able to recover a sample of 1041 transgender individuals from the 2016 Cooperative Congressional Election Study. Preliminary results suggest that the partisan gender gap is indeed represented in the transgender population. We theorize that this is the case due to the political content of gender and thus the potential for a performative aspect to one's politics.
Gender Identity Documents and Voting: The Relationship among Identification Cards, State Policies and Transgender Voting Habits
It has been proposed that voter identification laws may depress the turnout of transgender populations. Further, state policies vary in the ease to which identity documents may be changed. Both of these items suggest that state policies may depress the political engagement of transgender people. This study seeks to match the USTS respondents to the state policies they have in place. We will examine the relationship between policies and turnout, controlling for standard measures of political behavior (e.g., age, education, income and employment, partisanship, and race or ethnicity).
Together We Rise: The Role of Community Socialization in Transgender Citizens' Levels of Civic Engagement
In the academic debate on civic engagement, many variables have been considered as predictors, among them socio-economic status, race and ethnicity, and age. One understudied variable is community socialization and connectedness. Particularly for disadvantaged communities, however, community connectedness may be an important source of political socialization. This study will investigate the role of community in levels of civic engagement, considering political self-efficacy as a key moderator of that relationship. Specifically, the study predicts that community connectedness increases political self-efficacy, which in turn drives civic engagement. Moreover, as both the practice and study of the American transgender rights movement advances, it is important to understand the factors that drive transgender Americans' political participation. This study would helpfully contribute to our understanding of one potentially meaningful factor—connection to other trans people, as measured in the USTS.
Transgender Military Inclusion: Transgender Service Members' Health and Well-being at the Brink of Open Service
In 2015 the U.S. Armed Forces effectively halted discharges for transgender service members as the Department of Defense initiated a study on open transgender service. At the time of USTS data collection, service members' experiences were highly dependent upon the support of their military leadership and medical providers. Using a minority stress theoretical framework, the proposed study will investigate the impact of command support and access to transition-related care on the health and wellbeing of transgender Service Members. Researchers have demonstrated that experiences of minority stressors (such as gender-based trauma, expectation of rejection, experiences of discrimination, social rejection, etc.) predict poor health and mental health outcomes for transgender persons. However, critics of open transgender service continue to cite mental health disparities experienced by the transgender community in order to challenge the psychological and medical fitness of transgender service members. This study seeks to provide a more nuanced understanding of how systemic supports and barriers impact the health and wellbeing of transgender military personnel.
Gender Affirmation Interventions, Social Transition, and Suicide Risk in Transgender Adults With and Without History of Military Service
Data is requested to produce scholarly publications that investigate disparities in healthcare utilization and access to comprehensive gender affirmation care in transgender adults with and without a history of military service. This work will also analyze how these disparities relate to mental health symptoms, quality of life, and current and historical suicide risk in this population. The UTST data set is ideal to test these relationships as the large sample size will allow for us to test these relationships across the transgender/gender non-conforming spectrum, across stages of medical and social transition, and within ethnic and racial minority/majority veterans and non-veterans. We believe data from this project will have important implications for clinical and policy efforts that look to provide comprehensive gender affirmation and suicide prevention care for transgender veterans and civilians without history of service.
Exploring the Role of Spirituality/Religion in the Lives of Trans-Spectrum People
Over the past two decades, scholars have placed increasing focus on the spirituality and religious identity and its influence on various health & wellness outcomes. The research highlights the value that individuals place on this aspect of their life, along with a wide range of positive personal outcomes. Even so, there is sparse research exploring the spirituality and religion of queer spectrum people. More notably, current studies all but exclude the specific voices of non-cisgender individuals, due, in part, to small sample sizes. This study explores the role of spirituality/religion in the lives of trans spectrum people. Specifically, it focuses on trans spectrum spirituality/religion (section 5) and outcomes including suicidal ideation (section 16), resiliency, and the Kessler 6 (questions 12.2 and 12.3). To more fully illuminate across-group differences and allow for investigation of age-specific experiences, it will also examine demographic (sections 1 and 2) and college experience (section 26) data.
Faith Community Rejection and Transgender Well-being
Research has begun to document the negative impact of family rejection on the mental health and wellbeing on transgender individuals. However, little is known about the impact of religious community rejection for this same population. This study seeks to explore potential relationships between faith community rejection/disaffirmation and mental health and wellbeing for transgender individuals. This study will utilize the religious affiliation/history data from the USTS to explore experiences of faith community acceptance and rejection among transgender individuals. In order to isolate the impact of faith community rejection, family acceptance and rejection data will be used as control variables along with basic demographic data. Additionally, this study will explore possible relationships between faith community rejection and family rejection using data from the two sections described above. Outcome variables will be pulled from the mental and physical health data including suicidality and attempts, risk behaviors, substance abuse, and The Kessler Psychological Distress Scale. Regression analyses will be conducted using R and/or IBM SPSS. Results will contribute to the field of LGBT research by demonstrating the nature of the connections between faith community rejection, family rejection, and mental health and well-being for transgender individuals.
Exploring the Relationship of Religion and Spirituality in Trans/GNC Students' Likelihood to Enroll and Persist in Postsecondary Education
A significant period of identity, belief and community formation and conflict—including one's religious or spiritual worldview identity and understanding—happens in college (Astin, Astin, & Lindholm, 2010; Mayhew, Rockenbach, Bowman, Seifert, & Wolniak, 2016). Without proper, intentional engagement of religious diversity, campus communities can fracture and further oppress people of marginalized religious and spiritual identities (Nash, 2001). This study will look at religion and spirituality measures (section 5) of trans/gender non-conforming (GNC) identified people and their relationship to one's decision to leave college (questions 26.8, 26.9) or attend at all (coded by using demographic data under the assumption that high school/GED must be completed and they have not attended at least some college despite being of "typical college age"). We will also investigate this difference for people who reported attending graduate and/or professional school in comparison to those who did not. In order to control for covariate variables, we are also requesting access to demographic data (sections 1 and 2) since race, class, sexual orientation, and other identities have been found to uniquely interact both with one's religious and spiritual life (i.e., Mayhew, Rockenbach, & Bowen, 2016) and one's trans/GNC identity (i.e., Nicolazzo, 2016). In addition, we would like to include in our model other factors known to influence college recruitment and persistence in trans/GNC identified people such as trans kinship (Nicolazzo, 2015; questions 3.4, 4.11-4.12, and 12.21 related answers), a person's level of "outness" (Garvey & Rankin, 2015; questions 1.13-1.14, 2.3_2-2.3_3, 3.1-3.3, 4.1, 4.3, 4.5, and 26.1-26.3), and familial support (Oswald, 2001; Ryan, Russell, Huebner, Diaz, & Sanchez, 2010; questions 4.1-4.9, and 12.21).
The Labour Market Outcomes of Transgender, Gender Non-Conforming and Genderqueer Individuals
To date, there has been a remarkable lack of appropriate econometric analysis exploring the labour market outcomes and discrimination faced by transgender individuals in the economic literature. This research project aims to address part of this research deficit. This analysis will cover the following areas:
1. Quantifying the levels of wage discrimination faced by different sections of the diverse transgender community. For example, there is a well-established literature exploring the cisgender pay-gap. Controlling for productivity, demographic, health and other determinants of wages, do trans women experience an earnings penalty compared with trans men?
2. Exploring the differing labour market returns to human capital across multiple gender identities. For example, can transgender individuals partly shield against labour market discrimination through increasing their human capital levels? If so, is this effect uniform across minority identities?
3. Exploring the intersectional effect on earnings from identifying with a minority gender identity and a minority sexual orientation. In other words, is there a compounding negative effect on earnings from identifying with multiple minority categories?
This paper explores the labour market outcomes of different gender minorities by building on econometric techniques previously employed in the study of racial discrimination. I will primarily use interval regression analysis - ideal when survey data provides income data in intervals/bands. It is a generalisation of censored regression, estimated using maximum likelihood estimation.
Risk and Resilience Profiles Among Transgender Sex Workers
Previous scholarship on transgender individuals' experiences with engagement in the sex economy has heavily focused on individual and public health risk, consistently finding evidence that engagement in sex work confers a greater risk of contracting HIV and other sexually transmitted infections (Nemoto, Sausa, Operario, & Keatley, 2006; Sausa, Keatley, & Osperario, 2007), and experiencing violence and victimization (Farley & Barkan, 1998; Stotzer, 2009) and police harassment (USTS 2015). The multilevel risks associated with engagement in sex work vary based on a number of demographic, sociocultural, and contextual factors. For example, Nemoto and colleagues (2016) reported that different commercial venues (i.e. soliciting customers via the street or through a bar or club) demanded that workers negotiate varying physical locations, rules, expectations, and social hierarchies. While the risks of engagement in the sex work economy are well documented, limited research has examined the conditions under which transgender sex workers yield resilient outcomes, or the specific conditions under which sex work confers greater and lesser risk. Although research is scant, scholars have argued that involvement in the sex work economy is a complex site where participants can draw on, resist, and reimagine dominant and subjugated discourses about sex work (Smith 2017) and where transgender individuals negotiate boundaries between economic independence, self- empowerment, and relational resources (Nemoto et al. 2016; Sevelius, 2013).
From a pleasure-based positive sexuality perspective, we aim to examine risk and resilience profiles among transgender individuals engaged in the sex work economy. Based on previous literature, we hypothesize heterogeneity in the experiences of transgender sex workers as a function of demographic covariates and and sociocultural contextual factors. Different transgender sex work profiles will likely indicate varying degrees of risk and resilience which can inform harm-reduction interventions and depathologize the elements of sex-work that confer resources to transgender individuals.
Transgender Men and Women in 2015: Employed, Unemployed or Not in the Labor Force
This study will examine the percentages of transgender individuals who are employed, unemployed, and not in the labor force, and compare the rates for men versus women. In addition, I will perform logit analysis to explore the relationships between labor force status and other variables such as education, age, racial/ethnic identity, disability status, partnership status, presence of children, perceived gender incongruity (that is, whether people can tell that the individual is a transgender person even if not told), and whether the individual lives in a state that has an employment non-discrimination law covering gender identity.
The Impact of Party Affiliation of US Governors and State Legislature on Labor Market Outcomes of Transgender Individuals
This study will investigate whether there is a causal impact of party affiliation of U.S. state governors and state legislature on the labor market outcomes of transgender individuals. The common perception is that Republicans favor pro-labor policies and are more likely to believe a person's gender is determined by their sex assigned at birth than Democrats. Such beliefs can influence voting, policies, and practices. We use survey data on economic outcomes and other individual-level characteristics from the U.S. Transgender Survey as well as state-level data on governance in 50 states. We exploit variations in the party affiliation of governors and variation in the number of state representatives and senators associated with each political party between various states of the country. In addition to Ordinary Least Squares (OLS) estimation, we employ Propensity Score Matching (PSM) techniques to provide additional support to the main findings. The outcomes of interest include employment status, hours worked, earnings, as well as the extent of underground labor market activities. We will also investigate the heterogeneous effect by gender identity, race and ethnicity.
Intersections of Oppression: Intersectionality and Occupational Discrimination of Transgender and Gender Non-Binary Adults
This study will explore the impact of occupational discrimination on the psychological distress of transgender and gender non-binary/gender-queer (TGNB) individuals. The aim of this study is to explore the effects of occupational discrimination on mental health. Special attention will be paid to intersecting identities including people of color and those with disabilities that have been shown in the preliminary USTS report to compound various health disparities. The data explored in this study will be taken from the U.S. Transgender Survey (2015). Implications for these findings will provide suggestions for a framework to assess and reduce stigma-based discrimination in occupational settings inclusive of the external (distal) stressors and internalized (proximal) stressors unique to multiple intersecting identities. Findings will provide formative data to develop interventions to address stigma-based workplace discrimination and identify the individuals who may be at increased risk for psychological distress.
Trans Men in the Sex Work Industry
Despite the increase of research including trans identities over the past 10 years, little is known about this specific population. Regarding the field of sex work, literature and data collection neglects the specific circumstances of trans men in the industry. A lack of knowledge and the invisibility of male identified trans sex workers increases the obstacles and risks faced by this group. The chapter "Trans Men in Sex Work" will first give a general introduction about trans masculine identities. I will show the overall risk factors faced by this community, with an emphasis on socioeconomic circumstances, mental and physical health aspects. The introduction is followed by a description of the current situation reported by trans men in the sex work industry. Research shows that trans masculine sex workers mostly work independently and name on the one hand several specific concerns about their health and safety, but also report on the other hand about empowering elements of engaging in sex work. This given picture is based on the outcomes of an online survey amongst trans male sex workers, which has been conducted in 2017/18, specifically for this book chapter. Data from the 2015 USTS about the experiences of trans men who have participated in sex work will be explored in this chapter.
Report on Transgender Adults in the Workplace
This report will describe the workplace experiences of USTS participants nationwide. The report will describe participants' career trajectories (educational attainment, rates of paid employment and self-employment, union membership, income, and source of health insurance coverage). It will then address rates of discrimination in the workplace, including access to gender-appropriate facilities, discrimination in hiring, promotion and job separation, and gender-based harassment. When appropriate, rates of these experiences will be presented separately by gender, race and age group. The report will be written for a non-scholarly audience and is intended to support efforts to improve transgender inclusion in the workplace.
Connecting the invisible dots: A look into the intersectionality of transgender undocumented persons
Being an immigrant often means operating within two identities: one that is hoping to hold on to a culture of an origin country and another that is tirelessly attempting to assimilate to the new land. Throughout this process, immigrants can feel as though there is rarely a space that is specific to them and the idea of citizenship is blurry. Another group of individuals that face this double consciousness are members of the LGBTQ community. One way that immigrants, specifically undocumented immigrants, and LGBTQ individuals lose a sense of control over their private rights is when their bodies are under the power of the public government. Undocumented immigrants use their bodies as a way to physically move from one space to another, crossing borders in order to gain better opportunities. Transgender individuals also attempt to take control over their bodies by making the decision to become seen as who they are while crossing gender lines. Relying on Michel Foucault's definition of biopower, this paper investigates the challenges that trans-undocumented individuals face and how healthcare accessibility is a focal point in their move but the lack thereof in the US creates for a continued dangerous setting.
Radical Reproductive Justice Accompliceship: Following the Lead of Trans BIPoC
Reproductive justice analyses have detailed the varying state and interpersonal mechanisms that continue to be used against women of color through the control of their bodies, their children, and their families. However, there is little documentation that highlights the experiences of trans and nonbinary Black, Indigenous, and people of color (BIPoC) in relation to their reproductive health. In this study, we call for a continued movement within the sociological understanding and analyses of reproductive justice. Focusing solely on white, cisgender women's bodies and needs within reproductive justice neither alleviates the burden of trans exclusionary, able-bodied healthcare nor recognizes the history of racialized violence toward bodies of color. Therefore, we seek to analyze secondary data from USTS participants to assess reproductive health disparities with transgender and nonbinary people of color. We intend to analyze racial and ethnic disparities (primarily between Black people, Indigenous people, and other people of color) between adverse health experiences with practitioners, sexual health, access to hormone replacement therapy, HIV meds, and other related health care while incarcerated and/or detained, access to insurance, educational attainment, levels of poverty, and other variables. We place a theoretical focus on how potentially statistically significant disparities in these variables are related to reproductive injustice. Additionally, we place an emphasis on data reported from the state of Georgia to further inform a more community-based approach for future research.
Impact of time between personal realization and stages of transition on well-being on transgender individuals
Transgender individuals experience poor mental health outcomes that we know are related to discrimination, internalized negative feelings and poor access to healthcare. Many trans individuals experience a social and medical transition in which they must disclose their identity and make medical decisions to live a life more authentic with their gender identity. This time of transition is an under researched stressor that is likely exacerbated by experiences of discrimination and access to healthcare. Being able to identify the impact of the length of time between certain stages of transition have on health long after a person has transitioned can help us understand the significance of transition (a time of varying lengths for individuals, and a notable stressor in a transgender person's life) with their overall well-being.
The proposed research will explore the relationship between time to transition (based on when a person thought they were trans, started to tell people, started living full time, and started taking HRT) and current distress, mental health, and suicidality among binary transgender individuals living full-time in the gender different from their gender assigned at birth. Analyses will be conducted separately by age cohorts to account for historical/political shifts in trans awareness in society (cohorts will be determined after exploring the sample age distributions) and primary gender identity. This work will provide a foundation for understanding the role of time in transition stages with long-term mental health, taking into account current life stressors (losing a job, housing eviction, dropping out of school, and new health diagnoses) for binary transgender men and women. More importantly, results will inform us on how significant the transition time is in overall well-being among binary transgender individuals who live full-time as a gender different from the gender assigned at birth.
Transgender Identity Development Across the Lifespan: Findings from the 2015 U.S. Transgender Survey
Recent studies of transgender and gender nonconforming (TGNC) people indicate that, in addition to minority stress, stress associated with the process of identity development affects health, psychosocial adjustment, and wellbeing. Many TGNC individuals adapt successfully to the related challenges and develop resilience over time. This study will examine associations between stage of identity development, operationalized through such proxy variables as age, status and time passed since relevant developmental milestones (e.g. disclosure, social transition, medical transition), perceived stigma and outcomes of mental health and wellbeing.
Educational Attainment of Transgender Adults: Does the Timing of Transgender Identity Milestones Matter?
Adolescence is a difficult life stage in which to navigate a transgender identity, yet adolescence plays a key role in shaping educational trajectories. While transgender-related stigma and victimization within secondary school persists, the social climate in which transgender adolescents navigate their identity has changed over time. Analyzing data from the U.S. Transgender Survey, a national, non-probability sample of U.S. transgender adults, we propose to address the following research questions: 1) Is experiencing transgender identity milestones in adolescence associated with educational attainment?; 2) Does this association vary by birth cohort?
The Relationship Between Age of First Awareness and Later Identity, Social Transition, and Medical Intervention in Transgender and Gender Non-Conforming Adults
Even though approximately 1/3 of adults in the 2015 U.S. Transgender Survey (USTS) self-identified as something other than binary transgender, there has been very little research specifically looking at the developmental aspects of nonbinary identities (Harrison, Grant & Herman, 2012). In addition, a binary transnormative narrative (Johnson, 2016) continues to exist which asserts/assumes that all transgender and gender non-conforming (TGNC) individuals: a) become aware of the incongruence between their assigned sex and affirmed gender at a very young age; b) will benefit from early (prepubertal) social transition; and c) desire "complete" medical transition, referring to hormones and various gender confirmation surgeries. The extent to which a TGNC person is influenced by this narrative often impacts the way one thinks about one's gender identity and the various decisions that are made about both social and medical transition. Given this, it is important to ascertain the extent to which this assumed narrative actually fits the population. In this study, the relationship between the age that TGNC adults first became aware of their TGNC identity and the decisions they made about a) their identity/identity labels, b) the extent of and age of social transition, and c) the extent of and age of sought medical interventions will be examined. Due to the cultural shifts that have occurred overtime, the proposed study will also examine these relationships from a developmental perspective. For example, people who are now in their 70's compared will be compared to those who are in their 20's, 30's, 40's, etc. to look for any generational differences in the way these variables relate to one another.
Gender Identity Profiles and Trans-Related Health Care Seeking
Gender identity can be conceptualized as a latent, multi-dimensional construct with contributions from an individual's personal identification, interactions with others, and timelines of gender development. The USTS survey gives individuals the opportunity to identify in multiple, complex ways. Latent profile analyses can be used to be begin to cluster identity trajectories together and correlate them with treatment seeking behaviors and intentions. Such a nuanced analysis allows for a better understanding of how stated gender identity characteristics fit with treatment needs and creates an opportunity to examine norms in treatment and insurance coverage for treatment and how those things are or are not attuned to individual identity profiles.
State-Level Discrimination Laws, Violence Victimization, and Self-Harm among Transgender and Gender-Nonconforming People
Little research to date has investigated violence victimization and self-harm in transgender and gender-nonconforming (GNC) populations. Evidence indicates that legal climates, such as the presence or absence of state-level gender identity nondiscrimination laws, may have a significant effect on the health and safety of transgender and GNC individuals. This analysis will use data from the U.S. Transgender Survey (USTS) to assess the relationship between state-level discrimination laws and violence victimization and self-harm reported by USTS participants. We hypothesize that a lack of state-level nondiscrimination laws inclusive of transgender and GNC populations creates environments that sanction discrimination and ultimately foster violence against transgender and GNC people. The analysis will be a multi-level logistic regression using a mixed effect regression model, which allows for the use of both fixed and random effects to model observations with intracluster correlations. A two-level model will be used to specify random effects for the site clusters and adjust for any unobserved individual- or state-level confounding. We will specify person at level one and state at level two (i.e. the state in which the participant current resides) and will focus on experiences of violence within the last 12 month. Outcomes of interest will include suicidal ideation, suicide attempt(s), physical violence victimization, verbal harassment, and unwanted sexual contact. Individual-level covariates (level 1) will include variables frequently associated with violence in transgender or GNC populations, such as race and socioeconomic status. At the state level (level 2), the main relationship of interest will be between experiences of violence and whether the state has any state-level statutes or regulations prohibiting discrimination on the basis of gender identity. Other descriptive analyses will be conducted to complement the findings, including frequency of violence, perpetrators, and access to care and services following violence victimization or self-harm.
Impact of Pro-LGBT Legislation on the Social and Health Disparities Experienced by Transgender People
Studies and reports have shown transgender populations to report high levels of discrimination and distress. To address this, advocates and others seek to establish legislative protections against discrimination and violence. Currently, there are 16 states and 400 cities and counties with nondiscrimination legislation targeting discrimination against people's sexual orientation and gender identity, and 17 with anti-LGBT hate crime legislation. Using data from the 2015 U.S. Transgender Survey, this study will examine the difference between states and cities/counties with legislative protection and those without to examine the protective effects of such legislation. Do these legislative remedies benefit transgender people by reducing their experiences with discrimination, or reduce their distress and provide benefits to their health and well-being?
Examining Race Differences in the Relationship Between State-Level Stigma-Related Policies and Transgender Health
State-level policies can be either protective (e.g., state-level non-discrimination policies) or harmful (e.g., bathroom bills, religious exemptions) for transgender and gender diverse communities. These policies may contribute to experiences of interpersonal stigma (e.g., discrimination and victimization), resilience (e.g., through social support), mental and physical health, and healthcare use. Furthermore, building on an intersectionality framework, these relationships between state-level policies and experiences of stigma, resilience, and health may vary across racial groups. This study will use the 2015 USTS to examine how state-level stigma-related policies (e.g., state-level non-discrimination policies, bathroom bills, religious exemptions) are associated with mental health (measured as psychological distress), physical health (measured as self-reported physical health), and healthcare use among transgender and gender diverse people. We will fit three separate multilevel multinomial regression models (one for each outcome) with the state as the random effects term (to understand the relationships of individuals grouped by state) and race as the random slope (to determine if the relationship between state-level policies and health vary by race). This analysis will control for individual experiences of stigma (e.g., discrimination and victimization across multiple settings) as well as individual experiences of resilience (e.g., social support) and will examine differences in states across multiple state-level policies related to transphobic stigma (e.g., state-level non-discrimination laws, bathroom bills, religious exemptions).
Legal gender recognition, psychological distress, and suicide risk among transgender adults in the United States
Legal (or administrative) gender recognition is important to the well-being, safety, and dignity of trans people. However, few studies have examined the impacts of access to legal name and/or gender changes on mental health outcomes. A Canadian study found that having at least one identity document with a sex marker concordant with lived gender was associated with reductions in past-year suicidal ideation and attempts, with the potential to prevent 90 cases of ideation per 1,000 trans persons and 230 attempts per 1,000 with ideation. This is a finding with important implications for public policy advocacy, particularly if replicated and extended in a different population. Therefore, this project will ask:
(1) is legal gender recognition associated with psychological distress and suicide risk among trans people in the U.S.?
(2) are legal name changes associated with psychological distress and suicide risk among trans people in the U.S.?
(3) are these relationships moderated by non-binary identification?
(4) are these relationships mediated by exposure to harassment, discrimination, or violence related to non-concordant identity documents?
Public policy and the public experience: A case for comprehensive transgender-affirming identity document policy
The study gender and sexual minorities continues to garner the interest of scholars and maintain the status of a methodologically rich, but understudied, field. Fortunately, the United States Transgender Survey (USTS) provides significant opportunity for rigorous scholarship. James (2017) most notably crafted a paradigmatic dissertation about the political behavior and characteristics of transgender people using USTS. The proposed research will employ a public policy and politics framework to assess the statistical significance of identity document incongruences with the negative experiences of transgender people in public spaces, while controlling for other factors. It will explore how the presentation of incongruent name and gender markers on four identity document types leads to transgender people's greater likelihood of being denied services, harassed, or even physically assaulted.
The Health and Well-being of Trans, Nonbinary, and Gender Nonconforming Adults in the Upper Midwest
The objective of this project is to assess health status, access to care, and experiences of violence among TGNC people in the Midwestern United States, with particular attention to Wisconsin and the Upper Midwest (IA, IL, MI, MN, ND, SD, WI). According to the Transgender Law Center, 9 out of 12 states in the Midwest and 7 out of 8 states in the Upper Midwest are rated as "low" or "negative" policy environments in terms of TGNC-affirmative health laws and policies. The overall policy environment in the Midwest is uneven, with only two states (Illinois and Minnesota) scoring "high" in terms of laws and policies that support TGNC residents. In a series of comparative analyses, our research will evaluate health access and outcome measures within Wisconsin by respondent gender identity, sex assigned at birth, age, race/ethnicity, socioeconomic status, and so on, as well as between states in the region and the Midwest in relation to the U.S. overall. Particular measures of interest include: health insurance coverage, access to transition-related, general, and mental health care, quality of care, health status indicators, and experiences of interpersonal and structural violence. Methods will include descriptive and inferential statistical analyses, as well as (if relevant) textual analysis of open-ended responses. Outputs from this project will include infographics and factsheets for community members and policy makers, as well as scholarly articles in social and health science journals.
Report on Transgender Adults in Mississippi, Alabama and Arkansas
This report will focus on the experiences of USTS participants living in Mississippi, Alabama and Arkansas, comparing the experiences of participants in these three states to the national sample. Where there are substantial differences between the three states, data will be presented separately for each. In addition, where there are notable differences by participants' race, age and gender identity, these findings will be presented separately. The report will cover outcomes in the areas of violence; police contact and incarceration; sex work; employment; and healthcare access. The report will be written for a non-scholarly audience and is intended to support programmatic and policy efforts in the states.
Small Area Estimation of the Transgender and Gender Nonconforming Population in Seattle-King County: Demographics and HIV Related Health Outcomes
In contrast to other urban settings, Public Health Seattle-King County (PHSKC) estimates low HIV prevalence among transgender and gender nonconforming (TGNC) individuals living in Seattle, with just 55 prevalent HIV infections among transgender women, and 3 among transgender men ever reported as of 2016. This discrepancy likely results from the misclassification of TGNC individuals in HIV surveillance data due to historically inaccurate methods of capturing gender identity. The proposed research aims to address the current gaps in HIV surveillance data and knowledge of the sexual health of TGNC people living in Seattle. We will characterize the demographics of the TGNC population in Seattle-King County, and estimate prevalence of key health outcomes using the USTS 2015 dataset. Specifically, we will apply small area estimation statistical methods to estimate the prevalence of HIV testing, self-reported HIV infection, and antiretroviral therapy coverage, and related outcomes, as well as HIV risk factors among TGNC people living in Seattle. Ultimately, these estimates will be used to parametrize a deterministic compartmental mathematical model of the HIV epidemic among sexual and gender minorities in Seattle. We will model how the scale-up of biomedical interventions among TGNC people, including PrEP and ART, would reduce 10-year HIV incidence. Epidemic models that include all gender minorities (i.e. transgender men and non-binary individuals, in addition to transgender women) are needed as a critical tool to inform HIV prevention outreach to TGNC people. Further, development of these estimation methods will support other public health departments in understanding local HIV and STI epidemics among TGNC populations and inform local public health strategies.
Trans-cending categories and interrogating the method: Trans/GNC people's experiences with quantitative categories
This study has three broad research questions: 1. How do current "best practices" on survey construction capture participants' gender? 2. How do participants resist and conform to quantifiable categories on gender in surveys? 3. How do trans and gender non-conforming people experience surveys on their identity? To answer these questions using the U.S. Trans Survey, the researcher will compare interactions across different educational attainment levels (question 2.22) and geographic locations (2.26). This study will look at how trans/GNC identified people interact with a survey publicized through the National Center for Transgender Equality focused on benefiting rather than pathologizing the trans community. How are we quantifying trans/GNC people and how are they critiquing and interrogating quantitative methods with their stories (section 32) and what does this mean for researchers, practitioners, and policy-makers? Open-ended responses and open fields will be assessed specifically around gender and sex/gender identification (Section 1; Section 2.1-2.8).
The Lives of Trans Millennials
This study will use qualitative data from the USTS to examine differences between the participants who were 35 years old or younger at the time they completed the survey. Specifically, it will consider responses to the last question, "Please tell us anything else that you would like to tell us about your experiences of acceptance or discrimination so we can better understand your experiences." The study will focus on the different experiences the respondents discussed in response to that questions and the language they used in discussing these experiences.