Prevalence of Discrimination and the Association Between Employment Discrimination and Health Care Access and Use — National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019–2020

Supplements / January 25, 2024 / 73(1);51–60

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Amy R. Baugher, MPH1; Evelyn Olansky, MPH1,2,3; Larshie Sutter, MPH1,4; Susan Cha, PhD1; Rashunda Lewis, MPH1; Elana Morris, MPH1; Christine Agnew-Brune, PhD1; Lindsay Trujillo, MPH1,2,3; Ebony Respress, PhD1; Kathryn Lee, MPH1; National HIV Behavioral Surveillance Among Transgender Women Study Group (View author affiliations)

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Abstract

Transgender women experience discrimination in many settings, including in employment. Because employment and health insurance are intertwined in the United States, employment discrimination might be related to lower health insurance coverage and health care use, including gender-affirming care. This analysis used data from transgender women (N = 1,608) in seven urban areas in the United States collected during 2019–2020 to present the prevalence of six discrimination types (employment, housing, bathroom, businesses, health care, and abuse) and to measure the association between employment discrimination (defined as trouble getting a job or fired due to being transgender) and sociodemographic characteristics, health care access, and health care use. Log-linked Poisson regression models were conducted to estimate adjusted prevalence ratios and 95% CIs. Seven in 10 transgender women experienced at least one type of discrimination during the past 12 months. During the same period, 9.9% of transgender women were fired and 32.4% had trouble getting a job because of being transgender. Employment discrimination was associated with younger age and lower socioeconomic status. Having trouble getting a job was associated with health care access and health care use factors, including having no health insurance or having Medicaid only, having an unmet medical need because of cost, never having transgender-specific care, and having an unmet need for gender-affirming procedures. These findings suggest that employment discrimination contributes to transgender women’s economic marginalization and their ability to obtain adequate health insurance coverage and achieve their transition goals. These findings might help guide efforts that protect transgender women’s right to pursue their work, health, and life goals without discrimination.

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Introduction

Transgender women have historically been marginalized in public spaces and institutions, including the workplace (1). In the United States, discrimination against job applicants or employees by employers on the basis of gender identity or transgender status is illegal (2), yet discrimination persists (3,4). Employment discrimination operates as a multilevel phenomenon (5–7): structural (e.g., law), organizational (e.g., workplace policies regarding identification and legal names), interpersonal (e.g., inappropriate questions from coworkers), and individual (e.g., health and financial outcomes). Because employment and health insurance are intertwined in the United States, employment discrimination might be related to lower health insurance coverage and care use (8), including gender-affirming care, which is important for transgender women’s mental health (9), quality of life (10), transition goals (11), and HIV prevention and care engagement (12). In addition to employment discrimination, discrimination of any type is related to delays in health care (13,14), suicidal ideation (15), and negative health outcomes (1) among transgender women. Therefore, it is important to understand the prevalence of multiple types of discrimination that transgender women experience. Previous reports on discrimination among transgender women focus on transgender women who are predominantly White and have higher socioeconomic status (SES) (3); this analysis was conducted to understand discrimination in a diverse and lower SES population.

The objectives of this analysis were to describe the prevalence of multiple types of discrimination toward transgender women and to measure the characteristics of employment discrimination and its association with health care access and use. Policymakers can use these results to guide civil rights legislation efforts.

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Methods

Data Source

This report includes survey data from the National HIV Behavioral Surveillance Among Transgender Women (NHBS-Trans) conducted by CDC during June 2019–February 2020 to assess health and prevention behaviors and HIV prevalence (16). Eligible participants completed an interviewer-administered questionnaire and were offered HIV testing. Additional information about NHBS-Trans eligibility criteria, data collection, and biologic testing is available in the overview and methodology report of this supplement (17). The NHBS-Trans protocol, questionnaire, and documentation are available at https://www.cdc.gov/hiv/statistics/systems/nhbs/methods-questionnaires.html#trans.

Applicable local institutional review boards in each participating project area approved NHBS-Trans activities. The final NHBS-Trans sample included 1,608 transgender women in seven urban areas in the United States (Atlanta, Georgia; Los Angeles, California; New Orleans, Louisiana; New York, New York; Philadelphia, Pennsylvania; San Francisco, California; and Seattle, Washington) recruited using respondent-driven sampling. This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable Federal law and CDC policy.*

Measures

Six measures for discrimination types were assessed: 1) employment (fired or had trouble getting a job), 2) housing (denied housing or evicted), 3) bathroom (denied bathroom access), 4) discrimination in businesses (treated poorly in businesses), 5) health care (denied or given lower-quality health care), and 6) abuse (verbally abused or physically abused). Other measures included health outcomes, health care access and use, and gender-affirming care.

Demographics and social determinants of health were measured, including age, race and ethnicity, poverty, homelessness, severe food insecurity, incarceration, disability, and sex work. Definitions of discrimination, demographics, and social determinants of health are available in the overview report of this supplement (17). Health care access variables included currently having health insurance, type of health insurance, living in a state where Medicaid laws explicitly covered gender-affirming care in 2019 when data were collected (18), having a usual source of care, unmet need for health care because of cost, health insurance coverage for hormone therapy among transgender women with health insurance, and transgender-specific health care. Health care use included visiting any health care provider during the past 12 months, unmet need for hormone therapy, using nonprescription hormones among transgender women who used any hormones, and unmet need for gender-affirmation procedures (Table 1).

Analysis

Log-linked Poisson regression models with generalized estimating equations clustered on recruitment chain were used to obtain adjusted prevalence ratios and 95% CIs. Referent groups were selected based on who was expected to have the most favorable outcome. Models comparing group differences in employment discrimination were adjusted for urban area and network size (19). Models comparing trouble getting a job to health care access and use outcomes were adjusted for urban area, network size, and age. Certain categories were not modeled because of sparse data. Statistical significance was determined by whether the CI crossed the null of 1.0. Analyses were conducted using SAS software (version 9.4; SAS Institute).

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Results

Overall, 69.9% of 1,608 transgender women in seven urban areas experienced at least one type of discrimination during the past 12 months because of being transgender. Among transgender women, 53.9% were verbally abused; 39.1% received poorer service in restaurants, stores, or businesses; 32.4% had trouble getting a job; 26.6% were physically abused; 22.3% were denied access to a gender-affirming bathroom; 13.9% were denied housing or evicted; 10.8% were denied or given lower quality health care; and 9.9% were fired from a job (Figure).

Transgender women aged 18–29 years were more likely to be fired because of being transgender than those who were aged ≥50 years (Table 2). Transgender women who reported experiencing homelessness and severe food insecurity were more likely to have been fired during the past year because of being transgender than those who did not have those experiences.

Transgender women aged <50 years were more likely to have trouble getting a job than transgender women who were aged ≥50 years. Transgender women who had income at or below the Federal poverty level, experienced homelessness, experienced severe food insecurity during the past year, had been incarcerated during the past year, had received money or goods in exchange for sex during the past year, or had a disability were more likely to have had trouble getting a job than transgender women who did not have those experiences. Transgender women who were Black or African American (Black) or multiracial were less likely to have trouble getting a job than White transgender women. (Persons of Hispanic or Latina [Hispanic] origin might be of any race but are categorized as Hispanic; all racial groups are non-Hispanic.)

Having trouble getting a job was related to health care access and use (Table 3). Among transgender women who had trouble getting a job because of being transgender, 62.4% had Medicaid only, 21.6% were uninsured, and 7.2% had private health insurance only. Transgender women who had Medicaid were 1.57 times as likely to have trouble getting a job as those with private insurance only. Although most (81.5%) participants lived in states where Medicaid explicitly covers gender-affirming care, transgender women who lived in states where Medicaid does not explicitly cover this care were twice as likely to report difficulty getting a job. Transgender women who had an unmet need for health care because of cost and never had transgender-specific health care were more likely to have trouble getting a job than those who did not. Most transgender women visited a health care provider during the past year, were currently taking hormones, or had insurance coverage for hormones; no differences were found because of high prevalence of these variables. Among transgender women who used any hormones, those who used nonprescription hormones were 1.24 times as likely to have had trouble getting a job as transgender women who did not. Transgender women who had an unmet need for gender-affirmation procedures were more likely to have trouble getting a job than those with no unmet need.

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Discussion

Seven in 10 transgender women experienced transphobic discrimination, and one in three reported employment discrimination during the past year. Having trouble getting a job because of being transgender was associated with poor social determinants of health and lower health care access and use, including gender-affirming procedures.

The prevalence of discrimination in NHBS-Trans had certain similarities to and differences from previous studies, including the 2015 U.S. Transgender Survey (USTS) (3). Compared with USTS participants, NHBS-Trans participants reported similar prevalence for employment discrimination (32% NHBS-Trans versus 30% USTS); higher prevalence of bathroom discrimination (22% versus 9%), poorer treatment in businesses (39% versus 31%), verbal abuse (59% versus 12%), and physical abuse (27% versus 1%); and lower prevalence of housing discrimination (13% versus 23%) and health care discrimination (11% versus 33%). These differences might be partially explained by the sociodemographic composition of these two surveys: participants in the NHBS-Trans sample were predominantly Black or Hispanic and had lower SES, whereas participants in the USTS sample were predominantly White and had higher SES. In addition, during 2015–2019, transgender persons reported increased discrimination and minority stress because of a political climate that was increasingly hostile toward transgender persons (20). Finally, NHBS-Trans and USTS had differences in their questionnaires.

Employment discrimination occurs at the overlapping nexus of poverty, homelessness, incarceration, health insurance, disability, food insecurity, and survival sex work. These issues are interconnected. When economically marginalized transgender women are refused employment, this refusal cyclically contributes to economic hardships and might lead them to engage in survival sex work (8) and potentially incarceration, increasing their chances of facing further employment discrimination. For many persons, sex work might be their main form of employment, and employment discrimination also might occur as a part of sex work; however, that could not be examined in this analysis. In addition, although discriminating against job candidates with a disability is illegal, one third of transgender women who had a disability reported trouble getting a job. Previous studies found that transgender persons with disabilities experience high rates of employment discrimination (21), such as not receiving reasonable accommodations.

Employment discrimination was associated with poorer health care access, including being uninsured, having an unmet medical need because of cost, and never having transgender-specific health care. Private health insurance plans often have more provider choices and higher quality of care (22); therefore, employment might influence a person’s ability and opportunity to choose a gender-affirming provider, which is associated with engagement in care and improved health behaviors (23,24). In addition, having a provider with whom the person is comfortable discussing gender issues is related to pre-exposure prophylaxis use for HIV-negative transgender women (25,26) and engagement in HIV care among transgender women with HIV infection (24). Because transgender women who experienced employment discrimination were more likely to have no health insurance coverage or coverage through Medicaid only, improving health care staff members’ cultural competency and respect in serving transgender patients, regardless of their health insurance coverage, and increasing staff members’ representation of persons of transgender experience in health care settings is important (27).

The majority of transgender women in NHBS-Trans had Medicaid, which is the largest source of insurance coverage for persons with HIV infection (28). Four in 10 transgender women had an HIV-positive diagnosis and half reported having a disability. Therefore, the finding that Medicaid was the most common source of insurance was not unexpected. Employers also might discriminate against transgender women in part because they have low income (29), have an HIV-positive diagnosis (30), or have a disability (21), which is interrelated with qualifying for Medicaid.

The type of health insurance coverage that is available to transgender women is related to employment and disability status. For example, Medicaid can function as a safety net for persons experiencing sudden unemployment (31). Expanding Medicaid could help transgender women without health insurance qualify for Medicaid; however, Medicaid coverage of gender-affirming care varies by state (11,32). These variations can be a barrier for medically necessary health care for transgender persons with low income (33). In NHBS-Trans, most participants lived in states in which Medicaid programs explicitly cover gender-affirming care, with the exception of Georgia and Louisiana (18). This variable is likely a proxy for larger structural factors, such as negative community attitudes toward transgender persons (34), which can influence Medicaid policy in certain states (35). Furthermore, states that have not expanded Medicaid are primarily in the South, which has large numbers of Black and Hispanic residents (36). Historically, Medicaid policy has been shaped by structural racism, which has contributed to health inequities among Black and Hispanic persons (36).

Most transgender women visited a health care provider or currently use hormones; no association for these experiences was found with employment discrimination. Engagement with the health care system is usually necessary for those who desire hormones or other gender-affirming procedures; therefore, transgender women are highly motivated to seek health care and pursue hormone therapy, sometimes even at the expense of other basic needs (37,38). To achieve their transition goals, certain transgender women might even seek nonprescription hormones, which can be dangerous and unregulated (39,40), or ration prescription hormones because of cost (41). Improving health insurance coverage of gender-affirming care across all states could help protect transgender women from pursuing dangerous alternatives to prescription hormones. However, obtaining gender-affirming procedures without health insurance is more difficult; thus, the relation of an unmet need for gender-affirming procedures with employment discrimination is notable, which might be a structural barrier to health care access. Transgender women possibly have lower access to gender-affirming procedures in part because of employers refusing to hire them, and therefore being uninsured or inadequately insured.

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Limitations

General limitations for the NHBS-Trans are available in the overview and methodology report of this supplement (17). The findings in this report are subject to at least five additional limitations. First, because transgender women are hard to reach, the data might not be representative of all transgender women residing in the seven urban areas. Second, the data are self-reported and subject to recall and social desirability biases, which could underestimate results. Third, causality cannot be inferred because of the cross-sectional study design. For example, whether employment discrimination directly caused loss of health insurance or care outcomes is unknown. Fourth, whether participants are employed, how many jobs they hold, or sectors of employment where they faced discrimination is unknown. Nevertheless, transgender persons are twice as likely to be unemployed as cisgender persons (42). Finally, the discrimination questions were limited to transphobia and thus lack an intersectional framework. Transgender women could face discrimination because of race and ethnicity, age, weight, income, disability, and other characteristics that were not collected in the survey. Black transgender women experience unique marginalization differently from White transgender women or Black cisgender persons (43). This analysis indicated that Black transgender women reported less employment discrimination than White transgender women; however, this finding might be attributable to unmeasured intersectionality and not demonstrative of less discrimination. Previous studies have found that Black transgender women experience high employment discrimination (43,44); however, they are more likely to attribute discrimination to racism (45). Asking Black and Hispanic transgender women if they experienced discrimination solely because of being transgender likely explains some of the discrepancies between this study and other studies. Furthermore, Black and Hispanic transgender women often report mistrust in institutional systems and, therefore, might be reluctant to apply for jobs out of fear of anticipated discrimination (8), which could result in fewer discriminatory situations. Previous studies demonstrate that transgender persons sometimes strategically avoid certain jobs on the basis of perceptions of anticipated discrimination (44).

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Conclusion

Transgender women face many types of discrimination, which contribute to their economic and social marginalization. A transgender person’s ability to pursue their life goals and express their identity is compromised by lack of health insurance coverage for gender-affirming care (33), banning gender-affirming care for minors, and state bans that deny access to gender-affirming bathrooms (46). To that end, the findings from this report might be useful to guide legal, health care, and employment efforts to address threats to transgender women’s rights. Although discrimination on the basis of gender identity is illegal, employment discrimination toward transgender women still occurs; lawyers, legislators, and others can work to ensure those laws are enforced. Transgender women who have been discriminated against in the workplace can file lawsuits or complaints with the Equal Employment Opportunity Commission (47). Other legislative actions that have improved access to health insurance and health care include Medicaid expansion (6) and explicit Medicaid coverage of gender-affirming care (48). Employers across sectors can implement antidiscrimination trainings and policies that protect transgender women from hiring and workplace discrimination. Increased representation of transgender persons across workplace sectors might help avoid bias and build cultural competency. At an individual level, persons who are not transgender can help reduce workplace discrimination through self-education and providing social support to transgender colleagues. This analysis, which examined how employment discrimination is associated with lower health care access and use for transgender women, demonstrates the importance of transgender women working and living with dignity and without fear of unfair treatment.

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National HIV Behavioral Surveillance Among Transgender Women Study Group

Narquis Barak, CrescentCare; Kathleen A. Brady, Philadelphia Department of Public Health; Sarah Braunstein, New York City Department of Health and Mental Hygiene; Jasmine Davis, CrescentCare; Sara Glick, University of Washington, School of Medicine, Division of Allergy and Infectious Diseases, Public Health – Seattle & King County, HIV/STD Program; Andrea Harrington, Philadelphia Department of Public Health; Jasmine Lopez, New York City Department of Health and Mental Hygiene; Yingbo Ma, Los Angeles County Department of Public Health; Aleks Martin, , Public Health – Seattle & King County, HIV/STD Program; Genetha Mustaafaa, Georgia Department of Public Health; Tanner Nassau, Philadelphia Department of Public Health; Gia Olaes, Los Angeles County Department of Public Health; Jennifer Reuer, Washington State Department of Health; Alexis Rivera, New York City Department of Health and Mental Hygiene; William T. Robinson, Louisiana State University Health Science Center in New Orleans – School of Public Health, Louisiana Office of Public Health STD/HIV/Hepatitis Program; Ekow Kwa Sey, Los Angeles County Department of Public Health; Sofia Sicro, San Francisco Department of Public Health; Brittany Taylor, Georgia Department of Public Health; Dillon Trujillo, San Francisco Department of Public Health; Erin Wilson, San Francisco Department of Public Health; Pascale Wortley, Georgia Department of Public Health.

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Corresponding author: Amy R. Baugher, Behavioral and Clinical Surveillance Branch, Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC. Telephone: 404-639-1956; Email: yda1@cdc.gov.

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1Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, Georgia; 2Social & Scientific Systems, Inc., Silver Spring, Maryland; 3ICF, Fairfax, Virginia; 4Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee

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Conflicts of Interest

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No conflicts of interest were disclosed.

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* 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

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References

  1. Casey LS, Reisner SL, Findling MG, et al. Discrimination in the United States: experiences of lesbian, gay, bisexual, transgender, and queer Americans. Health Serv Res 2019;54(Suppl 2):1454–66. https://doi.org/10.1111/1475-6773.13229 PMID:31659745
  2. US Equal Employment Opportunity Commission. Protections against employment discrimination based on sexual orientation or gender identity. Washington, DC; US Equal Employment Opportunity Commission. https://www.eeoc.gov/laws/guidance/protections-against-employment-discrimination-based-sexual-orientation-or-gender
  3. James S, Herman J, Rankin S, Keisling M, Mottet L, Anafi M. The report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf
  4. Martinez-Velez JJ, Melin K, Rodriguez-Diaz CE. A preliminary assessment of selected social determinants of health in a sample of transgender and gender nonconforming individuals in Puerto Rico. Transgend Health 2019;4:9–17. https://doi.org/10.1089/trgh.2018.0045 PMID:30719502
  5. Glick JL, Lopez A, Pollock M, Theall KP. Housing insecurity and intersecting social determinants of health among transgender people in the USA: a targeted ethnography. Int J Transgender Health 2020;21:337–49. https://doi.org/10.1080/26895269.2020.1780661 PMID:34993513
  6. Tran NK, Baker KE, Lett E, Scheim AI. State-level heterogeneity in associations between structural stigma and individual health care access: a multilevel analysis of transgender adults in the United States. J Health Serv Res Policy 2023;28:109–18. https://doi.org/10.1177/13558196221123413 PMID:36040166
  7. Du Bois SN, Yoder W, Guy AA, Manser K, Ramos S. Examining associations between state-level transgender policies and transgender health. Transgend Health 2018;3:220–4. https://doi.org/10.1089/trgh.2018.0031 PMID:30596149
  8. Smart BD, Mann-Jackson L, Alonzo J, et al. Transgender women of color in the U.S. South: a qualitative study of social determinants of health and healthcare perspectives. Int J Transgender Health 2020;23:164–77. https://doi.org/10.1080/26895269.2020.1848691 PMID:35403118
  9. Lett E, Abrams MP, Gold A, Fullerton FA, Everhart A. Ethnoracial inequities in access to gender-affirming mental health care and psychological distress among transgender adults. Soc Psychiatry Psychiatr Epidemiol 2022;57:963–71. https://doi.org/10.1007/s00127-022-02246-6 PMID:35137246
  10. Baker KE, Wilson LM, Sharma R, Dukhanin V, McArthur K, Robinson KA. Hormone therapy, mental health, and quality of life among transgender people: a systematic review. J Endocr Soc 2021;5:bvab011. https://doi.org/10.1210/jendso/bvab011 PMID:33644622
  11. Cohen WA, Sangalang AM, Dalena MM, Ayyala HS, Keith JD. Navigating insurance policies in the United States for gender-affirming surgery. Plast Reconstr Surg Glob Open 2019;7:e2564. https://doi.org/10.1097/GOX.0000000000002564 PMID:32537307
  12. Van Gerwen OT, Blumenthal JS. Providing gender-affirming care to transgender and gender-diverse individuals with and at risk for HIV. Top Antivir Med 2023;31:3–13. PMID:37018731
  13. Glick JL, Theall KP, Andrinopoulos KM, Kendall C. The role of discrimination in care postponement among trans-feminine individuals in the U.S. National Transgender Discrimination Survey. LGBT Health 2018;5:171–9. https://doi.org/10.1089/lgbt.2017.0093 PMID:29589995
  14. Jaffee KD, Shires DA, Stroumsa D. Discrimination and delayed health care among transgender women and men: implications for improving medical education and health care delivery. Med Care 2016;54:1010–6. https://doi.org/10.1097/MLR.0000000000000583 PMID:27314263
  15. Lelutiu-Weinberger C, English D, Sandanapitchai P. The roles of gender affirmation and discrimination in the resilience of transgender individuals in the US. Behav Med 2020;46:175–88. https://doi.org/10.1080/08964289.2020.1725414 PMID:32787726
  16. CDC. HIV infection, risk, prevention, and testing behaviors among transgender women—National HIV Behavioral Surveillance, 7 U.S. cities, 2019–20. Atlanta, GA: US Department of Health and Human Services, CDC; 2021. https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-27.pdf
  17. Kanny D, Lee K, Olansky E, et al.; National HIV Behavioral Surveillance Among Transgender Women Study Group. Overview and methodology of the National HIV Behavioral Surveillance Among Transgender Women—seven urban areas, United States, 2019–2020. In: National HIV Behavioral Surveillance Among Transgender Women—seven urban areas, United States, 2019–2020. MMWR Suppl 2024;73(No. Suppl-1):1–8.
  18. Mallory C, Tentindo W. Medicaid coverage for gender-affirming care. Los Angeles, CA: Williams Institute; 2019. https://williamsinstitute.law.ucla.edu/wp-content/uploads/Medicaid-Gender-Care-Oct-2019.pdf
  19. Stafford JE, Cocanougher BA. Reference group theory [Chapter 16]. In: Selected aspects of consumer behavior. Alexandria, VA: National Science Foundation; 1977:361–80.
  20. Gonzalez KA, Ramirez JL, Galupo MP. Increase in GLBTQ minority stress following the 2016 US presidential election. J GLBT Fam Stud 2018;14:130–51. https://doi.org/10.1080/1550428X.2017.1420849
  21. Kattari SK, Walls NE, Speer SR. Differences in experiences of discrimination in accessing social services among transgender/gender nonconforming individuals by (dis)ability. J Soc Work Disabil Rehabil 2017;16:116–40. https://doi.org/10.1080/1536710X.2017.1299661 PMID:28447917
  22. Spencer CS, Gaskin DJ, Roberts ET. The quality of care delivered to patients within the same hospital varies by insurance type. Health Aff (Millwood) 2013;32:1731–9. https://doi.org/10.1377/hlthaff.2012.1400 PMID:24101062
  23. Christian R, Mellies AA, Bui AG, Lee R, Kattari L, Gray C. Measuring the health of an invisible population: lessons from the Colorado Transgender Health Survey. J Gen Intern Med 2018;33:1654–60. https://doi.org/10.1007/s11606-018-4450-6 PMID:29761263
  24. Lee K, Trujillo L, Olansky E, et al.; National HIV Behavioral Surveillance among Transgender Women Study Group. Factors associated with use of HIV prevention and health care among transgender women—seven urban areas, 2019–2020. MMWR Morb Mortal Wkly Rep 2022;71:673–9. https://doi.org/10.15585/mmwr.mm7120a1 PMID:35588092
  25. Morris E, Teplinskaya A, Olansky E, Kemp Rinderle J, Chapin Bardales J; National HIV Behavioral Surveillance Study Group. Characteristics associated with pre-exposure prophylaxis discussion and use among transgender women without HIV infection—National HIV Behavioral Surveillance Among Transgender Women, seven urban areas, United States, 2019–2020. In: National HIV Behavioral Surveillance Among Transgender Women—seven urban areas, United States, 2019–2020. MMWR Suppl 2024;73(No. Suppl-1):9–20.
  26. Rivera AV, Lopez JM, Braunstein SL. Exploring the association between gender affirmation and PrEP use among transgender women in New York City. AIDS Behav 2023;27:1523–30. https://doi.org/10.1007/s10461-022-03944-7 PMID:36574185
  27. Ding JM, Ehrenfeld JM, Edmiston EK, Eckstrand K, Beach LB. A model for improving health care quality for transgender and gender nonconforming patients. Jt Comm J Qual Patient Saf 2020;46:37–43. https://doi.org/10.1016/j.jcjq.2019.09.005 PMID:31708472
  28. Kaiser Family Foundation. Medicaid and HIV. San Francisco, CA: Kaiser Family Foundation; 2019. https://www.kff.org/hivaids/issue-brief/medicaid-and-people-with-hiv/
  29. Peterman DE. Socioeconomic status discrimination. Va Law Rev 2018;104:1283–357. https://virginialawreview.org/wp-content/uploads/2020/12/Evans_Online%20Revised.pdf
  30. Maulsby CH, Ratnayake A, Hesson D, Mugavero MJ, Latkin CA. A scoping review of employment and HIV. AIDS Behav 2020;24:2942–55. https://doi.org/10.1007/s10461-020-02845-x PMID:32246357
  31. Benitez J, Perez V, Seiber E. Medicaid access during economic distress: lessons learned from the Great Recession. Med Care Res Rev 2021;78:490–501. https://doi.org/10.1177/1077558720909237 PMID:32129138
  32. Singer S, Yeung H, Mostaghimi A. State Medicaid coverage of dermatologic procedures and other gender-affirming services for transgender patients in the United States. LGBT Health 2020;7:166–8. https://doi.org/10.1089/lgbt.2019.0161 PMID:32096701
  33. Gomez I, Ranji U, Salganicoff A, et al. Update on Medicaid coverage of gender-affirming health services. San Francisco, CA: Kaiser Family Foundation; 2022. https://www.kff.org/womens-health-policy/issue-brief/update-on-medicaid-coverage-of-gender-affirming-health-services
  34. Lewis DC, Flores AR, Haider-Markel DP, Miller PR, Tadlock BL, Taylor JK. Degrees of acceptance: variation in public attitudes toward segments of the LGBT community. Polit Res Q 2017;70:861–75. https://doi.org/10.1177/1065912917717352
  35. Baker AM, Hunt LM. Counterproductive consequences of a conservative ideology: Medicaid expansion and personal responsibility requirements. Am J Public Health 2016;106:1181–7. https://doi.org/10.2105/AJPH.2016.303192 PMID:27196640
  36. Yearby R, Clark B, Figueroa JF. Structural racism in historical and modern US health care policy. Health Aff (Millwood) 2022;41:187–94. https://doi.org/10.1377/hlthaff.2021.01466 PMID:35130059
  37. Sevelius JM, Keatley J, Calma N, Arnold E. ‘I am not a man’: trans-specific barriers and facilitators to PrEP acceptability among transgender women. Glob Public Health 2016;11:1060–75. https://doi.org/10.1080/17441692.2016.1154085 PMID:26963756
  38. Sevelius JM, Saberi P, Johnson MO. Correlates of antiretroviral adherence and viral load among transgender women living with HIV. AIDS Care 2014;26:976–82. https://doi.org/10.1080/09540121.2014.896451 PMID:24646419
  39. Olansky E, Lee K, Handanagic S, Trujillo L; National HIV Behavioral Surveillance Among Transgender Women Study Group. Nonprescription hormone use among transgender women—National HIV Behavioral Surveillance Among Transgender Women—seven urban areas, United States, 2019–2020. In: National HIV Behavioral Surveillance Among Transgender Women—seven urban areas, United States, 2019–2020. MMWR Suppl 2024;73(No. Suppl-1):34–9.
  40. Stroumsa D, Crissman HP, Dalton VK, Kolenic G, Richardson CR. Insurance coverage and use of hormones among transgender respondents to a national survey. Ann Fam Med 2020;18:528–34. https://doi.org/10.1370/afm.2586 PMID:33168681
  41. Restar A, Dusic EJ, Garrison-Desany H, et al. Gender affirming hormone therapy dosing behaviors among transgender and nonbinary adults. Humanit Soc Sci Commun 2022;9:1–11. https://doi.org/10.1057/s41599-022-01291-5 PMID:36636110
  42. Baboolall D, Greenberg S, Obeid M, Zucker J. Being transgender at work. Atlanta, GA: McKinsey & Company; 2021. https://www.mckinsey.com/featured-insights/diversity-and-inclusion/being-transgender-at-work
  43. Nourafshan A. The new employment discrimination: intra-LGBT intersectional invisibility and the marginalization of minority subclasses in antidiscrimination law. Duke J Gend Law Policy 2017;24:107–41. https://scholarship.law.duke.edu/cgi/viewcontent.cgi?article=1316&context=djglp
  44. Kattari SK, Whitfield DL, Walls NE, Langenderfer-Magruder L, Ramos D. Policing gender through housing and employment discrimination: comparison of discrimination experiences of transgender and cisgender LGBQ individuals. J Soc Social Work Res 2016;7:427–47. https://doi.org/10.1086/686920
  45. Center for Black Equity. Black LGBTQ Community Survey, 2020–2021. Corte Madera, CA: Community Marketing & Insights; 2021. https://www.cmi.info/documents/temp/LGBTQ_Black-LGBTQ-Community-Survey_2020-2021.pdf
  46. Barbee H, Deal C, Gonzales G. Anti-transgender legislation—a public health concern for transgender youth. JAMA Pediatr 2022;176:125–6. https://doi.org/10.1001/jamapediatrics.2021.4483 PMID:34747979
  47. National Center for Transgender Equality. Know your rights: employment (general). Washington, DC: National Center for Transgender Equality; 2023. https://transequality.org/know-your-rights/employment-general
  48. Padula WV, Baker K. Coverage for gender-affirming care: making health insurance work for transgender Americans. LGBT Health 2017;4:244–7. https://doi.org/10.1089/lgbt.2016.0099 PMID:28708447

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TABLE 1. Measures, questions, and analytic coding for prevalence of discrimination and the association between employment discrimination and health care access and use, by type of discrimination and selected characteristics — National HIV Behavioral Surveillance Among Transgender Women, seven urban areas,* United States, 2019–2020Return to your place in the text
Measure Question Analytic coding
Discrimination type
Employment discrimination In the past 12 months, have you been fired from a job because you are transgender or gender nonconforming?
Had trouble getting a job because you are transgender or gender nonconforming?		 Yes or no
Bathroom discrimination past 12 months In the past 12 months, have you been denied access to bathrooms that were appropriate to your gender identity? Yes or no
Housing discrimination past 12 months In the past 12 months, have you been denied housing or been evicted because you are transgender or gender nonconforming? Yes or no
Health care discrimination past 12 months In the past 12 months, have you been denied or given lower quality health care because you are transgender or gender nonconforming? Yes or no
Discrimination in businesses In the past 12 months, have you received poorer services than other people in restaurants, stores, or businesses because you are transgender or gender nonconforming? Yes or no
Abuse In the past 12 months, have you been verbally abused or harassed because of your gender identity or presentation?
Been physically abused or harassed because of your gender identity or presentation?		 Yes or no
Health outcome
HIV status NHBS biologic HIV test result Negative, positive, unknown result, or did not consent to test
Disability† Are you deaf or do you have serious difficulty hearing? Are you blind or have serious difficulty seeing, even when wearing glasses? Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? Do you have serious difficulty walking or climbing stairs? Do you have difficulty dressing or bathing? Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone, such as visiting a doctor’s office or shopping? Yes or no
Health care access and use
State Medicaid laws explicitly cover gender-affirming care, 2019§ City of residence Yes or no
Usual source of health care Is there a place that you usually go when you are sick or you need advice about your health? Please do not include Internet websites. Yes or no
Visited health care provider past 12 months In the past 12 months, that is, since [fill with interview month, formatted as text] of last year, have you seen a doctor, nurse, or other health care provider? Yes or no
Unmet need for health care because of cost past 12 months During the past 12 months, was there any time when you needed medical care but didn’t get it because you couldn’t afford it? Yes or no
Comfort with health care provider Do you have a health care provider with whom you feel comfortable discussing gender-related health issues? Yes or no
Gender-affirming care
Unmet need for hormone therapy Have you ever taken hormones for gender transition or affirmation? Are you currently taking hormones for gender transition or affirmation? Would you like to take hormones for gender transition or affirmation? Yes or no
Health insurance covers hormone therapy Does your current health insurance cover hormones for gender transition or affirmation? Yes or no
Used nonprescription hormones past 12 months In the past 12 months, have you used hormones that were not prescribed to you by a doctor or other health care professional? Yes or no
Unmet need for gender-affirmation procedure Have you ever had any type of surgery for gender transition or affirmation? Do you plan or want to get additional surgeries for gender transition or affirmation? Do you want to have surgery for gender transition or affirmation? Yes or no

Abbreviation: NHBS = National HIV Behavioral Surveillance.
* Atlanta, GA; Los Angeles, CA; New Orleans, LA; New York City, NY; Philadelphia, PA; San Francisco, CA; and Seattle, WA.
† To assess difficulty in six basic domains of functioning (hearing, vision, cognition, walking, self-care, and independent living), based on U.S. Department of Health and Human Services disability data standard (https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0).
§ State Medicaid coverage as of 2019 was determined by the Williams Institute’s October 2019 report (https://williamsinstitute.law.ucla.edu/wp-content/uploads/Medicaid-Gender-Care-Oct-2019.pdf).

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Return to your place in the textFIGURE. Prevalence of types of transgender-specific discrimination during the past 12 months among transgender women — National HIV Behavioral Surveillance Among Transgender Women, seven urban areas,* United States, 2019–2021†
Figure is a bar graph indicating the prevalence of types of transgender-specific discrimination during the past 12 months among transgender women using data from the National HIV Behavioral Surveillance Among Transgender Women from seven urban areas in the United States during 2019–2020.

* Atlanta, GA; Los Angeles, CA; New Orleans, LA; New York City, NY; Philadelphia, PA; San Francisco, CA; and Seattle, WA.

† N = 1,608 participants.

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TABLE 2. Number and percentage of transgender women experiencing transgender-specific employment discrimination during the past 12 months, by selected characteristics — National HIV Behavioral Surveillance Among Transgender Women, seven urban areas,* United States, 2019–2020†Return to your place in the text
Characteristic Total no. Fired from a job (n = 158) Trouble getting a job (n = 513)
No. (%)§ aPR (95% CI) No. (%)§ aPR (95% CI)
Age group, yrs
18–29 496 64 (12.9) 1.71 (1.08–2.71) 214 (43.1) 2.47 (1.97–3.09)**
30–39 461 45 (9.7) 1.36 (0.76–2.42) 149 (32.3) 1.93 (1.53–2.43)**
40–49 307 26 (8.5) 1.22 (0.75–1.96) 92 (30.0) 1.71 (1.42–2.06)**
≥50 343 23 (6.7) Ref 58 (16.9) Ref
Race and ethnicity††
American Indian or Alaska Native 17 2 (11.8) —§§ 5 (29.4) —
Asian 30 3 (10.0) — 4 (13.3) —
Black or African American 569 54 (9.5) 1.07 (0.68–1.69) 125 (22.0) 0.54 (0.40–0.72)**
Native Hawaiian or other Pacific Islander 42 1 (2.4) — 6 (14.3) —
White 180 19 (10.6) Ref 79 (43.9) Ref
Multiple races 124 8 (6.5) — 30 (24.2) 0.63 (0.47–0.86)**
Hispanic or Latina 643 71 (11.0) 1.28 (0.79–2.08) 263 (40.9) 0.90 (0.73–1.11)
Poverty¶¶
Above Federal poverty level 585 46 (7.9) Ref 140 (23.9) Ref
At or below Federal poverty level 1,008 108 (10.7) 1.29 (0.94–1.77) 365 (36.2) 1.42 (1.25–1.62)**
Homeless past 12 months***
No 936 78 (8.3) Ref 240 (25.6) Ref
Currently homeless 364 49 (13.5) 1.72 (1.24–2.39) 160 (44.0) 1.67 (1.39–2.00)**
Homeless during the past 12 months but not currently 306 31 (10.1) 1.30 (0.89–1.89) 113 (36.9) 1.48 (1.19–1.83)**
Severe food insecurity past 12 months†††
Yes 637 103 (16.2) 2.72 (2.18–3.39) 291 (45.7) 1.87 (1.59–2.20)**
No 968 55 (5.7) Ref 221 (22.8) Ref
Incarceration§§§
Never incarcerated 670 69 (10.3) Ref 209 (31.2) Ref
Incarcerated >12 months ago 658 63 (9.6) 0.95 (0.75–1.21) 183 (27.8) 0.89 (0.76–1.04)
Incarcerated past 12 months ago 277 26 (9.4) 0.92 (0.62–1.38) 120 (43.3) 1.29 (1.16–1.45)**
Received money or goods in exchange for sex past 12 months
Yes 549 54 (9.8) 1.08 (0.86–1.36) 217 (39.5) 1.45 (1.25–1.69)**
No 1,058 104 (9.8) Ref 295 (27.9) Ref
Disability status¶¶¶
Yes 853 92 (10.8) 1.31 (0.99–1.72) 310 (36.3) 1.41 (1.17–1.70)**
No 747 66 (8.8) Ref 200 (26.8) Ref
NHBS HIV test result****
Negative 902 95 (10.5) Ref 337 (25.5) Ref
Positive 659 61 (9.3) 1.00 (0.73–1.38) 168 (37.4) 0.80 (0.69–0.94)**

Abbreviations: aPR = adjusted prevalence ratio; NHBS = National HIV Behavioral Surveillance; Ref = referent group.
* Atlanta, GA; Los Angeles, CA; New Orleans, LA; New York City, NY; Philadelphia, PA; San Francisco, CA; and Seattle, WA.
† N = 1,608 participants. Numbers might not sum to totals because of missing data.
§ Row percentages.
Models are adjusted for network size and urban area.
** Statistically significant; 95% CIs do not cross the null of 1.0.
†† Persons of Hispanic or Latina (Hispanic) origin might be of any race but are categorized as Hispanic; all racial groups are non-Hispanic.
§§ Models were not conducted for fields with sparse data.
¶¶ 2019 Federal poverty level thresholds were calculated on the basis of U.S. Department of Health and Human Services Federal poverty level guidelines (https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines/prior-hhs-poverty-guidelines-federal-register-references/2019-poverty-guidelines).
*** Living on the street, in a shelter, in a single room occupancy hotel, or in a car.
††† Not eating for a whole day because there was not enough money for food at some point during the past 12 months.
§§§ Held in a detention center, jail, or prison for >24 hours.
¶¶¶ Serious difficulty hearing, seeing, doing cognitive tasks, walking or climbing stairs, dressing or bathing, or doing errands alone. Adjusted for age. Based on U.S. Department of Health and Human Services disability data standard (https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0).
**** Participants with a reactive rapid NHBS HIV test result supported by a second rapid test or supplemental laboratory-based testing. Adjusted for age.

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TABLE 3. Number and percentage of transgender women having trouble getting a job during the past 12 months, by health care access and use — National HIV Behavioral Surveillance Among Transgender Women, seven urban areas,* United States, 2019–2020†Return to your place in the text
Characteristic Total
no.		 Trouble getting a job (n = 513)
No. (%)§ aPR (95% CI)
Health care access
Current health insurance coverage
Uninsured 270 111 (41.1) 1.74 (1.38–2.20)**
Private insurance only 173 37 (21.4) Ref
Medicaid only 910 320 (35.2) 1.57 (1.25–1.97)**
Medicare only 44 4 (9.1) —††
Multiple insurance types 143 21 (14.7) 0.88 (0.59–1.30)
Other insurance type 66 19 (28.8) 1.25 (0.80–1.95)
State Medicaid laws explicitly covered gender-affirming care, 2019§§
Yes 1,311 407 (31.0) Ref
No 297 106 (35.7) 2.02 (1.10–3.71)**
Usual source of health care
Yes 1,325 406 (30.6) Ref
No 279 105 (37.6) 1.21 (0.98–1.48)
Unmet need for health care because of cost past 12 months
Yes 323 170 (52.6) 1.74 (1.47–2.07)**
No 1,285 343 (26.7) Ref
Health insurance covers hormone therapy¶¶
Yes 1,101 323 (29.8) 0.78 (0.57–1.06)
No 71 26 (37.7) Ref
Transgender-specific health care***
Current 1,251 375 (30.0) Ref
Past but not current 143 50 (35.0) 1.03 (0.85–1.25)
Never 208 84 (40.4) 1.22 (1.03–1.44)**
Health care use
Visited a health care provider past 12 months
Yes 1,502 478 (31.8) 0.94 (0.78–1.14)
No 105 35 (33.3) Ref
Unmet need for hormone therapy
Currently taking any hormones 1,149 350 (30.5) Ref
Do not want to take hormones 121 41 (33.9) 1.04 (0.86–1.26)
Want to take hormones 317 114 (36.0) 1.12 (0.93–1.36)
Used hormones, nonprescription†††
Yes 246 98 (40.2) 1.24 (1.03–1.50)**
No 1,009 304 (30.6) Ref
Unmet need for gender-affirmation procedures§§§
No unmet need 448 101 (22.5) Ref
Had procedures, wants more procedures 232 60 (25.9) 1.16 (0.87–1.53)
Wants but has not received procedures 840 327 (38.9) 1.44 (1.28–1.61)**

Abbreviations: aPR = adjusted prevalence ratio; Ref = Referent group.
* Atlanta, GA; Los Angeles, CA; New Orleans, LA; New York City, NY; Philadelphia, PA; San Francisco, CA; and Seattle, WA.
† N = 1,608 participants. Numbers might not sum to totals because of missing data.
§ Row percentages.
Models are adjusted for network size, urban area, and age.
** Statistically significant; 95% CIs do not cross the null of 1.0.
†† Models were not conducted for fields with sparse data.
§§ State Medicaid coverage as of 2019 was determined by the Williams Institute’s October 2019 report (https://williamsinstitute.law.ucla.edu/wp-content/uploads/Medicaid-Gender-Care-Oct-2019.pdf).
¶¶ Limited to persons with health insurance.
*** Has had a provider with whom they are comfortable discussing gender-related issues.
††† Limited to persons who currently use any hormones.
§§§ Vaginoplasty, orchiectomy, or breast augmentation.

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Suggested citation for this article: Baugher AR, Olansky E, Sutter L, et al. Prevalence of Discrimination and the Association Between Employment Discrimination and Health Care Access and Use — National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019–2020. MMWR Suppl 2024;73(Suppl-1):51–60. DOI: http://dx.doi.org/10.15585/mmwr.su7301a6.

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