ChapterPDF Available

Abstract and Figures

We want to stress at the outset of this chapter that the task of representing the transsexual and transgender population is nothing if not daunting. The difficulties, as we see them, stem from two main sources: (1) though a general “trans” sensibility exists in both the United States and worldwide, there are currently few measurable and/or standardized criteria (e.g. physical, social, political, etc.) regarding what might or should constitute a transgender person; and (2) problems with locating and accounting for this population are compounded by the relative invisibility through which many transgender individuals exist in their daily lives. Marginalized by political, religious, legal, medical, and other cultural institutions, transgender persons encounter levels of discrimination that range from simple misapprehension and/or exclusion by an uneducated public, to explicit acts of sexual and physical violence. Indeed, many in what is often referred to as the mainstream, including transgender individuals, are first exposed to the idea of “transgender” through media that often sensationalize and misrepresent the issues most salient for this population.
Content may be subject to copyright.
289
A.K. Baumle (ed.), International Handbook on the Demography of Sexuality,
International Handbooks of Population 5, DOI 10.1007/978-94-007-5512-3_16,
© Springer Science+Business Media Dordrecht 2013
Introduction
We want to stress at the outset of this chapter
that the task of representing the transgender
population is nothing if not daunting. The
dif culties, as we see them, stem from two main
sources: (1) though a general “trans” sensibility
exists in both the United States and worldwide,
there are currently few measurable and/or stan-
dardized criteria (e.g. physical, social, political,
etc.) regarding what might or should constitute a
transgender person; and (2) problems with locat-
ing and accounting for this population are com-
pounded by the relative invisibility through
which many transgender individuals exist in
their daily lives. Marginalized by political, reli-
gious, legal, medical, and other cultural institu-
tions, transgender persons encounter levels of
discrimination that range from simple misap-
prehension and exclusion by an uneducated
public, to explicit acts of sexual and physical
violence (Mizock and Lewis 2008 ; Richmond
et al. 2012 ). Indeed, many in what is often
referred to as the mainstream, including trans-
gender individuals, are rst exposed to the idea
of “transgender” through media that sensation-
alize and misrepresent the issues most salient
for this population.
In this chapter, we attempt to correct, as well
as explain the bases for many of the unfounded
and problematic assumptions made about trans-
gender persons in the contemporary U.S.
Transgender politics and visibility in the U.S. are
uniquely, almost contradictorily, contoured: at
the same time that celebrity culture brings the
faces of RuPaul and Chaz Bono into the homes
of many Americans, private and market-driven
health insurance (which, outside the context of
the Affordable Care Act, is tied to employment
and/or marital status) leaves many transgender
persons without adequate resources to manage
their general medical and transition needs. In
contrast, the single-payer healthcare systems of
Northern Europe and Canada have covered these
services for several decades, allowing research-
ers in these countries to produce some of the
most useful and accurate data regarding this pop-
ulation. In line with Valentine ( 2007 ) , we sug-
gest that such disparities index how the category
transgender is imagined by various communi-
ties, and that an understanding of these local
in ections is a crucial element in grasping the
contemporary signi cance of a transgender
identity.
S. C. Meier (*)
Department of Psychology, University of Houston ,
Houston , TX , USA
e-mail: ftmresearch@gmail.com
C. M. Labuski
Sociology Department, Virginia Polytechnic Institute
and State University , Blacksburg , VA , USA
e-mail: chrislab@vt.edu
1 6
The Demographics
of the Transgender Population
Stacey Colton Meier
and Christine M. Labuski
290 S.C. Meier and C.M. Labuski
Transgender identity has long been character-
ized as sexually or socially deviant; it has also
been labeled a “natural diversity in human sexual
formation.”
1 Theories about trans identity and
practices have ranged from nineteenth century
ideas about inherited and familial degeneracy to
decidedly twenty- fi rst century neuro physiological
accounts of brain and hormonal sex differentia-
tion in utero. Demographic populations are only
as stable as the socially recognized variables
through which they are de ned, some of which
are more xed (e.g. chronological age) than oth-
ers (e.g., “race”). Winters and Conway ( 2011 )
argue that “minorities do not count until they are
counted.” Because the trans population has long
been (mis)recognized in terms of sexual orienta-
tion, rather than the bodily incongruity that domi-
nates many contemporary trans narratives, we
argue that the population itself is in an almost
constant state of rede nition and re nement.
2
This assertion is meant to discount neither the
importance nor utility of a demographic overview
of the trans population; rather, we wish to under-
score that the population under review is one that
is broadly in transition, and that any relevant facts
about it should be interpreted in socially and
historically-speci fi c terms.
A Guide to Terms
In their work Same-Sex Partners: The Social
Demography of Sexual Orientation , Baumle et al.
( 2009 ) begin their analysis by asking readers to
consider what it would require to “bring the study
of sexuality more into the mainstream of demog-
raphy” (3). Noting that “the eld of sociology has
long suffered from a lack of focus on issues of
sexuality,” (3) the authors argue that it is high
time for this to change, and for sex and sexuality
to occupy more prominent roles in contemporary
demographic analyses. Sexual orientation, they
continue, is not only a factor that can in uence one
of demography’s core processes (i.e., fertility—via
behavioral practices), but should also be under-
stood as “an important personal characteristic
that can shape and inform [other] demographic
processes” (4), such as residential patterns and
income levels.
Demographers who agree with these authors rec-
ognize both the importance of and the dif culties
inherent in collecting meaningful data about
groups often labeled as sexual “minorities.” Indeed,
when Laumann and colleagues ( 1994 ) sought,
over a decade ago, to include homosexuality in
their volume called the The Social Organization of
Sexuality , they grappled explicitly with the chal-
lenges of accurately representing a group whose
identity was—at least partially—constructed
through speci c cultural and historical context(s):
To quantify or count as something requires unam-
biguous de nition of the phenomenon in question.
[…] When people ask how many gays there are,
they assume that everyone knows exactly what is
meant. [But h]istorians and anthropologists have
shown that homosexuality as a category describing
same-gender sexual desire and behavior is a rela-
tively recent phenomenon […] peculiar to the
West. [… E]ven within contemporary Western
societies, one must ask whether this question refers
to same-gender behavior, desire, self-de nition,
identi cation, or some combination of these ele-
ments. In asking the question, most people treat
homosexuality as such a distinctive category that
it is as if all these elements must go together.
On re ection, it is obvious that this is not true. (290)
In this chapter, we argue that what was true for
homosexuality in the mid-1990s is true for trans-
genderism almost two decades later. That is,
given both the socially constructed—and thereby
unstable—nature of a category like transgender,
as well as the intensely material ways through
which transgender individuals live their identity
(e.g. restroom challenges, hormonal side effects),
demographers interested in researching this
population face a peculiar set of analytical and
descriptive challenges. Whether and to what extent
transgender constitutes the type of “distinctive
category” posited by Laumann and colleagues about
which knowledge can be accurately generated
1 http://www.truecolours.org.au/publications/development.
html
2 To this end, the American Psychological Association is
set to release its fth version of the Diagnostic and
Statistical Manual of Mental Disorders in 2013, in which
the diagnosis Gender Identity Disorder will more than
likely be renamed Gender Dysphoria. See the Mental
Health section for further discussion of this issue.
29116 The Demographics of the Transgender Population
and about whom demographic statistics and
claims can be reliably asserted, are questions taken
up in the following section.
Trans as Gender Identity
A key issue facing the transgender population is
nomenclature, i.e., which terms or categories
best re ect the population itself (ALGBTIC
2009 ; Bockting and Coleman 1991 ; Green 2004 ;
NCTE 2009 ) . Since 1949, the word transsexual
has referred to individuals who had a clear sense
of being “[born] in the wrong body” (Meyerowitz
2004 ) . More speci fi cally, a transsexual lives full-
time in a cross-gender social role: a person
assigned male at birth that lives full time as
female would be identi ed as a male to female
(MTF) transsexual, while a birth-assigned female
that lives full time as male would be identi ed as
a female to male (FTM) transsexual. Represented
by celebrities such as Renee Richards, Christine
Jorgensen, and Chaz Bono, this is an identity
characterized by beliefs about body-mind incon-
gruity and (most typically) a desire to have one’s
body align with one’s gender identity or reas-
signed into the other sex.
The term transgender has become increasingly
popular in the past decade and re ects a less restric-
tive or binarized set of beliefs (Green 2004 ; Valentine
2007 ) . More speci fi cally, transgender describes
persons who do not feel like they t into a dichoto-
mous sex structure through which they are identi ed
as male or female. Individuals in this category may
feel as if they are in the wrong gender, but this per-
ception may not correlate with a desire for surgical
or hormonal reassignment. For example, people
who were assigned female at birth who enjoy ste-
reotypically masculine (per their cultural norms)
attire, activities, and presentation may identify as
transgender because their gendered preferences and
expression are incongruent with the cultural expec-
tations of females. While these female assigned
people are gender non-conforming, they may iden-
tify as transgender without feeling trapped in or
wanting to modify their bodies. A transgender per-
son may dress, behave or self-identify anywhere
along a culturally de ned gender spectrum, i.e., a
non-binarized and three-dimensional palette of gen-
der and sex expression. The primary difference
between the two is often described in terms of the
restrictiveness of the category transsexual, which
implies that a person desires body modi cation and
to be socially recognized as the “other” gender.
Indeed, after physically transitioning, many trans-
sexual people consider themselves men or women
and no longer identify as transsexuals (Bolin 1988 ;
Devor 1993 ; New eld et al. 2006 ) .
Theories about the etiology of transgender
and transsexual identity are numerous. Many of
the most recent focus on “brain sex” or “brain
gender,i.e., speci c anatomical sites and/or
brain-regulated hormonal processes that “sex” a
person as either male or female (Gooren 2006 ;
Hines 2004 ; Kruijver et al. 2000 ; Moir and Jessel
1989 ; Zhou et al. 1995 ) . Although there has been
a marked increase of research in this area within
the past decade, there is a range of opinion about
its explanatory power. Some of this disagreement
extends to terminology. Research has thus far
failed to attribute gay and lesbian identities and/or
behaviors to biological causes (Frankowski 2004 ;
Herrn 1995 ) , and many in the transgender com-
munity interpret their experience along the same
lines, i.e., as a complicated and overdetermined
mix of biological, social, psychological, hor-
monal, and possibly neuro-anatomical factors.
Others, however, believe that theories of “brain
sex”—that anatomical sex differentiation can
occur along separate brain and genital trajecto-
ries—are more resonant with the experience of
transgender persons. According to this argument,
gender identity is (biologically) located in the
brain rather than the genitalia (Rametti et al.
2011 ), and altering one’s body and/or lifestyle to
more properly align with this sex should not be
understood in terms of a transition, but rather an
af rmation. This at times contentious dynamic
within the community itself has led one activist
and researcher to label the terms MTF and FTM
“prejudiced, inaccurate and genitocentric”
3 and
3 http://www.truecolours.org.au/publications/ypwts.html .
See also:
http://www.annelawrence.com/brain-sex_
critique.html for a critique of the brain-sex theory.
292 S.C. Meier and C.M. Labuski
to propose acronyms that better re fl ect this
approach: af fi rmed females (AF) and af fi rmed
males (AM) for individuals whose brains are
sexed female and male, respectively (
Fenway
Health 2010 ) . A leading adolescent medicine
expert suggests referring to transgender youth as
asserted males and asserted females because
asserted does not imply that someone else has to
af rm their gender identity for it to be authentic
(Olson, personal communication, 2012). Notably,
these terms could include women and men whose
genitals align with their brain and who choose to
stay that way; these individuals are often referred
to by gender activists, however, as cisgender per-
sons (i.e., non-transgender persons). Cis women
and cis men (the latin cis means “same”) live in
and identify with the same body in which they
were born.
Many transsexuals feel strongly about mak-
ing a commitment to a gender identity, where
transitioning marks a clear move across, i.e.,
from one gender to the other (Namaste 2000 ) .
For these individuals, there is an unambiguous
divide between men and women, one dictated by
anatomy, hormones and an overall “sense of
self.” For others, the line between genders is less
clear, and many may not require genital surgery,
hormones, or any changes in clothing, partner
choice, occupation, or social role(s) in order to
feel as if they are living in the gender with which
they most closely align. For others still, the line
between genders is not a line at all. Rather, the
binary between male and female is illusory and,
for them, playing with sex and gender is a cre-
ative, political, or rebellious way to express that
on a daily basis (Bornstein 1994 ; Feinberg 1997 ;
Nestle et al. 2002 ) . Importantly, it is not only
trans people who believe in deconstructing this
binary; many cisgender and transgender people
live the details of their lives in ways that pur-
posely and consciously challenge the often
restrictive categories of male and female. A per-
son with an active disinvestment in the gender
binary who does not identify as either “male” or
“female” per say might call themselves gender-
queer in order to indicate that what is getting
“queered” is the gender binary itself, not the
sexual orientation of the person in question.
Also of importance is that none of these terms
have historically included individuals born with
bodies that could not be easily categorized as
male or female by parents and/or physicians. In
fact, these people have been historically excluded
from the DSM-IV-TR diagnosis of Gender
Identity Disorder in order to separate the “typi-
cally-sexed” transgender population from those
born with more “ambiguous” sex characteristics
(APA 2000 ) . This latter group, currently described
as intersex, may be surgically “assigned” a single
sex shortly after birth (Kohler et al. 2012 ); some
grow up to reject that assigned sex, however,
owing to some of the same factors that transgen-
der persons cite: an incongruence between
chromosomal, hormonal, anatomical, and/or
affective experiences of their sexed and gendered
selves. Some intersex persons prefer to be
included as trans, while others would rather dis-
tance themselves from this population. Again,
this population remains relatively unquanti ed,
despite a decade-old uptick in both writing and
research about intersex persons. This research
includes important works by critical biologist
Anne Fausto-Sterling, who attempted to enumer-
ate and quantify ve “sexes” in 1993 (though
she has since revised this taxonomy), as well
as historian Alice Dreger, whose book
Hermaphrodites and the Medical Invention of
Sex ( 2000 ) has been praised for bringing the
voices of intersex individuals and clinicians into
critical dialogue with one another. Suzanne
Kessler ( 1990, 1998 ) and Katrina Karkazis ( 2008 )
have each conducted long-term ethnographic
research with families and clinicians and intersex
activists, including Cheryl Chase (
1998, 2003 )
and Riki Wilchins ( 1997, 2004 ) have written
scores of popular, clinical, and scholarly publica-
tions on the subject.
There are divisions among clinicians about
which disorders of sexual development/differen-
tiation should be counted as intersex, and most
surgeons, wanting to “leave well enough alone,
have neglected to conduct long-term follow-up
research with the individuals they have assigned
at birth (Karkazis 2008 ) . As with trans issues,
word choice and terminology are profoundly
political within this population, re ecting dynamic
29316 The Demographics of the Transgender Population
notions of identity informed by new information,
the perfection of surgical techniques, and shifts in
social attitudes (Dreger et al. 2005 ) . Terms that
have been used thus far—hermaphrodite, ambigu-
ous genitalia, intersex, and disorders of sexual
development/differentiation (DSD)—do not cap-
ture the complexity of many of these individuals’
identities. Many who feel that their surgery was
performed improperly have become politically
active and have vociferously called for an end to
what they understand as genital mutilation. There
are also adults living far more quietly in their sex
of assignment, to varying degrees of contentment,
who remain invisible and uncounted. Many of
these individuals would consider themselves to
have transitioned if their gender identity is differ-
ent from the sex they were assigned. Many, per-
haps because of the acute way that their own
bodies signal the inadequacy of the gender binary,
choose to live in terms closer to genderqueer
(Nestle et al.
2002 ) . What is most relevant here is
that regardless of ideological positioning, this
population experiences many of the same issues
as the transgender population under consideration
in this chapter.
In order to capture the largest population of
gender variant individuals, we will use the
broader term trans to refer to persons who wish
to be socially recognized as a gender distinct
from their assigned sex, with or without the desire
for body modi cation. For reasons of order and
containment, we will limit our presentation of
data and discussion to populations—however
inconsistently de ned—that have either transi-
tioned from one gender to another or who present
with a desire to do so. Much of what is both excit-
ing and challenging to document is the shifting
nature of the population itself; there is currently
no uniform de nition of what it means to be
transgender , partly because the various commu-
nities prefer it this way. Research that purports to
represent a transsexual or transgender group or
population should be critically evaluated for
inclusion and exclusion criteria (surgery, hor-
mones, lifestyle changes, social and legal identi-
ties) before conclusions are drawn from the
results or generalizations are made. Indeed, it is
likely that by the time this chapter goes to press,
another term or set of terms will have emerged,
rendering those employed here irrelevant or even
politically incorrect!
Sexual Orientation and Sexual Behavior
One of the more unfortunate ways that trans peo-
ple are publicly imagined are as objects of erotic
curiosity and grati cation, a subculture organized
around transgressive and fetishistic sexual behav-
iors; this reality is underscored by any Google
search, including images, of the word “transgen-
der.” However, trans identity does not correlate
with any particular primary object(s) of desire.
Rather, a trans identity re ects the gender that a
person feels, lives, and wishes to express, includ-
ing all of its non-sexual aspects. Although ele-
ments of one’s gender are in uenced by one’s
object(s) of desire, gender scholars are careful to
stress that con ations of gender identity and sexual
orientation x, rather than unsettle, heteronor-
mative assumptions about sex and sexuality
(Halberstam 1998 ; Karkazis 2008 ) . Contemporary
attitudes about homosexuality re ect increasingly
tolerant scholarly and social discourses, both of
which include the understanding that same-sex
desire does not inevitably correlate neatly with
dominant de nitions of masculine or feminine. It
is important, therefore, that we disrupt beliefs that
even some trans people might have about why
they are in the wrong body/sex/gender: were a
same-sex attraction the only criteria leading peo-
ple to believe they were trans, we might caution
them to think their desire through more carefully,
stressing the inadequacy of that attraction as the
sole criteria for changing genders. In other
words, in order to most adequately apprehend the
bodily and affective experiences of trans people,
including their varied approaches to change via
surgical, hormonal and behavioral means, we
must de-naturalize many of the habitual assump-
tions made about the relationship between gender
identity and any particular “sexuality.
Carefully separating sexual orientation from
gender identity as well as from physical sex
draws attention to the ways that each of these
domains is socially constructed, or at least informed
294 S.C. Meier and C.M. Labuski
(Bornstein 1994 ; Denny and Green 1996 ;
Diamond
2001 ) . This is a key issue for many
individuals who want to make a socially recog-
nized gender transition that is unrelated to her or
his object(s) of sexual desire; a person assigned
female at birth who transitions to male may have
male, female, trans, all, or no sets of these people
as sexual partners. Moreover, labeling inconsis-
tencies complicate the scienti c literature because
early research frequently used birth-assigned sex
rather than current gender identity as the basis
for assigning a sexual orientation to transsexuals.
For example in one study, FTMs who were
attracted to women were labeled homosexual
and in another, more recent, study, FTMs who
were attracted to men were labeled homosexual
(Bockting et al. 2009 ; Chivers and Bailey 2000 ) .
This presents a problem in discussing research
because sexual orientation labels, which are often
organized around birth sex, are frequently more
complex and nuanced with the transgender popu-
lation, rendering any conclusions about the “sexual
orientation” of any trans person questionable at
best. FTMs who identify as men (and no longer
as trans men) and who are attracted to males may
identify as “homosexual;” whereas male-attracted
FTMs who may be somewhat earlier in the tran-
sition process, or who still identify strongly with
a trans component to their male identity, may
identify as “queer” or as a “tranny fag” (Pardo
2008 ; Valentine 2007 ) .
At least part of this confusion can be attributed
to the fact that the 4th of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-
IV-TR), published in 2000 by the American
Psychiatric Association, classi ed Gender Identity
Disorder (GID) in terms of sexual attractions,
despite a growing body of research to the contrary
(APA 2000 ; Coleman et al. 1993 ; Meier et al.
2013 ; Rachlin 1999 ) . (Much of this research has
been conducted by trans and known trans-ally
researchers, an epistemic shift that should not be
overlooked; we will return to this point below). As
the ultimate arbiter of psychiatric and normalizing
categories, the DSM produces knowledge around
which individuals and groups are encouraged to
conform, and through which many of us come to
understand speci c populations. This authoritative
discourse nds its way into the general population,
leading many trans individuals—and their sexual
partners—to worry unnecessarily about the success
or stability of their transition if they nd their part-
ner choices changing. By making sexual orienta-
tion part of its diagnostic speci cation for GID, the
DSM-IV-TR con ated two elements of experien-
tial identity that both trans activists and gender
scholars endeavor to keep distinct. For these
groups, the more important questions to pursue
involve the ways that sexual orientation and gender
identity intersect not only with each other, but also
with other aspects of identity, including race/
ethnicity, socioeconomic status, and education.
Not only has recent research demonstrated that, at
least for many cis women and trans men, sexual
orientation is far more uid and shifting than pre-
vious studies have reported (Diamond 2008 ; Meier
et al. 2013 ) , but also that the lived experience of a
“gendered sexuality” is far more complex and
varied than criteria-based pro les can adequately
represent.
Further, research attempting to examine the
psychological differences between trans people
who reported differing sexual attractions (to
females, to males, to both, to neither) has pro-
duced mixed results (Lawrence 2010a , b ; Meier
et al. 2013 ; Nuttbrock et al. 2010 ) . The World
Professional Association for Transgender Health,
Inc. (WPATH), formerly the Harry Benjamin
International Gender Dysphoria Association,
issued a response to the proposed DSM-5 GID
replacement disorder Gender Dysphoria (De
Cuypere et al. 2010 ) . The WPATH committee
stated that they supported the removal of sexual
attraction speci ers as Gender Dysphoria crite-
ria, as sexual identity is irrelevant to a distress-
focused disorder. The DSM-5 will be published
in 2013 and its Gender Dysphoria diagnosis will
not have sexual attraction speci ers. It is antici-
pated that clinicians will have to specify whether
the patient is intersex. Unfortunately many of the
non-medically trained clinicians who use the
DSM for diagnostic purposes including psychol-
ogists, therapists, and social workers, may not be
not able to determine this.
It is reasonable and important to note that
trans individuals engage in the same varieties of
29516 The Demographics of the Transgender Population
sexual behaviors as do heterosexual and LGB
(lesbian, gay, bisexual) individuals; this can
include kissing, manual and oral stimulation of
the genitalia, vaginal and anal penetration, frot-
tage, mutual masturbation, phone or cybersex,
watching or performing in sexually explicit
media, BDSM practices, a variety of what are
referred to as “paraphilias,” sex work, partial/
total celibacy, or abstention from sexual activity
all together (Bauer et al.
2012 ; Meier et al.
2010a ) . What might be considered unique about
this population is that its behavior often disrupts
assumptions about the relationship between
genitals and gender. Though many trans men
(FTMs) employ strap-on dildos or other pene-
tration aides, many others do not and, in fact,
many trans men incorporate the penetration and
stimulation of their own vaginas and vulvas into
their sexual behavior (Bauer et al. 2012 ; Meier
et al. 2010a ) . Similarly, many trans women
enjoy penetrating their partner(s) and/or do not
desire vaginal penetration even if they have gone
through surgical “reassignment.” These genital-
gender incongruencies can be confusing to unin-
formed healthcare providers or other
well-meaning individuals, leading to awkward
and embarrassing exchanges or even denied
access to healthcare when, for example, a trans
man presents at a clinic for vaginal discharge or
an abortion.
Baumle et al. ( 2009 ) note that sociology has
typically attended to “sexuality” via the ways that
it interferes with the traditional demographic cat-
egory of fertility; that is, homosexual behavior
and sexually transmitted infections become cate-
gories of analytical interest because of the
effects that they have on reproduction. This
emphasis, they argue, forces us to think about
sexual orientation as a set of behaviors rather than
an identity (3–4). Though we have used the previ-
ous section to “complicate” the stability of such
an identity when it comes to the category trans-
gender, we stress that the remainder of the chapter
takes such a category at (relative) face value. The
following discussions of prevalence, medical and
mental health, family and relationships, discrimi-
nation, and work issues are all grounded in the
real-life experiences of individuals who are seeking
to or have already “transitioned” to the best of
their ability. Though, again, we believe that the
contemporary transgender experience resonates
with Laumann and colleagues’ description of
homosexuality, i.e., as “a multidimensional phe-
nomenon that has manifold meanings and inter-
pretations” ( 1994 : 301), we bracket the open-ended
nature of the category for the remainder of the
chapter in order to offer the most useful and up-
to-date information possible.
Prevalence
In general, we might think about prevalence in
two ways, either as: (a) a snapshot that can answer
questions such as: How visible is a particular
population or identity-based group of individu-
als? How likely are members of a society to
encounter trans individuals in their daily lives or
believe that they are “real,” possibly even a part
of their existing world?; and (b) demographic
prevalence that is driven by statistics on a partic-
ular set of variables in a population.
Snapshot Prevalence
Thomas Beatie made headlines in 2008 when he
was popularly dubbed “the pregnant man.
4
Beatie, a Filipino-American former beauty queen,
posed for photographs, was interviewed by Oprah,
and was featured in a number of print and web-
based media during the months of his pregnancies
providing a particular kind of “face” to the trans
man population. As we have noted, Beatie’s body
breaks with the conventions of a transsexual , but
the combination of his male gender identity and
(procreative) female reproductive organs is con-
sistent with the category of transgender with
which we are working in this chapter.
4 Though perhaps the rst to go public, Beatie was not the
rst trans man to become pregnant. Beatie has since had
his second and third babies and is in the process of divorc-
ing his ex-partner who is a cis woman. See:
http://www.
dailymail.co.uk/femail/article-2197581/Worlds-pregnant-
man-Thomas-Beatie- fi nds-love-prepared-conceive-
FOURTH-time-new-lover-cant.html
296 S.C. Meier and C.M. Labuski
Media stars like Oprah have the power to
rede ne and recontextualize marginal popula-
tions; a televised interview with someone like
Beatie can provide a cultural legitimacy that is
unavailable through (previously) popular dis-
course. The 20/20 production of “My Secret
Self,” featuring Barbara Walters exploring the
lives of transgender children, had a similar effect
in 2007. Sensitively produced, the program reso-
nated throughout much of the trans community
and continues to be used as a resource in public
relations, education, and training efforts. Though
this chapter will not deal extensively with trans-
gender children, it is worth mentioning that there
may be an increasing prevalence of GID among
younger people, including children (Möller et al.
2009 ; Reed et al. 2009 ; Rosin 2008 ; Zucker et al.
2008 ) . Studies of young children nd that parents
report that 0.5 to 1.4% of birth assigned male
children and 0.6 to 2.0% of birth assigned female
children wish to be the other gender (Verhulst
et al. 1997 ; Yu 2009 ). Internationally, between
0.7 to 0.9% of birth assigned male college stu-
dents and 2.2 to 2.9% of birth assigned female
college students report that they wish they were
the other gender (Chi in preparation ; Lai et al.
2010 as cited in Winters and Conway 2011 ).
Zucker et al. ( 2008 ) report that their number of
referrals of children with GID has nearly tripled
from 2000 to 2004. It still remains to be seen,
however, whether that increase is: (a) real; (b)
related to greater social tolerance and visibility;
or (c) causally connected to other biocultural
events (e.g., industrial pollutants and endocrine
disruptors) through which embryological brain
and genital development is being affected.
For reality-TV fans, entertainer RuPaul is the
face of the trans population, and his MTV-
produced show Drag Race has a loyal and diverse
audience (Stanley 2009 ; Wieselman 2010 ) ; for
political a cionados, it is Amanda Simpson, the
Senior Technical Advisor to the Department of
Commerce, and the nation’s rst transgender
presidential appointee.
5 For economists, it is
Deirdre (formerly Donald) McCloskey, an
internationally renowned economist and
University of Illinois professor who published a
memoir about her very public transition in 1999.
6
And for the parents of young children, it is the
availability of a book called 10,000 Dresses
(Ewert
2008 ) , which chronicles a transgender
girl’s struggle to be recognized by her family.
Though much of this media celebrity, along
with the popularity of trans-speci c procedures
on surgical reality shows, might cater to the more
prurient interests of the general public, many
members of the trans population take comfort in
any measure of public recognition that does not
actively advance discriminatory attitudes or
behaviors. Transsexual, transgender, and trans
ally scholars, activists, and researchers have also
begun to take greater control over how the trans
community is represented by conducting and dis-
seminating their own research and media, aided
by the inception of The International Journal of
Transgenderism in 1997.
Our purpose in providing this “snapshot” over-
view is to provide a social and representational
context to the prevalence data in the next section.
Though we do not suggest that there is any par-
ticular correlation between the recent visibility of
the trans population and the numbers that follow,
we do encourage the reader to use both kinds of
data in their own attempts to better understand the
populations under consideration here.
Demographic Prevalence
Dif culties with measuring the trans population
stem from the de nitional dilemmas that we have
discussed thus far. Though numerous researchers
have reported prevalence statistics, they must be
cited with caution because of the inconsistency
with which “transsexual” and “transgender” have
historically been de ned. Prevalence estimates
have traditionally come from gender clinics,
where patients have been: (a) seeking body and
hormonal modi cations not necessarily sought
by all trans-identi fi ed people; (b) compelled to
6 Crossing: A Memoir , University of Chicago Press.
5 Appointed by Barack Obama in January, 2010.
29716 The Demographics of the Transgender Population
identify in a particular way in order to access the
clinic services offered (van Kesteren et al.
1996 ;
Weitze and Osburg
1996 ) . Compounding the sec-
ond problem are the verbal commitments to a
sexual orientation that some of these patients
have had to make in order to either secure ser-
vices or be considered to have transitioned “suc-
cessfully” (Lev
2005 ) . Moreover, the personal
and professional investments made by individual
researchers in de ning this population often play
a signi cant role in their inclusion/exclusion cri-
teria. In other words, because the community
itself remains divided as to the “nature” of a
trans-identity—its relationship to “brain sex,
culturally constructed gender roles, and homo-
sexuality, for example—research conducted
among this population re ects the multiple lenses
through which transgender individuals are under-
stood. Indeed, at least one researcher has sug-
gested that most trans-children are cis and
homosexual, and that behaviors consistent with
GID are the child’s way of “coming out of the
closet” (Zucker et al. 2008 ) .
The prevalence data most frequently cited
come from a gender clinic in the Netherlands
and demonstrate that 1 in 11,000 (.009%) per-
sons are MTF, and 1 in 30,400 (.0032%) are
FTM (van Kesteren et al. 1996 ) . A recent study
from Singapore found 1 in 2,900 (.034%) MTFs
and 1 in 8,300 (.012%) FTMs, while a study in
Belgium found 1 in 12,900 (.0077%) MTFs and
1 in 33,800 (.0029%) FTMs (Winter et al. 2009 ) .
The American Psychiatric Association, using
GID criteria, suggested that MTFs had a 1 in
30,000 (.0077%) prevalence rate, while FTMs
were 1 in 100,000 (.0029%) (APA 2000 ) . In
contrast, another investigator suggests that if
inclusion criteria were broad enough to cover
everyone on the transgender identity spectrum
(e.g., cross dressers with no desire for body
modi cations, intersex persons, genderqueer
persons, masculine females, feminine males,
etc.), we would nd 1 in 2,000 (.05%) people to
be trans (Conway
2002 ) . Finally, researchers
presenting at an annual transgender conference
in 2007 estimated that “recent incidence data
and alternative methods for estimating the prev-
alence of transsexualism [sic] […] indicate that
the lower bound on the prevalence […] is at least
1: 500 [for all combined], and possibly higher.
7
A research brief from the Williams Institute
estimates that there are around 700,000 trans
people in the U.S. (0.3% of the population;
Gates 2011 ). See Table 16.1 for a summary of
prevalence estimates.
Although still signi cantly smaller, the 1 in
500 (0.2%) ratio comes closest to the estimate
provided by the U.S.-based National Transgender
Advocacy Coalition: that 2–3% of the (U.S.)
population is transgender, some of whom overlap
with the lesbian, gay, or bisexual (LGB) popula-
tion and many that do not. This overlap is notable
because it indexes the dif culty in neatly classi-
fying the trans population into categories of sex-
ual orientation—how the person and/or researcher
de nes LGB in the context of a trans identity will
determine the manner in which the prevalence
rate will accordingly shift. In Iran, this articula-
tion is even more intriguing. Though it is cur-
rently illegal to be openly LGB in Iran, it is legal
and, to a degree, socially acceptable to undergo
gender transition. This has led to Iran having one
of the highest known “transgender” prevalence
rates in the world, somewhere between .12 and
.18% of the population (MTF and FTM com-
bined) and it is likely that many of these individu-
als would not identify as trans in other geopolitical
contexts (SAFRA 2009 ) . Based on their review
of trans prevalence literature, Winters and
Conway ( 2011 ) estimate that there are over 15
million trans people in the world.
These prevalence estimates are useful to a
degree as they repeatedly demonstrate that vastly
greater numbers of birth-assigned men appear to
transition to another gender than do birth-
assigned women (with the exception of Poland,
Sweden, Iran and Japan) and that the overall per-
centage of the trans population across geograph-
ical areas is typically less than 1% of the
population. The difference between these small
estimates, however, and those larger estimates
cited by Conway and others, point to the possible
7 http://www.truecolours.org.au/publications/ypwts.html#15 .
Paper presented at the WPATH 20th International
Symposium, Chicago, Illinois, September 5–8, 2007.
298 S.C. Meier and C.M. Labuski
Table 16.1 The prevalence of transsexualism
Country Year reported
Incidence
(per 100,000 age
15 or above) Total MTF FTM MTF:FTM Method Reference
Australia 1981 4.9 1 in 24,000 1 in 150,000 6.1 to 1 Reports from psychiatrists on
transsexual patients seen from
1976-1978
Ross et al. (
1981 )
Belgium 2007 10.7 1 in 12,900 1 in 33,800 2.6 to 1 Reports from plastic surgeons
and gender teams on trans-
sexual patients seen from 1985
to 2003
De Cuypere et al.
( 2007 )
Germany 1996 2.1 1 in 14,400 1 in 33,200 2.3 to 1 Data from German courts
regarding legal name and sex
changes from 1981 to 1990
Weitze and Osburg
( 1996 )
India 2009 167 1 in 600 Not available Not available Community estimate Winter ( 2009 )
Iran 2009 72 1 in 555 1 in 833 1.5 to 1 Community estimates SAFRA ( 2009 )
Iran 2009 45.5 1 in 2,200 to
3,300
Not available Not available Not available Clinic studies Winter ( 2009 )
Iran 2010 8 1 in 13,000 Not available Not available Not available Clinic based data Alizadeh ( 2010 )
Iran 2011 1.4 1 in 141,000 1 in 145,000 1 in 136,000 1 to 1.1 Reports on GID diagnoses from
the Tehran Psychiatric Institute
from 2002 to 2009
Ahmadzad-Asl et al.
( 2011 )
Ireland 1982 1.9 1 in 52,000 1 in 71,400 1 in 214,300 3 to 1 Gender clinic cases of GIDfor
14 years: 21 MTFs and 7 FTMs
Calculated from author’s North
Ireland 1982 population
estimate of 1,500,000
O’Gorman ( 1982 )
Ireland 2006 1.4 1 in 84,400 1 in 542,500 6.4 to 1 Gender clinic cases of GID
from 2000 to 2004: 45 MTFs
and 7 FTMs. Calculated from
Ireland’s 2000 population
estimate in 3,797,257
De Gascun et al.
( 2006 )
Japan (Western) 2008 1.4 1 in 173,913 1 in 114,613 1 to 1.7 Gender clinic cases of GID
from 1997 to 2005: 349 FTMs
230 MTFs. Calculated from the
authors Western Japan
population estimate 40,000,000
Okabe et al. (
2008 )
29916 The Demographics of the Transgender Population
Malaysia 2001 500 (MTF only) Not available 1 in 200 Not available Not available Community estimate Jamaludin ( 2001 )
Malaysia 2009 1,333 1 in 75 to 150 Not available Not available Not available Community estimate Winter ( 2009 )
Netherlands 1993 11.7 1 in 11,900 1 in 30,400 2.6 to 1 Gender clinic cases with gender
dysphoria from 1975 to 1993
Bakker et al. (
1993 )
New Zealand 2008 31.9 1 in 3,639 1 in 22,714 6.2 to 1 Passport data obtained from the
New Zealand Passports Of ce
Veale ( 2008 )
Poland 2000 0.26 1 in
1,692,000
1 in 497,700 1 to 3.4 Gender clinic data obtained
from 1980 to 1998
Dulko and
Imielinskia ( 2004 ) ,
as reported in
Herman-Jeglinska
et al. (
2002 )
Scotland 1999 8.2 1 in 61,000 1 in 15,200 4 to 1 Data from general medical
practices on patients with
gender dysphoria
Wilson et al. (
1999 )
Singapore 1988 35.2 1 in 2,900 1 in 8,300 2.9 to 1 Cases from the Department of
OB/GYN at the National
University of Singapore and
three private surgeons
Tsoi ( 1988 )
Spain
(Andalusia)
2006 16.8 1 in 5,954 1 in 9,685 1 in 15,456 1.9 to 1 Clinic study Esteva et al. (
2006 )
Spain
(Catalonia)
2006 6.83 1 in 14,632 1 in 21,031 1 in 48,096 2.6 to 1 Clinic study Gómez-Gil et al.
(
2006 )
Sweden 1996 0.17 1 in
1,008,400
1 in
1,411,700
1.4 to 1 Data from the Bureau of Social
Welfare les from 1972 to 1992
Landen et al. (
1996 )
Taiwan 2009 97.1 1 in 1,030 Not available Not available Not available Clinic studies Winter ( 2009 )
Thailand 2002 599 (MTF only) Not available 1 in 167 Not available Not available Community estimate Winter ( 2002 )
Thailand 2009 333 1 in 300 Not available Not available Community estimate Winter ( 2009 )
United States
(Massachusetts)
2011 476 1 in 214 Not available Not available Not available Telephone health survey Conron et al. (
2012 )
DSM-IV-TR 2000 4.3 1 in 30,000 1 in 100,000 3.3 to 1 Data from Europe and referrals APA (
2000 )
300 S.C. Meier and C.M. Labuski
limitations of these data and the de nitional
dilemmas discussed earlier. Sample sizes for
these studies are often small, making it dif cult
to generalize the results, and since they typically
come from gender identity clinics, they represent
what many would call the narrowest end of the
trans-identity spectrum (Horton
2008 ) . It has
also been suggested that many of these clinics
have used coercive methods in order to recruit
subjects, compelling hormone or surgery-seek-
ing patients to de ne themselves in terms they
might not otherwise in order to receive services
(Lev 2005 ; Meyerowitz 2004 ) . Indeed, in an eth-
nographic study conducted in New York City in
the 1990s, Valentine ( 2007 ) found that many of
the gender variant individuals that he came to
know only identi ed as “transgender” after they
were labeled as such by a social service or health-
care agency. It is dif cult to know if such meth-
ods contribute to an over-representation of the
population because of padded data or an under-
representation, due to the subsequent avoidance
of clinics by trans folks who learned to obtain
services elsewhere (see section below on “Health
and Healthcare”). There are also anecdotal data
to suggest that many trans persons avoid research/
gender clinics because they are asked to pay for
the psychological assessments that are performed
on them or do not want their transitioning related
data to be used for research studies (Anonymous
transgender patients, personal communication,
2009).
Some trans people who make a medical and
social gender transition choose to not disclose
their history, preferring to be perceived only as
their asserted gender. Indeed, a portion of these
individuals may have never identi ed as trans,
leading them to sometimes be referred to as
stealth (colloquially) or non-disclosing (Green
2004 ) . Though for some, a stealth identity might
be asserted as “I’m (just) a woman, not a trans
woman,” it might be more accurate to say that
there are levels of disclosure—from people that
completely disavow their past to people who sim-
ply do not make it public.
It is easy to see that numerous trans people are
ying under the proverbial radar. One group that
“avoids” gender clinics, and may therefore not be
counted, are people without the nancial
resources to access body modi cation, psycho-
therapy, or the social programs through which
many transgender people are located and
quanti ed. Some of these people will pursue sur-
gery and/or hormones in another country, online,
or through an informal market, and through these
channels may occasionally nd their way to a
researcher. But just as many will af rm their
gender within quite limited means (e.g. shaving
instead of waxing or electrolysis for the removal
of body hair), a situation that may make it easier
for them to “pass” in and out of a trans-identity
when and if necessary (Valentine 2007 ) . These
sometimes invisible members of the trans com-
munity are one more reason why clinic-based
prevalence estimates should be understood as
limited underestimates. Moreover, the tenacious
relationship between socioeconomic status (SES)
and race/ethnicity means that the majority of
transgender persons securing more permanent
(and aesthetically acceptable) forms of body
modi cation are white/Caucasian, leaving trans
people of color and of limited economic means
less visible to demographers but perhaps more
visible to a public that easily perceives an incon-
gruence. In an all-too-familiar vein, trans people
of color often show up in data focused on HIV,
substance abuse, sex work, and other risk factors
associated with lower SES. Some researchers
have critiqued this (often) uncritical pooling of
“risk” factors (Boehmer 2002 ; Valentine 2007 ) ,
as it is typically more connected to structural
inequality than to any sex or gender-based iden-
tity. Clearly, much work remains to be done in
nding methods that can most adequately repre-
sent the complexity of this population (Mikalson
et al.
2012 ), as “our lack of knowledge about how
to identify transgender respondents on general
population surveys hinders efforts to improve
the health and socioeconomic status of this mar-
ginalized community” (SMART
2009 , p. iv).
The regularity with which trans women out-
number trans men in these estimates remains
a compelling pattern, and one that remains
insuf ciently explained. One set of theories
suggests that birth-assigned females transition
less because there is greater social room in
30116 The Demographics of the Transgender Population
which they can maneuver with more masculine
behavior (e.g. clothing, occupation). Even these
categories have their limits, however, and trans
men have been increasingly articulate about
both the dif culties and the rewards of making
bodily changes that more fully secure their
positions as men (Schilt and Connell
2007 ;
Valentine 2007 ) . Valentine has argued that this
non-transitioning space in which “masculine”
and other women navigate is unavailable to men
and that this may partially explain why more
birth-assigned men make the bodily commit-
ment to af rming their female identities. In
other words, Valentine suggests that there is no
socially acceptable equivalent to the butch
straight woman for men who wish to live a fem-
inine identity that does not correlate with an
LGB one. He concludes that gender “reassign-
ment” may be the only way for men to gain
access to this space. Confounding these more
speculative theories, however, are compelling
data from Poland that demonstrate a signi cantly
higher rate of FTMs than MTFs (Herman-
Jeglinska et al. 2002 ; Levy et al. 2003 ) than do
data from the Netherlands and other reporting
countries. And though explanatory models
remain scarce, some researchers have long
questioned MTF/FTM disparities and nd the
Polish data neither new nor surprising (Herman-
Jeglinska et al. 2002 ; Hoenig and Kenna 1974 ) .
In fact, many researchers and clinicians believe
that FTMs are more likely to “go under the
radar,” even from researchers, and therefore
have been routinely underestimated in preva-
lence data (Green J, Meyer M, Schilt K, 2008–
2010, personal communication).
Importantly, when trans researchers start mea-
suring members of their own population, larger
sample sizes are typically collected. Samples of
trans people in research conducted by cis
researchers have historically ranged from 1 to
100 (Van Borsel et al. 2000 ; Chivers and Bailey
2000 ; Cohen et al. 1997 ; Lothstein 1984 ) , yet
recent research by trans researchers produce data
sets from 200 to over 1,000 (Davis and Meier,
submitted; Dickey 2007, 2010 ; Meier et al.
2010a , 2013 ; Veale et al. 2008 ) . Trans researchers
tend to be more aware of the community’s needs
and potentially offensive language than even
well-meaning cis researchers. Participants in the
trans author’s (of this chapter) thesis and disser-
tation research have consistently expressed relief
that the study in which they are participating is
being conducted by “one of us.” Trans partici-
pants also have far less to lose when disclosing
atypical gender-related desires if the research is
not being conducted within the context of a gen-
der clinic; this may lead to the collection of more
accurate information. Lastly, because the trans
community has a strong Internet presence, they
are well connected and can refer many other trans
people to studies that they deem “sensitive” and
“worthwhile,” whereas they may also warn oth-
ers not to participate in studies not considered
“safe.”
Prevalence in the DSM-IV-TR Gender
Identity Disorder (now Gender
Dysphoria) and Children
The DSM presents yet another de nitional chal-
lenge to establishing prevalence. One major con-
cern that arises from the lack of a standardized
de nition for the term transgender is whether
and how to include children and adolescents in
this category. Because GID is the most measur-
able and longest running set of criteria related to
being trans, there has been a signi cant degree of
con ation between gender dysphoria and the cat-
egory of transgender when these individuals are
being assessed and evaluated. While a GID diag-
nosis exists for children and adolescents, experts
have noted that many of those who meet the cri-
teria for GID in childhood grow up to identify as
LGB and not transgender (Wallien and Cohen-
Kettenis 2008 ; Zucker et al. 2008 ) . Further, many
transgender people report that they were not
aware of their transgender identity until adult-
hood or that they hid their gender non-conform-
ing expressions and behavior from others due to
shame and would not have met criteria for GID
in childhood (Seil 2004 ). As such, using the cri-
teria for GID in childhood for prevalence esti-
mation of transgender children and adults is
clearly limited.
302 S.C. Meier and C.M. Labuski
The DSM is used to help researchers calculate
the prevalence of mental disorders and it contin-
ues to carry a great deal of authority for research-
ers, clinicians, and insurance providers; this
presents a major problem for many both in and
outside of the transgender community who do
not view a gender identity that is incongruent
with one’s birth-assigned sex as inherently disor-
dered. Largely for this reason, the DSM has
recently revised both the criteria and the nomen-
clature for GID and it will be re-named Gender
Dysphoria.
8
Currently, there are two leading schools of
thought concerning how trans children should
best be approached: (1) Ehrensaft’s acceptance—
based on Brill and Pepper’s ideas of uncondi-
tional love and Ryan’s model of Family
Acceptance, this approach involves helping the
child to be comfortable in his or her asserted gen-
der identity (Brill and Pepper 2008 ; Ehrensaft
2011 ; Ryan et al. 2008 ) ; (2) change—based on
Zucker’s research, this involves attempting to
change the gender non-conforming expression,
roles, and preferences of the child (Dreger 2008 ;
Rosin 2008 ) . Supporters of the latter approach
caution about the dif culty and cost of a trans-
gender identity, arguing that being LGB is prefer-
able.
9 In a study with children labeled as
transgender, Wallien and Cohen-Kettenis ( 2008 )
found that the most common outcome of this
childhood pattern is an LGB non-transgender
identity.
Though the “disordered” language of the DSM
has long been a target of criticism, some of it has
been assuaged by the nomenclature and criteria-
based revisions underway. For some, however,
Gender Dysphoria continues to index a malady or
discordance that the phrase “normal expression
of gender variance” does not. Others have a cat-
egorical critique, and are concerned about GID’s
inclusion in a section (Sexual and Gender Identity
Disorders) that includes pedophilia and other
“paraphilias” such as voyeurism and fetishism.
Gender Dysphoria is set to be placed in its own
section in DSM-5. Further, many of the current
criteria for children are written with what seem to
be narrow interpretations of behavioral patterns.
The pathologization of boys who avoid “rough
and tumble play,” for example, indexes a set of
culturally-speci c gendered stereotypes through
which all kinds of “gendered” behavior can be
misunderstood. Some critics, and not just trans-
gender ones, go even farther and argue that the
DSM cannot adequately represent mental or
emotional disorders from the narrow perspective
of the U.S., as it remains unclear whether the
dif culties related to GID are intrinsic to persons
with GID or whether they are the outcomes of
feeling discriminated against, socially rejected,
or stigmatization (APA 2009 ; Winters 2009 ) .
Some see a DSM diagnosis as a possible path to
legitimacy, awareness, protection in discrimina-
tion lawsuits, and greater insurance coverage, but
this has been questioned as countries that now
cover gender af rmation treatment often only do
so if the patient agrees to a “full” complement of
therapies (chest and genital surgery, hormones
etc). The revisions to the GID diagnosis will be
published in DSM-5 and will affect prevalence
calculations for at least the next 10 years. Though
it is too early to tell, with both U.S. healthcare
reform and DSM revisions in the coming decade,
it is possible that the relationship to a childhood or
adult diagnosis of GID—and the prevalence rates
derived from it—will look vastly different than
they do now.
Social Complications and Context
There are multiple layers of social complications
that make prevalence estimates challenging.
Demographers attempting to count the number of
people who legally change their gender should be
aware of the procedures and barriers involved in
this process. Those who are attempting to separate
LGB and T persons for prevalence estimates may
not realize the political rami cations of such a
separation or the fact that many trans people iden-
tify with an LGB sexual orientation. Also, any
prevalence estimate of this population must take
8 The latest DSM will be its 5th revision, and a new name
for gender dysphoria will constitute the “condition’s” 3rd
revision. It is worth noting here that homosexuality was a
DSM-certi ed disorder until 1973 (Drescher
2009 ) .
9 J Cantor, 2009, personal communication.
30316 The Demographics of the Transgender Population
into account the overwhelming rates of suicide
among, and hate crimes against, trans people. We
compile these complications here as a guide toward
generating better estimates that are urgently needed
in order to inform the policies and regulations that
aid trans people in accessing medical, legal, and
social recognition and services.
One way researchers are attempting to calcu-
late the prevalence of trans people is by counting
the number of people who have had their gender
changed legally on identi cation documents
(Bauer
2012 ; Veale 2008 ) . Currently, the proce-
dures through which an individual can legally
change his or her name or gender vary widely,
both within the U.S. and across other countries. In
some U.S. states, individuals can simply check a
box on a form in the Department of Public Safety,
while other states require the individual to pay
hundreds of dollars, stand before a judge, and pres-
ent a psychological evaluation report or physi-
cian’s letter endorsing their suitability for name/
gender change (Transsexual Road Map 2010 ) .
Still other states do not allow one’s gender to be
legally changed without having undergone a
speci ed complement of gender af rmation treat-
ment, including chest and genital surgery. Further,
a few jurisdictions simply refuse to recognize a
gender change on a birth certi cate, regardless of
social or medical transitions. Demographers
should also take note that once a trans person
obtains a legal gender change on identi cation
documents, they may be less likely to indicate that
they are transgender on surveys, as they are socially
recognized as their gender identity and may not
wish to disclose their trans history. This may also
be the case for those trans people (regardless of
legal gender status) who do not identify their gen-
der to be “transgender,” but rather male or female.
Name change is an issue that relates directly
to legal identi cation documents (passport, driv-
er’s license, birth certi cate, social security card),
all of which need to be congruent in a variety of
situations, such as acquiring a bank loan, receiv-
ing one’s inheritance, working for particular
institutions, or receiving federal subsidies for
education or housing. Gender change, while
related to these issues, can also lead to charges of
fraud. Numerous trans persons have had inheri-
tances challenged by the children of a deceased
spouse who argue that their parent was the victim
of gender fraud (Bratter and Schilt 2009 ; Flynn
2001 ) . To date, these cases are typically handled
on a case by case basis, and no widespread legal
precedent currently exists to protect trans indi-
viduals from these types of suspicion and exclu-
sion. Finally, trans men may not attempt to obtain
a gender marker correction to ‘M’ on their drivers
license, as once they are legally recognized as
male, they are commonly denied insurance claims
for hysterectomies, pregnancy, and/or govern-
ment funded student loans, as most have never
applied for the draft. These complications, cou-
pled with the fact that some trans people will
never attempt to legally change their name and/or
gender, complicate this method of prevalence
estimation.
For some lawyers and legal scholars, trans
issues are a unique opportunity to rede ne and
reconceptualize categories of personhood, rights
and privileges. Some advocate for trans issues to
be conceptualized within a framework of human
rights, while others de ne the trans legal experi-
ence in terms of discrimination (Flynn
2001 ) .
Different legal conceptualizations of trans people
have implications for prevalence calculations
(e.g. should we estimate the number of LGBT
people or LGB and T people?). Trans activists
and the trans community itself are also multiply
positioned, with some preferring to identify
within the identity-based umbrella of “LGBT,
and others who feel that, because a trans identity
is not organized around sexual orientation, the
“LGB” movement has little to offer in the way of
political protection or advocacy and sometimes
trans people even face trans-negativity within the
LGB community (Currah et al. 2006 ) . Indeed,
this divide was brought into clear focus when the
gay and lesbian-focused Human Rights Campaign
(HRC) elected to exclude “trans” from their list
of identities deserving of special protection
against employment-based discrimination.
10
10 See especially Valentine ( 2007 ) for an excellent history
of this episode. Though beyond the scope of the chapter, it
is worth noting that some of the discourse surrounding
this decision was related to the (formal) LGB political
community’s desire to appear to be as “normal” as possi-
ble, a move that some argue sacri ced allegiance with the
trans community for mainstream social acceptability.
304 S.C. Meier and C.M. Labuski
Another complexity concerning estimating
the prevalence of the trans population is the
incredibly high rates of suicide and homicide
(See section below on “Population Health:
Mental Health” for a more in-depth discussion
of suicide and Table
16.5 for rates). Recent
research has demonstrated that LGB youth and
adults may be at signi cantly higher risk for sui-
cide attempts than their heterosexual peers
(King et al. 2008 ; Marshall et al. 2008 ) , yet
research on the prevalence of these problems
within trans populations is rare. As many as
16–45% of trans individuals have attempted sui-
cide (Bockting et al. 2005 ; Clements-Nolle et al.
2006 ; Grossman and D’Augelli 2007 ; Kenagy
2005 ; Meier et al. 2011 ; Xavier et al. 2005 ) ; it is
unknown how many more have been successful.
Lobato and colleagues ( 2002 ) found that, com-
pared to heterosexual and gay cis individuals,
trans individuals had higher rates of completed
suicide attempts than any other group except for
lesbians (Lobato et al. 2002 ) .
Homicidal and non-fatal hate crimes also
occur at high rates in the trans population
(Marzullo and Libman 2009 ) . An expert af fi liated
with the Harvey Milk Institute in San Francisco
estimates that “transgender individuals living in
America today have a 1 in 12 chance of being
murdered.” (Brown 1999 ) . In contrast, the aver-
age person has about a 1 in 20,000 chance of
being murdered (FBI 2009 ) . 11 Taken together,
this implies that trans people may be more than
one and a half thousand times more likely to be
murdered than cis people, a startling statistic that
has obvious implications for attempting to quan-
tify the trans population. From November 2011
to November 2012, the murders of over 265 trans
people were reported, over 100 of them were
trans women who were living in Brazil (TGEU
2013 ). As trans people are dying at higher than
average rates due to suicide or homicide, overall
prevalence numbers are thought to be a gross
underestimate of the true prevalence.
Population Health Issues
For all the reasons outlined thus far, it has been
challenging to collect data regarding trans-
speci c health care problems: representational
categories dealing with this population have
shifted, many trans people have been reluctant to
participate in research, and there remains little to
no consensus on the “biological” nature of a trans
identity. What does exist, however, are a set of
health problems related to transitioning itself, as
well as a set of concerns among this population
regarding access to affordable and adequate
health care. This section will focus on the types
of problems for which trans people most often
seek trans-speci c care (e.g., hormones, surgery),
how clinicians can provide the most effective and
the least discriminatory care possible (primary or
specialized), as well as the vulnerabilities experi-
enced by trans people whose access to health
insurance is limited or compromised. Each of
these variables can impact the health of the popu-
lation as a whole.
An unfortunate number of healthcare providers
have declined to provide care—comprehensive
or episodic—to the trans population for reasons
related to personal prejudice (Grant et al. 2010 ;
Transgender Law Center 2004 ; Lambda Legal
2010 ) . The National Transgender Discrimination
Survey report on health and health care of over
7,000 trans respondents reported that 19%
reported being refused care, 28% were harrassed
in medical settings, and 50% reported having to
teach their provider about trans care (Grant et al.
2010 ). An even greater number, many of whom
deny any such feelings, remain uneducated
(Obedin-Maliver et al.
2011 ) about trans-speci fi c
healthcare needs, arguing that either: (a) the rela-
tively small size of the population precludes the
likelihood that they will see trans patients in their
practice; and/or (b) there are no special needs
about which to learn. For the authors of this chap-
ter, neither of these explanations is an acceptable
alternative to keeping a medical practice open
and referring (as appropriate) patients that go
beyond a practitioner’s level of expertise. Indeed, it
11 Based on the FBI’s “Uniform Crimes Reports, Crime in
the United States 2000,” showing the murder rate of 5.5
people per 100,000.
30516 The Demographics of the Transgender Population
is possible and even likely in some cities that
healthcare providers have attended to non-disclosing
trans patients in their practice who chose not to
return because of unfriendly practices or attitudes
and sometimes feeling burdened to educate their
providers. Not only does this poor communica-
tion further complicate prevalence estimates, it
can also perpetuate clinicians’ skewed beliefs
about the actual size of the trans population, and
the likelihood that they will encounter a trans
person in their practice. Additionally, since the
clinical needs of the trans population vary
widely—from basic and preventive screenings
and services, to the monitoring of hormone regi-
mens, to surgery-speci c follow-up care—it is
unlikely that even an uneducated provider will
have nothing to offer a trans patient.
12
The LGBT community has produced a num-
ber of excellent documents and guidelines meant
to educate and train providers, many of which
include speci c suggestions about training staff,
of ce logistics (e.g., forms, bathrooms), basic
Table 16.2 Trans healthcare resources
Organization/Author Resource/Title Website/Publisher
World Professional Association for
Transgender Health (WPATH)
Standards of care
http://www.wpath.org
Vancouver Coastal Health Guidelines for transgender care
http://transhealth.vch.ca/resources/
careguidelines.html
Vancouver Coastal Health Clinical protocol guidelines for
transgender care
http://transhealth.vch.ca/resources/
careguidelines.html
The Endocrine Society Clinical practice guideline
http://jcem.endojournals.org/cgi/content/
full/94/9/3132
Fenway Health Bibliography and resources
http://www.fenwayhealth.org/site/
PageServer?pagename+FCHC_srv_
services_trans_bibliography
Tom Waddell Health Center
(San Francisco Department
of Public Health)
Protocols for hormonal reassign-
ment of gender
http://www.sfdph.org/dph/ fi les/reports/
default.asp
University of California at San
Francisco (UCSF), Center of
Excellence for Transgender Health
Primary Care Protocol
http://transhealth.ucsf.edu/trans?page=
protocol-00-00
American Medical Students
Association (AMSA)
Transgender health resources
(includes guidelines from:
WPATH, The Tom Waddell Center,
The Endocrine Society, Vancouver
Coastal Health, UCSF, Fenway
Health)
http://www.amsa.org/AMSA/
Homepage/About/Committees/
GenderandSexuality?TransHlth.aspx
W.O. Bockting and J.M. Goldberg Guidelines for transgender care The Haworth Press, 2006
H.J. Makadon, K.H. Mayer,
J. Potter, Hilary Goldhammer
Fenway guide to lesbian, gay,
bisexual, and transgender health
American College of Physicians Press,
2007
G.E. Israel and D.E. Tarver II Transgender care: recommended
guidelines, practical information,
and personal accounts
Temple University Press, 1998
J. Olson, C. Forbes, and M. Belzer Management of the transgender
adolescent
http://archpedi.jamanetwork.com/article.
aspx?articleid=384321
1 2 Indeed, two recent developments regarding U.S. mili-
tary veterans demonstrate the degree to which trans con-
cerns have entered the “mainstream” of health care: the
Department of Veterans Affairs’ decision to cover the cost
of transition-related counseling and hormones for eligible
veterans (Department of Veterans Affairs
2011 ), and
research nding the rate of trans veterans is higher than
the general public (Shipherd et al.
2012 ).
306 S.C. Meier and C.M. Labuski
trans-speci c medicine (types of surgery, risks of
hormone therapy), and acceptable standards of
care. We strongly recommend these guidelines,
available in Table
16.2 , as we have found that
materials produced outside of the trans commu-
nity, even when well-intentioned, sometimes
sacri ce sound clinical information for a focus
on the exotic and curious aspects of the popula-
tion. Too often, these texts feature a number of
photographs of surgically-altered genitalia but
neglects to inform the reader about the medical
bene ts, risks, and/or follow-up related to that
same surgery.
The 2001 documentary Southern Comfort
chronicles the story of Robert Eads, a trans man
who died from ovarian cancer in 1999.
13 Eads
identi ed as a man, but had never pursued genital
surgery after he underwent chest reconstruction;
in other words, he was a man with the internal
reproductive organs of a woman. Eads bore two
children with an ex-husband (both were uncom-
plicated pregnancies and deliveries), but stopped
receiving routine gynecological care after he
transitioned. Though annual exams may not have
prevented his cancer, early detection and treat-
ment may well have reduced the major morbidity
and mortality that he subsequently suffered. Due
to a combination of some of the factors that we
have raised thus far—e.g., a lack of trust in and
comfort with providers, a lack of education on
the part of his provider(s), and the virtual non-
existence of trans-speci c screening programs—
Eads’ cancer remained unmanaged until it had
progressed signi cantly. Even when Eads became
aware of his cancer, his search for a provider that
was willing and able to manage it was virtually
fruitless.
14 Southern Comfort chronicles his
eventual death over a period of less than a year
and documents added barriers to care faced by
trans individuals in rural communities.
Though extreme and particularly poignant,
Eads’ story is far from unique. Rather, it indexes
the dif culty that trans patients and bodies pose
to the healthcare community: an incongruence
between the gender through which they present
and live (including to providers) and the “repro-
ductive” anatomy that their bodies may contain.
In short, the fact that many trans men have uteri,
cervixes, vaginas, and possibly breasts and that
many trans women have prostates, testicles, and
penises challenges the sex-speci c assumptions
upon which much healthcare is based. Medical
schools have not taught students how to care for
a pregnant man, nor how to manage the benign
prostatic hypertrophy of a woman; they are even
less prepared to offer guidance about how such
treatment would be coded and covered by health
insurance.
For some trans persons, the preservation of
internal/external reproductive organs or second-
ary sex characteristics is related to a direct chal-
lenge to the gender binary; for others, it is related
to a lack of access to the healthcare and resources
required to secure such physical changes. For a
sizeable, and perhaps increasing minority, it is
about preserving the genitalia and body parts
through which one derives (sexual) pleasure and/
or through which one might procreate; and for still
others, it is about submitting one’s body to as little
surgical intervention as possible (Meier et al. 2010a ) .
Regardless of the reasons, the trans population is
diverse, which provides challenges to clinicians’
assumptions regarding the prevalence of the pop-
ulation, as well as whether and how they could
provide care to these individuals.
While at least a minimum amount of training
about the trans population for students and clini-
cians would be ideal (Bradford et al. 2012 ), this
is a group of patients whose bodies disrupt the
sex/gender binary in which most of U.S. culture
is grounded. Clinicians do not fall outside of
these assumptions and, in fact, carry tremendous
cultural authority regarding the ways that all of
us understand the categories of male and female
(Karkazis 2008 ) . For this reason, this chapter is
not intended to chastise cis clinicians or readers
13 Information about Eads sometimes reports his cancer as
ovarian and sometimes as cervical; it is unclear which was
the primary cancer and if the other was a metastasis but
regardless of which, the issues that his story raises (e.g.
appropriately targeted screening and prevention efforts)
remain the same.
14 In the lm, Eads movingly describes the dif culties that
several physicians and their staff had with accommodat-
ing him as a patient; he was told, among other things, that
other patients (in the waiting room) would be offended or
made uncomfortable.
30716 The Demographics of the Transgender Population
for whom this population may pose a fair to
signi cant amount of cognitive or affective dis-
sonance. Rather, we review some of the barriers
in access to healthcare for the trans population in
order to provide an opportunity to consider ways
in which the health concerns of this population
can be more effectively addressed. With that goal
in mind, we review ve major components to
providing care for this population, and then pro-
vide a discussion of insurance data and concerns
for the trans population.
Health Care
Body Parts
Appropriate screening and clinical management
of the trans population requires that clinicians
shift their understanding of male and female
bodies. In the way that HIV taught many of us
to think about risky behaviors versus risky cat-
egories , we need to think similarly about body
parts in need of screening or intervention rather
than sexed bodies themselves. Only in this way
can stories like Robert Eads’ be avoided.
Beginning with patient forms that allow a trans-
gender person to identify themselves outside of
a box marked “male” or “female, clinicians
can learn to ask patients (particularly those who
feel comfortable enough to come out as trans)
about which types of body modi cations (if
any) they have pursued thus far, in addition to
inquiring about which might be planned or
desired. Open-ended questions that allow the
patient to describe the extent of their bodily
transitioning will provide the clinician with
the most accurate information regarding the
optimum medical management of the patient.
When this is not done, men who need mammo-
grams or a Gardasil vaccine and women who
need prostate-speci c antigen (PSA) bloodtests
will be ignored and preventable disease condi-
tions will likely go undetected.
Whether and to what extent such procedures
will be covered by insurance or federal or state-
sponsored healthcare subsidies is an entirely dif-
ferent set of questions. Because federal healthcare
reform was passed as this chapter was being
written, it is impossible to delineate the effects
that new regulations will have on the trans popu-
lation. However, we can say that clinicians who
are increasingly willing to provide these services
in an unbiased manner will likely contribute to
greater overall access and acceptance. Insurers
often take their cues from clinicians and will
likely respond to a market that demands and
requests services. With President Obama’s appoint-
ment of a trans woman to work in the federal
Department of Commerce, many in the trans
community are hopeful that insurance regula-
tions will be written with a sensitivity to some of
these issues.
Hormones
Regardless of surgical alteration, many trans peo-
ple use some kind of exogenous hormones as part
of their gender af rmation treatment, each of
which entails particular risks and health conse-
quences. Just as we stressed in the last section,
clinicians should evaluate the hormones in com-
bination with the particular body/body parts of
the patient: since exogenous estrogen has been
correlated with both uterine and breast cancers as
well as with strokes and other thrombotic events,
it is important that clinicians sort through the
potential risks that are speci c to each patient’s
hormonal and clinical pro le. Notably our pres-
ent discussion is limited to the use of hormones
in adults, and will not include the use of hormone
blockers in trans teens hoping to offset the physi-
cal and physiological changes associated with
puberty and with the advantage of being “revers-
ible” if one should wish to discontinue if discom-
fort ensued. Though data collected thus far have
shown the practice to be safe and effective in
alleviating gender dysphoria, it remains a highly
controversial topic.
15
Because peri-and post-menopausal women
have been using exogenous estrogen as a part of
their Hormone Replacement Therapy (HRT) for
some time, many of its risks and bene ts have been
15 Interested readers are encouraged to consult: Cohen-
Kettenis and van Goozen (
1998 ), Delemarre-van de Waal
and Cohen-Kettenis (
2006 ) , Olson et al. ( 2011 ) and Rosin
( 2008 ) for further discussion of the hormonal suppression
treatment of trans children and adolescents.
308 S.C. Meier and C.M. Labuski
well researched and delineated; we can therefore
draw some conclusions about the use of estrogen
therapy by trans women. Like (peri)menopausal
women, trans women using exogenous estrogen
will carry an increased risk for particular problems
and side effects, all of which should be thoroughly
discussed with the prescribing or managing pro-
vider. And also like these women, trans women
must weigh these risks against the bene ts that,
though distinct, make a material and daily differ-
ence in their bodily experience.
In general, estrogen use is associated with the
following side effects: a redistribution of fat to the
hips and breasts; an (eventually) lessened produc-
tion of body hair, and slowed loss of scalp hair;
and a likely decrease in spontaneous penile erec-
tions. Estrogens have also been shown to increase
bone density. In addition to these (mostly) desired
effects, hormones can lead to other effects that
can be problematic if not managed properly.
Estrogens can increase the risk of uterine and
breast cancers, and can lead to an increased inci-
dence of thrombosis, strokes, and other cardiovas-
cular events (Asscheman et al.
1989 ; Levy et al.
2003 ; Moore et al. 2003 ) . However, the long-term
effects of exogenous estrogen in birth assigned
males have yet to be delineated (Gooren 2005 ;
Gooren et al. 2007 ; Moore et al. 2003 ) .
For trans men, androgens can carry the fol-
lowing side effects: a redistribution of body hair
(to the face, chest and limbs); a deepening of the
voice; an emptying of fat from the breasts
16 and a
thickening of the waist; and an increase in the size
of the clitoris. There is also some data to suggest
that spatial sensibilities will be improved (van
Goozen et al. 1995 ) , and both men and women
have been shown to have increased libido with
the use of exogenous testosterone. Though regu-
lar use will likely lead to a cessation of menstrua-
tion in two to six months after initiation (WPATH,
2011 ; Olson et al. 2011 ), the overall effects of
testosterone on the female reproductive organs
are less clear. Some researchers assert that there
is little to no effect; others argue that because tes-
tosterone is aromatized to estrogen in the body,
there is a theoretical increased risk of breast and
uterine cancers (Baba et al.
2006 ; Mueller et al.
2008 ) . In a recent study of 134 FTM’s, Rachlin
and colleagues found that a signi cant number of
trans men undergo hysterectomy and/or oophorec-
tomy due to concerns about the effects of testos-
terone on female reproductive organs, though
their review of the data found no evidence that
these concerns were substantiated. What they did
nd, however, was that though trans men are
advised to decrease their levels of exogenous
testosterone after these surgeries, a reasonable
majority do not (Rachlin et al. 2010 ) . A recent
article in the International Journal of
Transgenderism speculates about the still-
unknown impacts of testosterone on the quality
and/or production of eggs in trans men (van
Trotsenburg 2010 ) . Though individuals like
Thomas Beatie have demonstrated that trans men
can indeed conceive and bear children using their
still-intact “female” reproductive organs, it is too
early to determine whether long-term use of tes-
tosterone will complicate or mitigate this possi-
bility for the larger population of trans men.
There is also speculation about the psychological
side effects associated with the use of both exog-
enous testosterone and estrogens (Gorton et al.
2005 ) ; it is dif cult, however, to disentangle
psychological side effects of hormonal therapy
from the psychological issues that often accom-
pany transitions at all stages.
Finally, many trans people take hormones
without a prescription (Gooren 2005 ; Moore
et al.
2003 ) , usually because it is either more
affordable or is more geographically accessible.
Clinicians must take care not to pass judgment on
these individuals but rather inquire about the
patient’s reasoning and seek to establish a system
of monitoring if the patient cannot participate in
a more clinically supervised regimen. Buying
hormones over the internet is common, but this
situation is not unique to trans patients—the pur-
chase of less expensive pharmaceuticals for
depression, hypertension, contraception, and a
16 For the vast majority of trans men, this will not satisfy
their desire (if they have it) to remove their breasts.
Testosterone cannot eradicate breast tissue; only a mastec-
tomy can do that. Some trans men may lose enough mass
with testosterone that binding can be enough for them,
however.
30916 The Demographics of the Transgender Population
host of other conditions has become quite
commonplace in the rst decade of the twenty-
rst century. Clinicians should explain the risks
of side effects and inquire as to whether s/he
wishes to be routinely monitored and have their
risks clinically managed (e.g., with appropriate
screening and early detection methods).
Research on hormone use is likely to yield
continued surprises, including that the use of
hormones may enable smoother transitions for
some trans people. For example, for the sub-
population of trans individuals who choose to go
“stealth,” (i.e., not disclose their transgender
status), many in the trans population believe that
the constant need to “hide” their identity can
provoke signi cant amounts of anxiety. This has
recently been challenged, however, by preliminary
data from Meier and Hughes (
2010 ) , who found
that individuals who consider themselves stealth
reported higher levels of quality of life than their
more open counterparts, a nding that was medi-
ated by testosterone use. This may indicate that
testosterone use contributes to higher quality of
life, regardless of stealth status. Indeed, this
research suggests that, on average, these people
were extremely well-adjusted.
As with other clinical regimens, the Endocrine
Society has published standards that clinicians
can use for guidance (Hembree et al. 2009 ;
Bockting and Goldberg 2006 ; Feldman and
Goldberg 2006 ; Gorton et al. 2005 ; Leli and
Drescher 2004 ; Lombardi 2001 ; Nesteby, n.d. ) .
Gender Identity Does Not Equal
Sexual Orientation
It is important for clinicians to understand this
fact (Diamond 2002 ) . As we reviewed in our
rst section, there is little to no consistent
data regarding the sexual orientation of this
population; indeed, data collected by the trans-
gender community is beginning to demonstrate
that transgender individuals are as sexually
diverse as any other demographic “group” (Meier
et al.
2013 ) . As with any other patient popula-
tion or individual, clinicians must continually
work to undo the assumptions that they have
about what kinds of sexual behavior and partners
these patients are likely to have.
Gender Af fi rmation Treatment (GAT)
There are many trans individuals who will pursue
what might be thought of as a “traditional” course
of treatment, i.e. one through which they desire to
transition from one clearly de ned sex/gender to
the other (as opposed to an other). For trans
women, this may include: breast augmentation,
penectomy and orchiectomy, vaginoplasty with
or without labiaplasty, and daily/maintenance use
of exogenous estrogen. Supplemental therapies
may include facial feminization procedures,
chondrolaryngoplasty (tracheal shaving), voice
retraining, and hair removal procedures (electrol-
ysis, waxing). For some trans men, a “complete”
transition may include mastectomy (possibly
with nipple repositioning), hysterectomy and
salpingo-oophorectomy, androgen/testosterone
supplemental maintenance, phalloplasty or
metoidioplasty with urethral extension, vaginec-
tomy, and scrotoplasty.
It is important that physicians are aware of
which aspects of gender af rmation treatment
(GAT) are and are not reversible; surgical
alteration is obviously irreversible, although
depending on the patient’s resources, additional
procedures can be performed to restore or
recon gure bodily changes. Hormonal effects
vary—most of the effects of both estrogens and
androgens are eventually reversible, although
the effects of testosterone are less reversible
than estrogen. For example, changes that tes-
tosterone induces to the skeletal structure
including the jaw and pelvis, the voice, male-
pattern baldness, additional body and facial
hair, and clitoral growth are not thought to be
reversible (Dahl et al. 2006 ; Gorton et al. 2005 ;
Meyer et al. 2001 ) . In the event that patients
were concerned about reversibility, it would be
important for a primary care clinician to care-
fully assess their reasons why, and to refer them
to a trans-specialist psychotherapist whether
these concerns are raised before or after treat-
ment. It is possible that a patient might seek out
GAT for reasons other than a “true” transgender
identity, e.g., a belief that if one has a homo-
erotic sensibility, then one must need to make
one’s sex/gender somehow congruent. It is also
possible that other forms of mental illness/
310 S.C. Meier and C.M. Labuski
pathology (e.g. schizophrenia) might manifest
as a desire to change sex or gender (Cohen-
Kettenis and Gooren 1999 ; Mizock and Fleming
2011 ) for this reason, major concerns about
reversibility should be carefully assessed and
properly referred in order to provide the best
care for the individual in question.
17
In summary, treating a transgender patient
requires a reorientation in clinical and personal
assumptions about sex and gender; it is vital that
clinicians unseat as many of their own as they
can in order to best care for this population.
Questions such as “What is your gender iden-
tity? Gender expression?” and “Have you had
any kinds of body modi cation? If yes, can you
describe them to me and do you wish to have
any in the future?” cannot only demonstrate a
fundamental respect for the transgender patient,
but can also assist the clinician in providing
the most comprehensive care for the unique
healthcare needs of each transgender patient.
For a trans man featured in Frameline’s short
lm “TRANSforming Healthcare” by Ethan
Suniewick, the distressing fact that his doctor
literally did not know what to do with his body
left him feeling profoundly medically neglected
(Suniewick 2007 ) . After being told “Well, if you
were a girl, I’d have you lay down like this,
but …,” he left the of ce and told the lmmakers,
“So I was pissed because I didn’t receive health
care.” In order for this trans man to not become
another Robert Eads, clinicians should consider
incorporating new cognitive, affective and psy-
chomotor skills (Ross 1984 ) that adequately
address the needs of the transgender
population.
Insurance
In general, GAT is not covered by insurance.
Costs for typical procedures and transition aids
can be quite high, as re ected by the estimated
costs in 2010 that are listed in Table 16.3 .
However, as we have stated, many of the health-
care needs of the trans population have nothing
to do with “reproductive” or sex-speci c body
parts or systems. In other words, a trans man or
woman who is able and willing to work with a
knowledgeable therapist and to be given a diag-
nosis of GID or Gender Dysphoria may ulti-
mately be able to secure insurance coverage for
their GAT. A trans person unable or unwilling to
be diagnosed as such, or who is less invested in
“transitioning” from one side of a binary to
another, will still have unique health care needs
outside of genital or hormonal transitioning.
It is likely that this care will remain uncov-
ered, even as health care reform is instituted in
the U.S.
Given the dif culties that trans people have in
work situations and in securing the legal right to
marry, it is likely that a majority of the population
will not have adequate healthcare coverage.
Currently, it is estimated that 32–87% of trans
people are insured, (Table
16.4 ; Transgender Law
Center
2008 ; Xavier et al. 2005, 2007 ) . However,
FTMs may be more likely to be insured than
MTFs, with one study of trans people of color
nding that 15% of MTFs and 58% of FTMs
have insurance (Meier et al.
2010a ; Xavier et al.
2005 ) . Having health care insurance does not
guarantee access to trans related health care, and
10% of the time trans people with insurance report
Table 16.3 Cost of transitioning aids (in U.S. dollars)
Price range
Surgical
Breast augmentation $3,000–$6,000
Breast reduction/chest
reconstruction
$6,000–$10,000
MTF genital reconstruction $12,000–$30,000
FTM genital reconstruction $5,000–$75,000
Hysterectomy $10,000–$20,000
Facial feminization $5,000–$100,000
Non-surgical
Breast forms $100–$2,000
Chest binders $30–$75
Electrolysis (facial hair removal) $800–$5,000
Packers $20–$100
Stand to pee devices $35–100
Penile prostheses $700–$2,000
Vocal coaching $20–$1,500
17 Interested providers can access primary care protocols
and provider trainings from:
www.transhealth.ucsf.edu
31116 The Demographics of the Transgender Population
that they have been denied primary health care.
Twenty-one percent of FTMs in one sample
reported that their insurance covered trans related
health care (Meier et al. 2010a ) . In another
sample of trans people, 33% of those surveyed
reported having been denied coverage for surgery,
27% for hormones, and 21% for counseling and
mental health services (Transgender Law Center
2008 ) .
These data regarding coverage could result in
trans individuals using what little money is avail-
able for healthcare on surgery and/or hormones,
or other costs associated with maintaining their
congruent gender expression. Without insurance,
hormones may be acquired through non-medical
channels or sources, and there is a reasonable risk
of using doses higher than what are recommended
by regulating institutional bodies. It is also true
that many trans individuals pursue GAT, espe-
cially surgical procedures, in countries where the
cost is much lower (e.g., Thailand, Mexico).
Indeed, there is anecdotal evidence suggesting
that some trans women acquire industrial-grade
silicone in order to increase the size of their
breasts at a lower cost. Available in liquid form,
and used by some transgender sex workers in
parts of Brazil, silicone can be directly injected
into the chest, buttocks and thighs by the indi-
vidual and/or an accommodating friend. This
cannot only pose problems for the U.S.-based
physicians who later manage these patients, but
also pose signi cant legal and re-entry problems
for patients whose gender identity and/or expres-
sion has changed while they have been out of the
country. Similarly, a transgender person wishing
to undergo sex-speci c GAT procedures, such as
a hysterectomy or mastectomy, may nd that the
surgeries are uninsured if they legally changed
their gender beforehand.
These practices could not only put these indi-
viduals at risk, but could also further alienate them
from clinicians who disapprove of non-compliant
patients. Twenty-four to thirty-three percent of
trans people report experiencing discrimination
or insensitivity from health care providers
(Xavier et al. 2005, 2007 ) . Though physicians
have the right—and at times responsibility—to
withhold services or treatment from patients who
do not follow their treatment guidelines, it is vital
that clinicians cultivate an appropriate sensitivity
to the plight of trans patients—a lack of economic
access and the desire to avoid discriminatory atti-
tudes are just two of the reasons that trans patients
may not readily “comply” with particular clinical
recommendations. Ironically, anecdotal evidence
has demonstrated that trans patients can be quite
compliant when cared for by educated providers.
Not only is it in their clinical interests (e.g. better
managed side-effects and/or surgical outcomes),
but “good behavior” is also more likely to secure the
letters and authorizations that many trans people
need in order to obtain legal and institutional-
level changes.
Table 16.4 Statistics from insurance-related studies of
trans people
Meier et al. 2010a (n = 1067; all FTMs)
Have insurance 74%
Of the uninsured: Do not have insurance due
to associated costs
31.6%
Of the insured: Insurance covers trans related
health care
20.5%
Transgender Law Center 2008 (n = 646; 375 MTFs,
271 FTMs)
Have insurance 86.5%
Were denied surgery 33%
Were denied hormones 27%
Were denied counseling and mental health
services
21%
Were denied gender-speci c care (such as pap
smears for trans men and prostate exams for
trans women)
15%
Were denied primary health care 10%
Delayed healthcare due to nances 42%
Health condition worsened because they
postponed care
26%
Xavier et al. 2007 (n = 350; 229 MTFs, 121 FTMs)
Have insurance 72%
Have a regular doctor 62%
Educated their doctor about their healthcare
needs
46%
Experienced discrimination from healthcare
provider
24%
Non-disclosing with regular doctor 29%
Xavier et al. 2005 (n = 248; 188 MTFs, 60 FTMs)
Have insurance 32%
Have access to annual physical exams 54%
Have access to gynecological care 10%
Experienced caregiver insensitivity 33%
312 S.C. Meier and C.M. Labuski
Population Health: Mental Health
Many mental health providers are hesitant to
work with transgender clients because they do
not feel informed on the population’s speci c
needs (Meier and St. Amand 2010 ) . Without a
better idea of the demographics of this popula-
tion, these providers may feel justi ed in never
working with trans people with the thinking that
“there aren’t very many of them.” With more
demographic data, as well as scienti c studies on
the ef cacy of treatment and updated treatment
guidelines, providers can feel more fully informed
and competent and less inhibited to work with
members of this population. This section, there-
fore, explores current data regarding the preva-
lence of mental health concerns within the trans
population. Further, we detail some of the pre-
cautions that must be taken when using these data
to estimate prevalence, as well as for developing
mental health interventions.
The history of mental health research on the
trans population is rife with two sets of claims:
that trans people are delusional or have gross
forms of psychopathology, and that trans people
are actually quite normal and are often of above
average intelligence (Huxley et al. 1981b ;
Gomez-Gil et al. 2008 ) . Many of these claims are
ideologically charged, making the task of “prov-
ing” their relative truth challenging at times. But
it is safe to say, based on a preponderance of psy-
chological research, that trans people demon-
strate consistently high levels of psychological/
mental health despite high incidences of risk for
negative outcomes (Meier et al. 2011 ; Rachlin
1999 ; Ross and Need 1989 ) .
Certain groups of trans people have been stud-
ied more than others, as most past research has
tended to focus on trans women (MTFs) rather
than trans men (FTMs). At this time, there are
extremely limited data on trans people who iden-
tify as genderqueer. This disparity may be due to
MTFs requesting medical services such as geni-
tal surgery more often than FTMs or genderqueer
people (refer to the Prevalence section) or it may
re ect that more FTMs are non-disclosing than
MTFs (Rachlin 1999 ) .
Conducting research among the trans popula-
tion is dif cult due to the relatively small size of
the population, but also because many trans peo-
ple are wary of researchers. Aware of the fact
that they have historically been presented in a
negative, pathologized light, many are hesitant
to participate in studies. This is especially true
for trans people of color, who are rarely repre-
sented in large studies (Erich et al. 2010 ).
Participants in a workshop conducted at a gender
conference for trans people of color voiced that
they would prefer not to be “guinea pigs” for
research studies. However, once they were
informed about how research can change both
legal and medical policies and the “you don’t
exist unless you are researched” phenomenon,
the participants spoke of how they would be
more willing to participate in studies, especially
if the investigator is a person of color (Erich
et al. 2010 ) .
Higher Incidence of Psychological
Problems
Do trans people really suffer from a higher inci-
dence of psychological problems? The answer to
this depends largely on the research that one is
consulting. Older formal studies measuring hos-
pital patients and sex workers, for example, pro-
vide vastly different results from studies
conducted over the Internet and more recent stud-
ies of patients at gender clinics, regardless of
which population is being described (APA 2009 ;
Hoshiai et al.
2010 ; Meier et al. 2011 ) . Critical
readers should therefore look carefully at who is
being measured by the research (how they de ne
the population), who is doing the measuring, the
temporal location of the population (“stage of
transition”, “puberty”), and the methodology, all
of which provide important interpretive context.
Increased rates of depression, anxiety, sub-
stance use and abuse, rape, intimate partner
violence, suicidality, and self-injurious behav-
ior have been reported to occur in the trans
population as compared to the cis population
(Clements et al.
1999 ; Cole et al. 1997 ; Courvant
and Cook-Daniels 1998 ; Dickey 2010 ; Grossman
31316 The Demographics of the Transgender Population
and D’Augelli 2007 ; Hendricks and Testa 2012 ;
Kenagy 2005 ) . Some researchers have suggested
that risk factors that increase these negative out-
comes may consist of being denied access to care
(Meier et al.
2011 ) , stigma (Bockting et al. 1998 ) ,
as well as the loss of social support from loved
ones (Meier et al. 2010b ) .
It is important to complicate these ndings,
however, as we should not assume that these rates
derive straightforwardly from a trans identity. The
APA Task Force on Gender Identity and Gender
Variance states, “Studies on the mental health of
transgender individuals are limited by the use of
convenience samples and may not be generalizable
to the overall transgender population” (APA
2009 :
42). Further, the results of these studies vary widely,
yet there is some evidence to suggest that trans
people who have experienced violence or victim-
ization are at greater risk for suicide attempts
(Goldblum et al. 2012 ; Testa et al. 2012 ). For
example, research has suggested that anywhere
from 16 to 52% of trans individuals have attempted
suicide and that rates of “recent heavy alcohol use”
within both MTF and FTM populations have
ranged from 8 to 31%; illegal drug use, when mea-
sured, has ranged from 3 to 71%, depending on the
drug (Bockting et al.
2005 ; Clements-Nolle et al.
2006 ; Garofalo et al. 2006 ; Grossman and D’Augelli
2007 ; Hendricks and Testa 2012 ; Kenagy 2005 ;
Ramirez-Valles et al.
2008 ; Xavier et al. 2005 ) .
See Table
16.5 for an overview of the research
studies on rates of suicide and problematic sub-
stance use.
While we recognize the importance of collecting
these data in order to better understand the asso-
ciation between a trans identity and high risk
behaviors, we also acknowledge that prevalence
rates can and do determine interventions and anal-
yses. Though compelling in its own right, address-
ing a suicide attempt rate of 16% may require a
Table 16.5 Rates of suicidal ideation/attempts and problematic substance use
Assessment Source Participants Rate Reference
Rates of suicidal ideation/attempts
Lifetime attempt(s) Community and clinic 392 MTF; 123 FTM 32% Clements-Nolle et al.
( 2006 )
Lifetime attempt(s) Internet 448 FTM 44% Meier and Pardo
( 2010 )
Lifetime attempt(s) Community 113 MTF; 69 FTM 30.1% Kenagy ( 2005 )
Lifetime attempt(s) Gender clinic 318 MTF; 117 FTM 15% Cole et al. (
1997 )
Attempt(s) and ideation Community; trans
people of color
188 MTF; 60 FTM 38%; 16% Xavier et al. (
2005 )
Attempt(s) and ideation LGBT youth services;
age 15–21
31 MTF; 24 FTM 26%; 45% Grossman and
D’Augelli ( 2007 )
Attempt or ideation
(past year)
Community 141 MTF; 34 FTM 52% Bockting et al.
( 2005 )
Rates of problematic substance use
Alcohol and Marijuana
use
Community agency;
youth of color age 16–25
51 MTF 65%; 71% Garofalo et al. (
2006 )
Heavy alcohol use Community, Latino GB
and T persons
549 GB; 94 MTF 26% Ramirez-Valles et al.
( 2008 )
Alcohol and drug
problems
Internet 448 FTM 23%; 19% Meier ( 2010 )
Substance abuse
problems
Gender clinic 318 MTF; 117 FTM 28% Cole et al. (
1997 )
Self reported substance
abuse
Community; trans people
of color
188 MTF; 60 FTM 48% Xavier et al. (
2005 )
Alcohol or drug
treatment
Community and clinic 392 MTF; 123 FTM 28% Clements-Nolle et al.
( 2006 )
314 S.C. Meier and C.M. Labuski
distinct set of tools from that required to address a
52% rate. As a result, it is important to take a criti-
cal look at the methods of psychological studies
on trans people, focusing on the sample and data
collection process (i.e., age, genders, recruitment
method, hormone/surgery status, race/ethnicity,
geographical location, etc.) in order to have a con-
text for how to interpret the data and the general-
izability of the results. Scholars should critically
evaluate ndings so as to not overlook important
mediating and moderating variables. For example,
an Internet study on mostly white and highly edu-
cated trans men found normal to mild levels of
depression and anxiety, which varied based on
whether the trans men were on testosterone or not
(Meier et al.
2011 ) . This could suggest that demo-
graphic factors, including race and education,
moderate the effects of a trans identity on mental
health outcomes.
Psychotherapy Concerns
Trans people also seek mental health services for
reasons unrelated to their gender identity and
expression or their desire for letters of support.
They may desire therapy to address depression,
anxiety, grief over the death of a loved one, sex-
ual assault, or any number of concerns. They may
also seek couple’s therapy or career counseling.
Regardless of why trans people come to therapy,
they always have a choice of whether or not they
are going to disclose a trans history. More accu-
rate demographic information will aid research-
ers in obtaining grant funding to determine which
pre-existing evidence-based interventions are
effective for trans clients and to develop novel
evidence-based interventions that are inclusive of
trans clients and their partners and families.
As we stated earlier, it is possible that a clini-
cian who does not believe that they have seen a
trans client actually has (see discussion of stealth
status in the Prevalence section). Clinicians
working with someone they perceive to be trans
need to determine if it is clinically relevant to
ask questions concerning the client’s body or
desire for body modi cation. Nonetheless, it is
important for providers to consider their reasons
for asking the question. If the answer is curios-
ity, it is likely that it is not clinically relevant and
asking prematurely could damage rapport with
the patient (though making assumptions about
someone’s trans status can be equally damag-
ing). For example, if a therapist is working with
a trans woman who has neither had nor desires
genital surgery and that therapist makes the
assumption that all trans people desire genital
surgery, the therapist may inadvertently behave
in a manner that pressures the client to pursue
surgery or to end therapy as she may not feel
understood. This mistake could be avoided more
often if clinicians had a better idea of the preva-
lence and costs of GAT in FTMs and MTFs (see
Tables 16.1 and 16.4 ).
Due to lack of education, training, and expo-
sure to trans people, many therapists unknowingly
assume that there is a single or “correct” trans his-
tory and identity where trans patients report feel-
ing trapped in the wrong body since childhood
and that they are 100% the “other” gender. While
that might be a common narrative, there is no
single or correct trans history or identity, as the
population is more diverse than most imagine.
There are some people whose gender identity is
uid and changes over time, others report feeling
“trapped in the wrong body” since early child-
hood, still others do not discover their gender
identity until late in life. Historic accounts of the
treatment of trans people who did not report a
“classic” history (i.e., genderqueer persons or
trans people reporting a post-transition gay orien-
tation), demonstrate that many of these individu-
als were not given letters for treatment and thus
denied many of the services they sought (Lev
2005 ) . For these reasons, it is important to collect
additional data so as to generate information
regarding the diversity of transition experiences
(IOM 2011 ).
Organizations that promote the idea of “chang-
ing” or “repairing” a person’s sexual orientation
and/or transgender identity are still in existence;
they are most typically af liated with religious
organizations. Despite a lack of solid empirical
evidence demonstrating the ef cacy of these
31516 The Demographics of the Transgender Population
treatments, many of these groups promote their
success on websites and through self-published
materials. Indeed, it is easy to encounter one of
these websites when casually searching online
for transgender information. It is important that
those invested in the transgender population keep
abreast of these trends and “treatments” as at
least one scientist has demonstrated that they
are associated with notable negative outcomes
(Drescher
2002 ) . In fact, the APA has issued a
press release stating that these “treatments” do
not have evidence supporting their effectiveness
and that psychologists should not tell clients
that they can change their sexual orientation
(Glassgold et al. 2009 ) .
In 2009, the American Counseling Association
published important new guidelines for profes-
sionals who counsel and/or conduct research with
trans people (ALGBTIC 2009 ) . The World
Professional Association for Transgender Health
also released suggestions for therapy with trans
people (WPATH 2011 ). Such guidelines hope-
fully can address a vital issue affecting the
competent mental health care of this population,
which is the lack of training and the lack of incor-
poration of the LGBT literature into mainstream
psychology (Goldfried 2001 ) . Numerous train-
ings exist to educate straight cisgender people;
however, many of these focus so heavily on LGB
issues that trans issues seem like an afterthought.
Some trainings neglect to mention the trans
population at all or when they do, emphasize
that “those people” are inherently different than
the “regular” LGB population. One of the authors
is part of a network that exists to address this
problem. The 44th Division of the American
Psychological Association recently created a
list of professionals who are available for com-
prehensive LGBT trainings.
18 Also, many valu-
able resources have already been created for
educating clinicians on culturally sensitive trans
af rming care (APA 2009 ; Lev 2004 ; Maguen
et al. 2005 ; Raj 2002 ) . Hopefully these resources,
and future resources which may be better
informed by demographers, can help mental
health practitioners to provide competent care to
this population.
Family Demographics
Relationships
Historically, researchers have been openly
shocked that cisgender people would want to
form or continue meaningful romantic and sexual
relationships with trans people (Brown 2009 ;
Fleming et al. 1985, 1984 ; Huxley et al. 1981a ) .
In fact, historical anecdotal reports from trans
people who were treated at gender clinics claim
that married trans people were encouraged to
divorce before starting their transition (Samons
2009 ) . Empirical data show that about half of the
partners of trans men stay with their partner
through transition, and, of the half that do not
stay together, half of them (25% of the overall
sample) end the relationship due to their partner’s
transition (Meier et al. 2010c ) .
More recently, many qualitative interviews
have focused on partners who stayed with their
transgender partner through transition (Brown
2009 ; Ehrbar 2010 ; Kraemer et al. 2010 ) . Partners
of trans people provide important social support
to their trans partner (APA 2009 ; Ehrbar 2010 ) .
However, partners also bene t from having their
own social support and accessing resources
related to transition (Ehrbar 2010 ; Meier et al.
2010c ) . Partners who stayed with their trans part-
ner through transition attributed the success of
their relationship to open communication, educa-
tion on transgenderism and the transition process
through accessing resources, community support,
and keeping their focus on the reasons they fell in
love with their partner in the beginning of their
relationship (Meier et al.
2010c ) . Kraemer and
colleagues ( 2010 ) encourage professionals who
work with the trans community to cite many pos-
itive and healthy examples of trans relationships
in which a cis partner accepts and af rms their
trans partner as they identify.
18 Interested readers can contact Division 44 of the
American Psychological Association for an updated list of
resources and contacts.
316 S.C. Meier and C.M. Labuski
Trans people can have relationships with all
types of partners: cis males and females, as well
as with other transgender people. In a study of
over 500 FTMs, about half of the participants
reported being in relationships at the time of the
survey, with 42 participants reporting being
legally married (Meier et al.
2010c ) . Over one-
third of the trans women in an Irish research
study reported being married currently or previ-
ously (De Gascun et al. 2006 ) . In some cases,
depending on the legal precedence where the
partners reside, these relationships may be legally
recognized in marriage or domestic partnerships.
Some partners conceptualize their relationship as
LGBQ and some as straight/heterosexual based
on the gender identities of the partners, as opposed
to their birth-assigned sexes. As such, demogra-
phers should be mindful of the way they attempt
to quantify these relationships.
Family
One in ve to one in three trans people are par-
ents, with trans women more likely to be parents
than trans men (De Gascun et al. 2006 ; Freeman
et al. 2002 ; Meier and Hughes 2010 ) . Depending
on the state or country, trans people may be
allowed to marry and/or adopt children within the
context of a heterosexual relationship or mar-
riage; when some do not identify as heterosexual,
trans individuals encounter obstacles to both of
these practices that are similar (though perhaps
heightened) to those encountered by gay men and
lesbians. These include: discrimination, inade-
quate legal rights (e.g., parental decision-making,
legal privileges on behalf of children and part-
ners), and accusations of gender fraud. Even with
these obstacles, having a trans parent has not
been found to be harmful for children (Green
1978 ) .
As with Thomas Beatie, people that delay or
opt out of genital surgery may father or bear chil-
dren within the context of a trans body and rela-
tionship. It should also be noted that some trans
people bear and raise children before they transi-
tion, in which case many of the issues faced by
these individuals are more personal than legal.
Children and other family members do not always
understand nor accept the trans person’s desire to
express their gender identity, and sometimes
sever ties as a result. Overall there is a paucity of
published research “on the family issues of adult
transgender people, in spite of the importance of
social support from families for satisfactory men-
tal health” (p. 3; APA
2009 ) . Though preliminary
data (Meier and Hughes 2010 ) suggests that trans
parents experience fewer symptoms of depres-
sion, anxiety, and stress than trans non-parents,
these measures of well-being seem to be corre-
lated with age, hormone usage, and/or time since
transition, indicating that older trans people expe-
rience fewer psychological symptoms (Meier and
Pardo 2010 ) . Many families eventually become
accustomed to having a trans parent (or aunt,
uncle, etc.) as much of the initial disruption evens
out over time; indeed, family members some-
times become politically active as a result of wit-
nessing the discrimination and obstacles faced by
their loved ones.
Many other trans individuals are not as fortu-
nate, however, and lose the support of their fami-
lies of origin and/or that of their partner/spouse
and children. Though not unique to this popula-
tion, such a loss can leave trans people without a
fundamental component of a social “safety net.”
Without legal access to a family of choice, it can
be crucial to have one’s family of origin in place
for nancial and emotional stability, particularly
when one is routinely subjected to discrimina-
tory tactics and attitudes. A potential negative
rami cation of being diagnosed with a “mental
disorder” is that an ex-spouse may use that diag-
nosis against a trans person in a custody case as
evidence “proving” the trans parent to be an un t
parent, as they “are mentally ill,” (Ehrbar
2010 ) .
Scenarios like this will likely be lessened when
research ndings demonstrating the “normal”
and competent parenting and relationships of
trans people become more widely available. Loss
of family support has been found to have delete-
rious effects on the mental and physical health of
trans people, as family support can act as a buf-
fer to stigma and discrimination (APA
2009 ) .
Data show that loss of family support is related
to lower general physical health and functioning
31716 The Demographics of the Transgender Population
quality of life ratings in FTMs, a result similar
to the ndings from the Family Acceptance
project’s work with LGB youth (Meier et al.
2010b ; Ryan et al. 2008 ) . The converse also
holds for both sets of data: the higher the social
support ratings of families that do accept their
children, the higher the quality of life results
for those children. Findings from a recent study
of Canadian trans youth demonstrate that trans
youth with strong parental support report higher
satisfaction with life, higher self-esteem, less
depression, fewer suicide attempts, and ade-
quate housing compared to trans youth without
strong parental support (Travers et al. 2012 ).
Organizations such as PFLAG (Parents and
Friends of Lesbians and Gays), which for over
a decade has incorporated a transgender arm
(T-Net), COLAGE, a national support and
advocacy group for children with (at least) one
gay, lesbian and/or trans parent, TYFA (Trans
Youth Family Allies) and Gender Spectrum (see
Brill and Pepper 2008 ) , both groups for fami-
lies of trans youth, are working to educate the
greater population about these issues.
Labor Demographics
The experiences of trans people in the workplace
have begun to reveal that all experiences of trans
people are not equal, and that broader social phe-
nomena such as masculine privilege can override
the discrimination that a trans person might expe-
rience on the job. In a sociological, interview-
based study with trans men, Schilt (
2006 ) found
that white, tall trans men who transition on the
job are more likely to keep their employment and
to get promoted than are short, trans men of color
and/or those trans men who are not on testoster-
one. Furthermore, cis men appear to recognize
trans men who make a gender transition on the
job as simply men , whereas cis women are more
likely to recognize these individuals as trans men
(or someone who once was a woman) (Schilt and
Westbrook
2009 ) . Schilt ( 2010 ) records a work-
place experience of a gay trans man who works
as a kindergarten teacher in Texas. This trans man
does not disclose his trans history to most of his
colleagues. During teacher meetings, he noticed
being treated differently than the other (mostly
female) teachers. Speci cally, he noticed that
because he is a socially recognized male, other
teachers often stop talking when he speaks and
that when he presents an idea, even if it was rst
raised by a female colleague, he is listened to and
taken more seriously.
Survey research has thus far borne out such
ndings. Schilt and Wiswall (
2008 ) tested the
concept of “gender/appearance-neutral” perfor-
mance reviews and pay structures. They hypoth-
esized that if this theory holds true, people who
transition should be paid the same amount for the
same work both before and after they transition.
What they found was that trans women, on aver-
age, lose $12/h after they transition and trans
women also make more than do the average male
and female workers before they transition. Trans
men, on the other hand, did not lose money
related to their transitions; indeed, some even
made a small amount more afterwards.
Because of these demonstrable and gendered
disparities, Schilt and Wiswall ( 2008 ) encourage
scholars to use caution when speaking about the
trans population and to not generalize about the
“transgender experience” at work. Moreover,
most research focuses on trans people at the time
of their gender transition; the workplace experi-
ences of people who transitioned in the more dis-
tant past are still relatively unknown.
Gender Alterity in a Broader Context
We conclude with both a restatement and an elab-
oration of our opening position: that this chapter
is written from a (primarily) U.S.-based set of
facts, beliefs and organizational frameworks
about a trans reality. It is important to restate this
because both authors believe strongly that the
aspects of sex and gender that are socially consti-
tuted and contoured cannot be disentangled from
those that may not be, i.e., that may originate
from a more “natural” source. This means that
we encourage the reader to understand this demo-
graphic pro le as representing an experience of
trans that is both historically and geographically
318 S.C. Meier and C.M. Labuski
speci c, one possible way that gender alterity can
be lived and expressed. Anthropologists in par-
ticular use both historical and cross-cultural evi-
dence to suggest that other societies and cultural
groups often hold an af rmative place for people
and bodies who are not neatly categorized by
either male or female. In order to underscore this
nal point, we will outline a few of the ways that
sex and gender expression are and have been
lived across other parts of the world and at other
points in time.
As we have mentioned, the terms transgender
and transsexual already connote a binarized
understanding of gender; the fact that one can
“cross” from one to the other is implied within the
words themselves. For the travesti in Brazil, how-
ever, there is no such easy crossing. Travesti are
what many in the U.S. would call MTF: birth-
assigned men who dress, act, and self-identify as
feminine (including calling themselves “girls”),
and who de ne their male partners in heteronor-
mative terms (Kulick
1998 ; see also Prieur 1998
for similar ndings in Mexico). A hallmark of
travesti identity is the injection of industrial-grade
silicone directly into the hips, buttocks and breasts,
a set of procedures that typically forti es the
incomes many of them make doing sex work.
Travesti are subjected to discrimination and
harassment, frequently from the police, and often
live at or below the poverty line. Given these
parameters, it is tempting for even gender schol-
ars to label these Brazilian women transsexual but
the travesti interviewed by Kulick spoke clearly
and openly about how that concept does not rep-
resent their experience. Indeed, the idea that a
man could “become” a woman through surgery
and/or hormonal therapy is quite unthinkable, and
many of the travesti in Kulick’s ethnographic
study report a bodily investment in their penis that
would preclude its excision or even subordina-
tion. Moreover, in both Kulick’s and Prieur’s stud-
ies, the category of transgender articulated with
particular forms of masculine or “bisexual”
expression, in that many of the steady sexual part-
ners of the transgender sex workers were men
who considered themselves to be heterosexual.
Indian hijras, on the other hand, have no such
investment in their male genitalia. Rather, the
nirvan surgery that many of these birth-assigned
males undergo consists of the complete excision
of both penis and testicles. Although the hijra
might also be loosely translated in MTF terms—
they dress as women, take female names, and
participate in female-gendered activities—their
gender alterity is rooted in a very speci c set of
spiritual and religious practices. Often referred to
as India’s “third sex,hijras sacri fi ce their genita-
lia to a goddess in exchange for the power to con-
fer fertility and blessings on (heterosexual)
newlyweds and newborn children (Nanda 1990 ;
Reddy 2005 ) . An important similarity that the
hijra have to travesti is that, contrary to what the
trans community is articulating in the U.S., they
understand their gender alterity at least partially
through their sexual practices. Both groups have
primarily male sexual partners; their understand-
ing of themselves as not exclusively male does
not arise from their identifying as “gay,” however.
Rather, both travesti and