590228

research-article2015
JAHXXX10.1177/0898264315590228Journal of Aging and HealthKattari and Hasche

Article
Journal of Aging and Health
1­–22
Differences Across Age © The Author(s) 2015
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DOI: 10.1177/0898264315590228
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Conforming People’s
Experiences of Health
Care Discrimination,
Harassment, and
Victimization

Shanna K. Kattari, MEd1

and Leslie Hasche, MSW, PhD1

Abstract
Objective: Given the increasing diversity among older adults and changes
in health policy, knowledge is needed on potential barriers to health care
for transgender and gender non-conforming (GNC) individuals. Method:
Using the 2010 National Transgender Discrimination Survey (NTDS),
logistic regression models test differences between age groups (below 35,
35-49, 50-64, and 65 and above) in lifetime experience of anti-transgender
discrimination, harassment, and victimization within health care settings
while considering the influences of insurance status, level of passing, time of
transition, and other socio-demographic factors. Results: Although more
than one fifth of transgender and GNC individuals of all ages reported health
discrimination, harassment, or victimization, significant age differences
were found. Insurance status and level of passing were also influential.
Discussion: Medicare policy changes and this study’s findings prompt

1University of Denver, CO, USA

Corresponding Author:
Shanna K. Kattari, Graduate School of Social Work, University of Denver, 2148 S. High St.,
Denver, CO 80208, USA.
Email: Shanna.Kattari@du.edu
2 Journal of Aging and Health 

further consideration for revising other health insurance policies. In addition,

expanded cultural competency trainings that are specific to transgender and
GNC individuals are crucial.

Keywords
transgender, health care services and policy, discrimination, harassment,
victimization

Introduction
The health care needs of transgender and gender non-conforming (GNC)
individuals are receiving increasing recognition from the Institute of Medicine
(IOM; 2011) and through some national research projects (Cruz, 2014;
Fredriksen-Goldsen et al., 2014; Grant et al., 2011). With an estimated rate of
0.3% to 5% of adults identifying as transgender/GNC (Gates, 2011;
Transgender Law and Policy Institute, n.d.; Trotter, 2010), approximately
700,000 older transgender individuals live within the United States (Witten &
Eyler, 2012). They may be a small proportion of health care patients and
older adults, yet transgender and GNC older individuals may be overlooked
and misunderstood. The term transgender refers broadly to individuals who
identify, express, behave, or transition from one gender to another or whose
gender non-conformity is a part of their identity (Grant et al., 2011). While
sex is assigned at birth based on visible characteristics, one’s gender identity
and expression is experienced as a multidimensional construct (Alegria,
2011) and is inclusive of varying identity terms such as transsexuals, gender-
queer people, androgynous, two-spirit and cisgender (which refers to non-
transgender individuals). Given these complexities and the projected growth
in older transgender individuals seen by health and aging providers (IOM,
2011), increased knowledge is needed on the health care experiences of trans-
gender and GNC individuals across all age groups.
Concern for the health disparities are well established for lesbian, gay, and
bisexual older adults in terms of overall disproportionate poor health, dis-
ability, and for specific conditions such as depression (Fredriksen-Goldsen
et al., 2013; IOM, 2011). Furthermore, in one study of lesbian, gay, bisexual,
and transgender (LGBT) older adults, age comparisons showed significant
differences with older age groups of LGBT adults reporting more chronic
health conditions and worse health-related quality of life (Fredriksen-
Goldsen, Kim, Shiu, Goldsen, & Emlet, 2015). Although the literature that
applies specifically to older transgender and GNC adults is limited, the results
point to a consistent concern for physical and mental heath disparities
(Fredriksen-Goldsen et al., 2014; Kenagy, 2005).
Kattari and Hasche 3

Much of the research on health disparities identifies the negative impact of

prior experiences of discrimination on health outcomes. Foglia and
Fredriksen-Goldsen (2014) described how non-conscious bias among health
care providers can shape attitudes, beliefs, and behaviors; can influence
whether and when an individual feels safe to disclose their gender identity to
health care providers; and can ultimately lead to health disparities among
LGBT older adults. Qualitative research highlights the long-term impact of
negative previous experiences of social exclusion and marginalization among
older LGBT adults (Van Wagenen, Driskell, & Bradford, 2013) and of dis-
crimination specifically when transgender older adults are seeking health
care (Siverskog, 2014). It is important to note that experiences of lifetime
discrimination and victimization related to one’s sexual and/or gender iden-
tity are significantly associated with physical and mental quality of life, and
varied across age groups, with the oldest-old experiencing the fewest number
of lifetime events, yet showing a stronger negative effect of these experiences
on health (Fredriksen-Goldsen et al., 2015). In this study, discrimination and
victimization were measured together, as a count of many different types of
experiences, such as physical, verbal and sexual threats and assault, property
damage across work, health, and community settings. In terms of health care
specifically, 40% of transgender older adults reported receiving inferior care
or being denied health care because of their sexual or gender orientation
(Fredriksen-Goldsen et al., 2011). Our research extends this work by explor-
ing the distinct experiences of discrimination, harassment, and victimization
in health care settings specifically for transgender and GNC adults.
A long history links health care discrimination to explicit and de facto poli-
cies within health care systems (IOM, 2011; Rosenbaum, Markus, & Darnell,
2000); thus, it is important to consider the role of insurance in research on dis-
crimination and disparities. Prior research identifies insurance status as the
most common reason for perceived discrimination in health care (Trivedi &
Ayanian, 2006), as impacting the level of health care a patient receives (Flocke,
Stange, & Zyzanski, 1997), and the location and type of health care accessed
(Rask & Rask, 2000). Among transgender and GNC individuals, insurance sta-
tus is a significant predictor of postponing use of health care (Cruz, 2014).
Therefore, many researchers and advocates see federal policy as a means to
directly address health care discrimination, such as a tool for combating stigma
against mental illness (Cummings, Lucas, & Druss, 2013) and as a means to
reducing racial disparities in access and quality of care (Snowden, 2012).
This study aims to examine transgender/GNC individuals’ experiences of
discrimination, harassment, and victimization across age groups, while consid-
ering the influences of insurance status, level of passing as non-transgender and
time of transition, and other socio-demographic factors. Understanding these
4 Journal of Aging and Health 

experiences can serve as a crucial step in minimizing how stigma and victimiza-
tion create health risks for older transgender individuals (Fredriksen-Goldsen
et al., 2014). By utilizing data from a national survey of transgender and GNC
adults, we are able to deepen our understanding of experiences of discrimination
in health care settings and apply a life course perspective. The life course per-
spective offers a framework for understanding how prior life experiences, cohort
differences, age groups, and broader socio-historical context affects subsequent
health and well-being outcomes in later life (Alwin, 2012).
Our study responds to the IOM (2011) request for more health research on
transgender adults and builds on prior research highlighting the negative
impact of health discrimination (Fredriksen-Goldsen et al., 2014). Given the
possibility of older adults having more health care experiences across historic
time periods that had more biased views on sexual and gender identities, we
propose the following hypotheses.

Hypothesis 1: Older individuals will report higher lifetime experience of

discrimination, harassment, and victimization than younger adults.
Hypothesis 2: Insurance status will be related to differences in experience
of discrimination, harassment, and victimization.
Hypothesis 3: Individuals’ level of passing and time of transition will be
related to experience of discrimination, harassment, and victimization.

Method
Participants and Procedure
This study uses the secondary data analysis of the 2010 National Transgender
Discrimination Survey (NTDS), which was collected by the National Center
for Transgender Equality (NCTE) and the National Gay and Lesbian Task
Force (NGLTF). Data from the NTDS (N = 6,456) were collected in 2009 and
2010 using online surveys, available in English and Spanish. Participants were
recruited via advertisements on both NCTE’s and NGLTF’s email lists, mem-
ber lists from partner organizations, and by the use of social media, which
included Facebook, Twitter, and various blogging sites. The sample was inclu-
sive of residents from all 50 U.S. states, as well as Washington, D.C., Puerto
Rico, and Guam. All participants were aged 18 and above, with every partici-
pant in this survey self-identifying as transgender and/or GNC. Participants
who did not provide an age were dropped from the sample for this study, given
the importance of age for grouping, resulting in n = 5,885. A description of the
sample is provided in Table 1. The institutional review board (IRB) at the
authors’ university approved the present secondary data analysis.
 Table 1.  Sample Description by Age Groups.

Age groups

  Below35 35-49 50-64 65 and above  

Variable Total n = 3,092 n = 1,583 n = 1,096 n = 114 Significance

Sexual orientation 5,823 ***
 Gay/lesbian 1,203 18.4% 21.1% 25.3% 30.0%  
 Bisexual 1,355 18.6% 27.9% 29.9% 20.9%  
 Queer 1,162 31.7% 10.4% 2.5% 2.7%  
 Heterosexual 1,217 17.7% 24.9% 23.9% 22.7%  
 Asexual 240 2.6% 4.7% 6.9% 10.0%  
 Other 646 11.0% 10.9% 11.5% 13.6%  
Race 5,885 ***
 White 4,465 69.0% 79.0% 88.8% 93.9%  
  People of color 1,420 31.0% 21.0% 11.2% 6.1%  
  Black 245 5.9% 3.5% .8% 0.0%  
  American Indian 73 1.1% 1.6% 1.2% 0.0%  
  Latino 192 4.6% 2.3% 1.1% 0.0%  
  Asian/Pacific Islander 125 3.4% 0.9% 0.5% 0.0%  
  Middle Eastern 5 0.2% 0.0% 0.0% 0.0%  
  Multiracial 780 15.8% 12.6% 7.6% 6.1%  
Primary gender today 5,868 ***
 Male/man 1,525 33.5% 23.5% 10.2% 9.7%  
 Female/woman 2,423 29.8% 48.5% 61.2% 61.9%  

5
(continued)
6
Table 1.  (continued)

Age groups

  Below35 35-49 50-64 65 and above  

Variable Total n = 3,092 n = 1,583 n = 1,096 n = 114 Significance

 Part-time 1,163 18.0% 19.4% 24.7% 27.4%  
  Not listed 757 18.8% 8.6% 3.8% 0.9%  
Relationship status 5,868 ***
 Single 2,037 44.6% 29.4% 17.2% 9.7%  
 Partnered 1,585 35.5% 21.9% 12.6% 7.1%  
  Civil union 67 1.3% 0.9% 1.0% 0.0%  
 Married 1,255 13.1% 28.8% 33.1% 30.1%  
 Separated 173 1.4% 2.8% 7.0% 7.1%  
 Divorced 665 3.4% 15.2% 26.2% 30.1%  
 Widowed 86 0.7% 0.9% 2.9% 15.9%  
Insurance type 5,804 ***
 Private 3,688 64.5% 64.0% 62.1% 46.0%  
 Public 1,029 14.0% 18.5% 23.5% 50.4%  
  No insurance 1,087 21.5% 17.5% 14.4% 3.5%  
Passing (People can tell that I am trans* . . .) 5,852 ***
 Always 376 7.8% 5.3% 4.3% 5.3%  
  Most of the time 944 18.1% 13.2% 14.6% 18.4%  
 Sometimes 1,594 26.5% 28.1% 28.6% 21.1%  
(continued)
 Table 1.  (continued)

Age groups

  Below35 35-49 50-64 65 and above  

Variable Total n = 3,092 n = 1,583 n = 1,096 n = 114 Significance

 Occasionally 1,744 27.3% 29.9% 36.2% 35.1%  
 Never 1,194 20.4% 23.4% 16.3% 20.2%  
Time of transition  
  Living part-time 5,444 ***
  M age 26.83 19.04 30.15 41.34 52.67  
Attempted to access 5,885  
 Doctor/hospital 4,701 76.6% 82.7% 84.9% 83.3% ***
  Emergency room 3,420 55.0% 61.4% 62.0% 58.8% ***
  Mental health 3,532 57.8% 62.5% 62.7% 61.4% **
 Ambulance/EMT 2,591 40.0% 47.0% 50.2% 52.6% ***

Note. EMT = emergency medical transportation.

*p < .05. **p < .01. ***p < .001.

7
8 Journal of Aging and Health 

Measures
Discrimination, harassment, and victimization.  Discrimination, harassment, and
victimization have many potential definitions, and even research using this
data set works off of different definitions (Langenderfer-Magruder, Whit-
field, Walls, Kattari, Ramos, 2014; Whitfield, Walls, Langenderfer-
Magruder, & Clark, 2014). For the purpose of this study, discrimination is
defined as inequitable treatment of an individual or a group in social settings
due to the individual or group’s social identity (Jones, 2000). Harassment is
defined as unwanted and annoying actions of one party or a group, including
threats and demands, although this study is focusing on experiences of verbal
harassment (U.S. Equal Employment Opportunity Commission [EEOC],
n.d.). Victimization is defined as physical abuse perpetrated by an individual
onto another individual for a number of reasons, including anger, sexual vio-
lence, and so on (Willis, 2008). The survey included 45 items that served to
measure the participants’ experiences of discrimination (phrased as “denied
equal treatment”), harassment (phrased as “experienced verbal abuse”), and
victimization (phrased as “experienced physical abuse”) across a variety of
situations including when accessing medical and mental health services,
existing in public spaces, when using public servants, and more. In this study,
12 of these items were used to determine experience of discrimination,
harassment, and victimization for each of the following service settings: doc-
tors/hospitals, emergency rooms, mental health centers, and ambulances/
emergency medical transportation (EMT). It is important to note this was a
cross-sectional survey, and these particular survey items asked only if each
participant had ever experienced discrimination, harassment, and/or victim-
ization at any point throughout their lifetime. No further data were collected
that would provide information as to when these events occurred, including
whether it was before, during, or after transition had begun. These questions
were phrased as “based on being transgender/gender non-conforming, please
check whether you have experienced any of the following in these public
spaces. (Mark all that apply.)” Participants could choose yes (experienced
discrimination), no (did not experience discrimination), or that they did not
attempt to access that particular service/location. For this survey, these
responses were recoded as yes or no, with those who did not attempt to access
a specific service not being included in the analysis.

Age and other socio-demographics.  For the purpose of this study, the following
demographic information was measured; sexual orientation, race, primary
gender (identity) today, and relationship status. Regarding age at time of the
survey, participants were placed into four age groups: below 35, 35 to 49, 50
to 64, and 65 and above.
Kattari and Hasche 9

Insurance status.  In the survey, the original options regarding the item asking
what type(s) of insurance each respondent had were no health insurance cov-
erage, through current/former employer, through another’s employer, pur-
chased insurance, Medicare, Medicaid, military/Veteran’s Affairs/Champus/
Tri-care, student health insurance, other public insurance, and other. For the
use of this analysis, we grouped these responses into private (through current/
former employer, through another’s employer, purchased insurance, student
health insurance, and other), public (Medicare, Medicaid, military/VA/
Champus/Tri-care, and other public insurance), and no insurance.

Passing and time of transition. Two additional items were included in this

study: level of passing (survey item was phrased “people can tell that I am
transgender/gender non-conforming even if I don’t tell them”) and age of
beginning part-time transition. Regarding the survey item of passing, the
answer options on the survey were always, most of the time, some of the time,
occasionally, and never. For this study, these were kept as a categorical vari-
able. The survey also measured age of full-time transition. However, due to
the fact that a large subset of participants had not reached a level of full-time
transition (for a variety of reasons), we chose to include the age of starting
part-time transition as the time of transition variable in the analysis to have a
larger sample and include those individuals who cannot or choose not to
reach full-time transition at this time.

Missing Data
Prior to starting analysis, all variables used were examined for missing data
including the amount of missing response per variable. Of the variables
included in the analysis, all had 1% or less of missing responses, except for
age of part-time transition, which had 7.5% missing. These missing cases
were dropped for the binary logistic regression analysis. Each of the variables
measuring experiences of discrimination, harassment, and victimization of
different health service areas (doctors and hospitals, emergency rooms, men-
tal health clinics, and ambulances and EMT) was recoded so that only partici-
pants who actually attempted to access each type of health service were
included. Thus, only those who had actually attempted to use these services
were included in the hypotheses testing. Those participants who had not used
or attempted to access each specific health service were excluded from that
individual analysis. Regarding whether someone had attempted to access a
service, missing responses were examined, and less than 10% of each vari-
able were missing, resulting in excluding these cases from analysis.
10 Journal of Aging and Health 

Statistical Analyses
Chi-square tests of independence were run to examine the relationship
between age groups and demographic variables. Then, chi-square tests of
independence were used to determine independence in prevalence and fre-
quency of discrimination, harassment, and victimization by age group (below
35, 35-49, 50-64, and 65 and above). Finally, logistic regression models were
run to examine whether age affected the likelihood of experiencing discrimi-
nation (Model 1), harassment (Model 2), and victimization (Model 3) while
accounting for insurance type, level of passing as non-transgender, time of
transition, and other socio-demographic variables.

Results
Age Differences in Socio-Demographic Variables and Insurance
Status
As per the results listed in Table 1, the differences across ages were signifi-
cant for all of the socio-demographic variables as well as the insurance status
variable. A larger percentage of older adults than those in the younger age
groups identified as gay/lesbian or asexual; reported being White; identified
as female/women; were married, divorced, or widowed; and had public insur-
ance. Compared with older adults (age 65 and above), more younger adults in
this sample identified as queer, identified with racial groups other than White,
identified as male/men or with an identity not listed, were single, had either
private insurance or no insurance at all, and had a younger age at which they
began to transition part-time. The level of passing varied significantly across
age groups, with the largest percentage of older adult reporting passing occa-
sionally (35%). The mean age of when one started living part-time in transi-
tion increased across age groups, with older adults reporting a mean age of
52.67 years.

Age Differences in Experiences of Discrimination, Harassment,

and Victimization
As shown in Table 2, the youngest age group (below 35) reported the highest
levels of discrimination overall (22.4%), when accessing doctors/hospitals
(24.3%), emergency rooms (16.1%), mental health facilities (12.7%), and
ambulances/EMT (7.1%). As age increased, percentages of individuals
reporting discrimination decreased for all types of health services, with those
reporting discrimination per age group as follows: aged 35 to 49 at 20.0%,
aged 50 to 64 at 14.7%, and age 65 and above at 4.2%.
 Table 2.  Lifetime Experience of Discrimination, Harassment, and Victimization in Health Care Settings by Age Groups for Those That
Used Health Services (n = 5,006).

Age groups

Variable Total Below 35 35-49 50-64 65 and above Significance

Discrimination—Any setting 23.6% 27.0% 23.0% 17.2% 6.1% ***
 Doctor/hospital 21.0% 24.3% 20.6% 14.7% 4.2% ***
  Emergency room 12.2% 16.1% 10.8% 5.6% 1.5% ***
  Mental health 10.6% 12.7% 10.1% 7.0% 2.9% ***
 Ambulance/EMT 4.9% 7.1% 3.9% 1.6% 0.0% ***
Harassment—Any setting 26.7% 31.4% 26.6% 15.4% 14.3% ***
 Doctor/hospital 22.6% 27.3% 22.2% 12.4% 11.6% ***
  Emergency room 15.7% 19.8% 14.0% 8.8% 6.0% ***
  Mental health 11.0% 14.6% 9.1% 4.8% 0.9% ***
 Ambulance/EMT 6.7% 8.3% 6.5% 3.8% 6.7% **
Victimization—Any setting 2.0% 3.0% 1.1% 0.5% 2.0% ***
 Doctor/hospital 1.1% 1.6% 0.7% 0.3% 1.1% **
  Emergency room 1.0% 0.7% 0.5% 0.3% 1.5% *
  Mental health 1.1% 1.8% 0.5% 0.1% 1.4% **
 Ambulance/EMT 1.1% 1.7% 0.7% 0.4% 1.7% *

Note. EMT = emergency medical transportation.

*p < .05. **p < .01. ***p < .001.

11
12 Journal of Aging and Health 

The youngest age group (below 35) reported the highest frequency of
harassment overall (26.1%), when accessing doctors/hospitals (27.3%),
emergency rooms (19.8%), mental health facilities (14.6%), and ambulances/
EMT (8.3%). As age increased, percentages of individuals reporting discrim-
ination decreased, with the exception of the older group (65 and above) when
accessing ambulances/EMT, when they reported the second highest level of
harassment (6.7%).
The youngest age group (below 35) reported the highest levels of victim-
ization overall (2.5%), when accessing doctors/hospitals (1.6%), emergency
rooms (0.7%), mental health facilities (1.8%), and ambulances/EMT (1.7%).
In general, as age increased, percentages of individuals reporting victimiza-
tion decreased, with the exception of the older group (65 and above) who
reported experiencing the second highest level of victimization overall
(1.8%), when accessing doctors/hospitals (1.1%), emergency rooms (1.5%),
mental health facilities (1.4%), and ambulances/EMT (1.7%).

Insurance Status and Influences of Time of Transition and Level

of Passing on Age Differences in Experiences of Discrimination,
Harassment, and Victimization
The influences of insurance status, time of transition, and level of passing on
age differences when experiencing discrimination, harassment, and victim-
ization at any of the health services were tested in three logistic regression
models, and the results are presented in Table 3.

Discrimination
With a reference category of those 35 and under, the likelihood of reporting
discrimination varied by age. When compared with those younger than age
35, those age 35 to 49 had a higher likelihood of reporting discrimination
(odds ratio [OR] = 4.73, 95% confidence interval [CI] = [3.78, 5.90]), yet
those aged 50 to 64 and those aged 65 and above had a lower likelihood of
reporting discrimination compared with those younger than age 35 (OR =
0.67, 95% CI = [0.54, 0.84] and OR = 0.17, 95% CI = [0.06, 0.48], respec-
tively). Those who had private insurance were less likely to report discrimi-
nation (OR = 0.62, 95% CI = [0.51, 0.76]) than the reference category of
those with no insurance. The level of passing was significant in that partici-
pants who indicated lower levels of passing had a higher likelihood of report-
ing discrimination (OR = 1.09, 95% CI = [1.02, 1.16]). The older the age at
which a participant began to transition part-time, the lower the likelihood of
Kattari and Hasche 13

Table 3.  Logistic Regression Models of How Age, Insurance Status, Passing, and
Time of Transition Relate to Experiences of Discrimination, Harassment, and
Victimization.

Model 1: Model 2: Model 3:

Variable Discrimination Harassment Victimization
Age group (below 35)
  35-49 years 4.73 [3.78, 5.90]*** 0.50 [0.38, 0.66]*** 1.66 [0.87, 3.19]
  50-64 years 0.67 [0.54, 0.84]** 0.26 [0.20, 0.34]*** 0.21 [0.07, 0.60]**
  Above 65 years 0.17 [0.06, 0.48]** 0.00 [0.00, 0.00] 0.00 [0.00, 0.00]
Insurance type (no insurance)
 Private 0.62 [0.51, 0.76]** 14.09 [9.37, 21.19]*** 1.91 [0.79, 4.57]
 Public 1.03 [0.80, 1.33] 3.68 [2.30, 5.88]*** 1.65 [0.57, 4.72]
Level of passing 1.09 [1.02, 1.16]* 0.99 [0.93, 1.07] 0.82 [0.65, 1.02]
Age of transition to 0.97 [0.96, 0.98]*** 0.96 [0.95, 0.96]*** 0.96 [0.93, 0.98]**
living part-time
Race (White)
  People of color 1.42 [1.20, 1.69]*** 1.04 [0.86, 1.27] 0.58 [0.28, 1.21]
Primary gender today (female/woman)
 Male/man 1.69 [0.88, 1.30] 1.10 [0.89, 1.36] 0.84 [0.42, 1.69]
 Part-time 0.33 [0.25, 0.43]*** 0.49 [0.37, 0.64]*** 0.78 [0.34, 1.79]
  Not listed 0.92 [0.72, 1.18] 0.99 [0.75, 1.29] 0.98 [0.40, 2.41]
Sexual orientation (heterosexual)
 Gay/lesbian 1.12 [0.88, 1.44] 1.29 [0.99, 1.69] 1.41 [0.64, 3.13]
 Bisexual 0.98 [0.76, 1.25] 1.10 [0.84, 1.44] 0.92 [0.39, 2.16]
 Queer 1.62 [1.27, 2.08]*** 1.23 [0.94, 1.60] 0.60 [0.23, 1.57]
 Asexual 1.64 [1.07, 2.50]* 1.27 [0.76, 2.11] 1.70 [0.46, 6.33]
 Other 1.25 [0.93, 1.67] 1.00 [0.72, 1.39] 0.67 [0.21, 2.18]

Note. Odds ratios are adjusted for the other predictors in the model.
Brackets refer to 95% confidence intervals.
*p < .05. **p < .01. ***p < .001.

them reporting discrimination (OR = 0.97, 95% CI = [0.96, 0.98]). People of

color were more likely to report discrimination (OR = 1.42, 95% CI = [1.20,
1.69]) than participants who were White. Those participants who lived as
their authentic gender only part-time had a lower likelihood of reporting dis-
crimination (OR = 0.33, 95% CI = [0.25, 0.43]) than the reference category
of those living as female/women full-time. Participants who identified as
queer had a higher likelihood of reporting discrimination (OR = 1.62, 95%
CI = [1.27, 2.08]) than heterosexual individuals, as did those who identified
as asexual in reporting discrimination (OR = 1.64, 95% CI = [1.07, 2.50]).
14 Journal of Aging and Health 

Harassment
When compared with those younger than age 35, those aged 35 to 49 had a
lower likelihood of reporting harassment (OR = 0.50, 95% CI = [0.38, 0.66]),
as did those aged 50 to 64 (OR = 0.26, 95% CI = [0.20, 0.34]). Both the par-
ticipants who had private insurance and public insurance reported higher
rates of harassment than those with no insurance (OR = 14.09, 95% CI =
[9.37, 21.19] and OR = 3.68, 95% CI = [2.30, 5.88], respectively). The older
the age at which a participant began to transition part-time, the lower the
likelihood reporting harassment (OR = 0.96, 95% CI = [0.95, 0.96]).
Participants presenting as their authentic gender only part-time had a lower
likelihood of reporting experiences of harassment (OR = 0.49, 95% CI =
[0.37, 0.64]), than those reported living as female/women full-time.

Victimization
Participants aged 50 to 64 had a lower likelihood of reporting victimization
compared with those in the reference group of below age 35 (OR = 0.21, 95%
CI = [0.07, 0.60]). As the age of transitioning part-time increased, the likeli-
hood of that participant having reported victimization lowered (OR = 0.96,
95% CI = [0.93, 0.98]). All other variables were non-significant in predicting
likelihood of reporting victimization.

Discussion
The aim of this study was to use a national sample to examine how age relates
to experiences of health discrimination, harassment, and victimization among
transgender/GNC individuals. These forms of transphobia were unfortu-
nately common; more than one in five participants of any age reported having
experienced discrimination and harassment due to their gender identity at
some point when attempting to access doctors/hospitals, emergency rooms,
mental health centers, or ambulances/EMT. And, while only 2% of the sam-
ple reported experiencing physical victimization when attempting to access
services may seem low, incidents of health care providers physically victim-
izing transgender and GNC individuals did occur. These findings are similar
to previous research (Fredriksen-Goldsen et al., 2011; Kenagy, 2005) and
indicate that health and aging providers need to address transphobia that
occurs within our health service systems.
While experiences of health discrimination, harassment, and victimization
occurred across all age groups, older age groups reported less experience of
discrimination and harassment, yet a higher percentage of older transgender
Kattari and Hasche 15

and GNC participants reported victimization than those in the age groups 35
to 49 and 50 to 64 when compared with those below 35. When controlling for
insurance status, time of transition, level of passing, and socio-demographics,
older age was not related to reporting harassment and victimization, and indi-
viduals within the older age group were less likely to report discrimination.
These findings do not support the hypothesis that given potentially more
years of accessing health services and historic differences in transphobia over
time, that older age would increase the likelihood of reporting discrimination,
harassment, and victimization. Given that the experience of discrimination
was affected by age, this may be due to generational influences on how one
defines, recognizes, and discusses discrimination. If younger adults are more
inclusive in how they define discrimination than older adults, this could lead
to older adults under-reporting experiences of discrimination. Future research
should consider how definitions of discrimination, victimization, and harass-
ment might vary over time and across generational cohorts so that more accu-
rate age comparisons may be explored.
It is important to remember that all discrimination, harassment, and vic-
timization variables assess whether these experiences occurred throughout
the participant’s lifetime, and do not indicate the age or point of transition
during which these experiences occurred. Thus, disentangling the age group
and age of transition’s link to experiences of discrimination, harassment, and
victimization is complicated by the participant’s individual developmental
life cycle, historic changes in how health providers view transgender and
GNC individuals, and generational differences. The definition and diagnosis
around transgender identities have changed significantly throughout the past
few decades, moving from “cross-dressing” (defined as women dressed in
men’s clothing and vice versa in public) as a crime in the 1930s and 1940s to
a mental illness of gender identity disorder in the first four editions of the
Diagnostic and Statistical Manual of Mental Disorders (DSM), to transgen-
der individuals’ current place in discussion of rights and access (IOM, 2011;
Teich, 2012). Given recent policy and public initiatives to decrease stigma
and increase protections within health care settings (NCTE, 2014), historic
and prospective longitudinal research is needed to understand how age, his-
tory, and generational differences may influence rates of health care discrimi-
nation, harassment, and victimization.
Private insurance decreased the likelihood of experiencing discrimination,
while it increased the likelihood of reporting experiences of harassment com-
pared with those with no insurance. Having public insurance also indicated
an increased likelihood of reporting experiences of harassment. As there was
no variable regarding frequency of attempting to access health services, it is
possible that those with any insurance (public or private) attempt to access
16 Journal of Aging and Health 

these services more frequently than those with no insurance, increasing the
number of opportunities during which they could have experienced discrimi-
nation or harassment. Regardless, these findings do support the hypothesis
that experiences of discrimination, harassment, and victimization vary by
insurance status. These findings regarding the important role of insurance
status aligns with prior studies of health care use and experiences (Cruz,
2014; Flocke et al., 1997; Rask & Rask, 2000). Future research may need to
explore how different types of insurance may facilitate or minimize the expe-
riences of discrimination and harassment, especially as Medicare coverage
changes for hormone therapy, surgeries, and other treatments.
These numbers shed light on some of the challenges facing transgender
and GNC individuals around health care, even when they have access to
insurance. Currently, there is much debate on whether or not insurance com-
panies should remove “transgender exclusions” from their policies, which
explicitly refuse to cover certain needs of this population including hormone
prescriptions, gender alignment surgeries, removal of gonads and reproduc-
tive organs, and so on (Wong, 2013). Nationally, Medicare has issued a pol-
icy to remove these transgender-specific exclusions, offering more inclusive
care to individuals of all gender identities (NCTE, 2014). As Medicaid and
private insurance companies decide these things on a state-by-state basis, this
study’s results showcase the need for more regulation supporting transgender
inclusive health care, not only with medical providers but with insurance
providers as well. If insurance companies begin to cover more of these medi-
cations and procedures, it may have a legitimizing effect in the medical field,
eventually reducing the amount of discrimination, harassment, and victimiza-
tion that transgender individuals experience when accessing health care
services.
The older the age at which participants reported transitioning at least
part-time to their authentic gender, the lower the likelihood of them report-
ing having experienced discrimination, harassment, or victimization when
attempting to access health services. This is likely due to these cross-sec-
tional data reporting on a lifetime of experiences; if they had not yet begun
a physical transition to their authentic gender, they were less likely to be
perceived as transgender when accessing these services, and therefore less
likely to have experienced any of these transphobic issues. Similarly, partici-
pants who indicated that “people can tell I am transgender” more often were
more likely to report discrimination. Those who reported their primary gen-
der today as living part-time had a lower likelihood of reporting experiences
of either discrimination or harassment. For sexual orientation, participants
who identified as queer had higher likelihood of reporting experiences of
discrimination.
Kattari and Hasche 17

Although gender expression, gender identity, and sexual orientation are

different constructs, a common finding is that how visible and salient one’s
gender non-conformity is to others, or the use of labels that are less socially
understood, may influence how health care providers respond (Lombardi,
2001). For some transgender and GNC individuals, presenting as their
assigned/legal gender when attempting to access health services may be an
attempt to minimize the risk for discrimination, harassment, and victimiza-
tion. Yet, given the intimate nature of health care services, those living full-
time as their authentic gender may lack an option of how to present in a way
that may trigger less transphobia when accessing health services. It is prob-
lematic that individuals may be forced to choose to not be authentic in their
gender presentation to attempt to prevent experiencing discrimination, vic-
timization, and harassment. Health care providers should strive to eliminate
acts of discrimination, harassment, and victimization in all patient interac-
tions. A person who identifies as transgender/GNC or queer should be open
to express their gender or sexual orientation in a way that best matches their
identity instead of as a defense against discrimination, harassment, and vic-
timization (Whittle, Turner, Al-Alami, Rundall, & Thom, 2007). Prior
research highlights the right to self-definition as a crucial implication for
health and aging professionals (Siverskog, 2014). Furthermore, by increasing
inclusivity around gender and sexual orientation, we may be able to broaden
opportunities for successful and healthy aging (Fabbre, 2015).

Limitations
These data were all collected in a cross-sectional manner, which limits the
ability to look at any of these issues from a longitudinal perspective. In addi-
tion, all of the questions in the variables regarding experiences of discrimina-
tion, harassment, and victimization asked about lifetime experiences, rather
than frequency, or in any time frame. Intersectionality also needs to be taken
into consideration; parsing out whether someone’s experience of discrimina-
tion, harassment, and/or victimization was due to their gender presentation,
their sexual orientation, their race, their socio-economic status, their age, or
some other identity is incredibly difficult, if not impossible. Although these
variables specifically asked about experiences based on gender presentation,
it is possible that any given experience was based on multiple oppressed
identities.
As this survey was conducted online, it was therefore only accessible to
those with Internet access. It was likely distributed mostly to those indi-
viduals who were already connected to transgender communities and
advocacy groups, whereas those who are newly out as transgender/GNC or
18 Journal of Aging and Health 

are unconnected may not have heard about or had access to the survey.
While the larger sample of the survey was incredibly diverse in terms of
race and sexual orientation, racial diversity represented a much smaller
portion of those 65 and above. This is a limitation, as research on older
transgender identified people of color is a serious gap in the literature, and
this population is one that certainly needs to have their experiences shared
in the research. Fewer than 10% of the older age group were man/male
identified individuals or those whose gender was not listed. It is important
to note that this survey was conducted before the Affordable Care Act was
rolled out, so there are likely changes in who is insured today compared
with 2011.
As with any measure attempting to measure the experiences of construc-
tions like discrimination, it is incredibly hard to narrow down a definition.
Transphobia can occur in many ways when attempting to access medical ser-
vices, from flat out refusal to be seen, use of the wrong name/pronouns, extra
“precautions” being used (such as gloves being used for exams when they are
normally not), use of offensive language, assumptions about body parts, and
so on. Even with the language used of being denied equal treatment, this defi-
nition may mean different things to different people, including along age
group and generational cohort groups, as mentioned above. Because of this,
the data collected may actually be an underestimate given that participants
may not have recognized, defined, or reported incidents that were indeed
discrimination, harassment, or victimization.
Future research should examine lifetime experiences of discrimination,
harassment, and victimization, as well as experiences of these post-transition,
and in the last 12 months, so as to better understand the nuances of these
experiences, as well as give more specific time frames. In addition, more
specific definitions and descriptions of what discrimination, harassment, and
victimization are would allow participants to be more specific in their
answers, and for research to be more accurate measurement. Other questions
that would be useful would be whether these experiences of transphobia were
perpetuated by medical providers, by administrative staff, or other people
present in the health care setting so that interventions could be catered more
specifically toward what would have the most impact. In addition, research
that examined more specifically the type of services, such as preventive
checkups, planned surgery, gender-specific surgery, individual therapy, group
therapy, as well as the participant’s report of the level of transgender inclu-
siveness offered by the provider, could provide a deeper understanding of
these experiences with the goal of offering education and cultural responsive-
ness training to change climates around transgender/GNC issues, creating
safer, more inclusive spaces.
Kattari and Hasche 19

Implications and Conclusions

Recent progress in policy changes that have supported more inclusive services
for transgender/GNC individuals, such as the change in Medicare to eliminate
transgender-specific exclusions (NCTE, 2014), demonstrates that a window of
opportunity may exist to promote inclusive insurance policies. Medicaid is regu-
lated on a state-by-state basis (compared with Medicare, which is regulated fed-
erally), and could be a next step in removing transgender exclusions in insurance
policies. More inclusive policies at the state level could be enacted with support
from state-specific Division of Insurance (DOI) bulletins, such as Bulletin 4.49
issues by the Colorado DOI, requiring that all Colorado insurance plans remove
any transgender-specific exclusion by 2015 (Colorado Department of Regulatory
Agencies Division of Insurance, 2013). Other areas that could benefit from
examination of and changes to their policies include public health, state com-
missions on health and equity, and the military’s insurance programs.
Given the recent changes in Medicare and this study’s findings, cultural
competency/responsiveness trainings of health care providers that are spe-
cific to transgender/GNC individuals are crucial. In addition to giving health
care providers the education and skills needed to provide more inclusive care
to transgender/GNC patients, these trainings could shift attitudes and behav-
iors. It is also important to consider the intersectionality of any individual,
given other demonstrated risks related to vulnerable social identities. When a
client holds multiple identities that are socially marginalized, they may have
an increased likelihood of experiencing negative outcomes when attempting
to access health care services. Therefore, these trainings should not only
address the transgender/GNC community but also other identities such as
age, race, and sexual orientation that may intersect with gender, and therefore
further impact clients’ experiences with health care settings.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The authors received no financial support for the research, authorship, and/or publica-
tion of this article.

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