The World Health Organization framework of soci= al determinants is very illustrative in the quest to understand transgender health. As demonstrated in th= is study, the three primary pathways through which social determinants affect transgender health are social exclusion, (lack of) social support, and stress. Each of these factors constitutes a major negative impact on the health outcomes of transgender people. The research here sho= ws how stress related to gender variance can emerge as soon as a person becomes aw= are of an internal difference, often as early as age five or six. This can be quickly followed by a = drop in social support from the birth family as they struggle to suppress the emerging gender variance in their child.&n= bsp; This drop in social support follows the family awareness of the child’s gender variance, and can emerge relatively near the childR= 17;s own personal awareness. Stori= es from this sample showed several people who faced this challenge before the = age of ten. Social exclusion can = also be present at this young age, primarily through hostility encountered in the educational system. Participa= nts in this study talked about this occurring as early as age six, and by the pret= een or teen years it was a widespread phenomenon.
The life histories document how these three soc=
ial
determinants can and do have a deleterious impact on people’s health =
from
a very early age. As the lite=
rature
on social determinants demonstrates, health impacts early in life have a
proportionately larger impact on lifelong health than those accrued later ADDIN EN.CITE
<EndNote><Cite><Author>Wadsworth</Author><Year&g=
t;1999</Year><RecNum>82</RecNum><record><rec-num=
ber>82</rec-number><ref-type
name=3D'Book Section'>5</ref-type><contributors><authors&=
gt;<author>Wadsworth,
M</author></authors><secondary-authors><author>Marm=
ot,
M</author><author>Wilkinson,
R</author></secondary-authors></contributors><titles&g=
t;<title>Early
Life</title><secondary-title>Social Determinants of
Health</secondary-title></titles><pages>44-63</pages&g=
t;<dates><year>1999</year></dates><pub-location&=
gt;New
York</pub-location><publisher>Oxford University
Press</publisher><urls></urls></record></Cite>=
;<Cite><Author>WHO
Regional Office for Europe.</Author><Year>2003</Year><=
RecNum>2</RecNum><record><rec-number>2</rec-number&=
gt;<ref-type
name=3D'Electronic Source'>12</ref-type><contributors><au=
thors><author>WHO
Regional Office for
Europe.,</author></authors></contributors><titles>&=
lt;title>Social
determinants of health: the solid facts</title></titles><vol=
ume>2005</volume><number>February
6th</number><edition>2nd</edition><dates><year&g=
t;2003</year></dates><pub-location>Denmark</pub-locati=
on><publisher>World
Health Organization</publisher><isbn>92 890 1371
0</isbn><urls><related-urls><url>http://www.euro.wh=
o.int/document/e81384.pdf</url></related-urls><pdf-urls>&=
lt;url>http://www.euro.who.int/document/e81384.pdf</url></pdf-u=
rls></urls><research-notes>The
field of the social determinants of health is perhaps the most complex and
challenging of all. It is concerned with key aspects of people’s livi=
ng
and working circumstances and with their lifestyles. It is concerned with t=
he
health implications of economic and social policies, as well as with the
benefits that investing in health policies can bring. 
Agis D. Tsouros
H=
ead,
Centre for Urban Health
WHO Regional Office for
Europe</research-notes></record></Cite></EndNote>
The findings show that, while not a uniform eff= ect, anything that served to delay a person’s ostracization for their gend= er variance tended to enable people to gain the benefits of early life supports. Some participants d= id not become aware of their gender variance until later in life. Others used coping strategies such= as alcohol or suppressing their gender variance to gain temporary acceptance. = Still others were able to find a supportive community for their early gender variance, most often among lesb= ians (i.e. female jocks in high school accepting the male-acting Craig easily).<= /p>
The three major adverse social determinants, to= gether with the high likelihood of a negative interaction with early life experien= ces, create a cascade of effects that impact each of the other six categories of social determinants. Social exclusion can have a negative effect on basic life supports such as housing= and employability, resulting in a precipitous slide down the social gradient in= to extreme poverty for some transgender people. Stress from many areas often= leads to the use of addictive substances as a coping strategy. Both poverty and the stress of vio= lence can impact food and transportation. Participants talked about their survival strategies in reference to getting enough food to eat as well as to their curtailed choices in transportation (and therefore exercise) modes.
The participant stories also demonstrated varia= bility in the above trends, reinforcing Link and Phelan’s reminder that in stigmatized populations “no one is fully trapped in a uniform disadvantaged position” (p. 380)27. Individual traits or opportunities obviously influenced this variability.&nbs= p; Demographic markers influenced it as well, sometimes creating trends= as they moderated the influence of the primary social determinants. Four of these demographic markers = will be discussed here: the ability to pass, early life SES, race/ethnicity, and gender vector.
As noted in the methods section, the participant population was heterogeneous on these demographic markers. This heterogeneity serves to stren= gthen the import of the trends that emerged across the population. As well, it strengthens the claim = that gender variance was causal in a portion of these outcomes, as that is the common factor shared by all participants.
The ability to pass as gender normative and ear= ly life SES both demonstrated a strong interactive effect with social determinants. In general, the people who could pass as gender normative could shield themselves from some adverse health effects, and therefore retain greater stability. Likewise, people who started life = at a higher SES, particularly those who obtained the most education, had more supports to use in resisting the negative influence of the adverse social determinants.
To a lesser extent an interactive effect was al= so noted between social determinants and the last two demographic variables: gender vector and race/ethnicity. The participant sample showed a clear association between gender vec= tor and life chances. MTFs report= ed less stability and greater exposure to adverse social determinants than FTM= s. Likewise there was a strong associ= ation between race or ethnicity and life chances. People of color reported less stab= ility and greater exposure to adverse social determinants than white people. Some information did emerge about = these relationships, for example: FTMs talked about how they felt their gender ve= ctor shielded them from some exposure to violence; a Black male participant talk= ed about how his race and gender variance interacted to move him down the soci= al scale; and an outreach worker spoke about how transgender people of color w= ere at the highest risk for street hostility.&= nbsp; These experiences are congruent with existing literature demonstrati= ng the multifaceted effects of both gender and race on social determinants57, 210-212 and support the hypothe= sis that both gender vector and race or ethnicity do interact with gender variance. But limitations of = this sample made it difficult to further hypothesize about the impact of these factors, since each was highly correlated with strong interactions noted previously. Gender vector was highly correlated with ability to pass; all but one of the FTMs in the study could pass at will. Likewise = race was correlated with early life SES; participants who were people of color h= ad lower early life SES. As a re= sult, we must rely on future studies to provide a clearer understanding of these = two relationships.
A core focus in sociology is the study of the u=
nequal
distribution of what Weber terms “life chances,” both through
access to important societal resources and perceived ability to achieve sta=
tus
or satisfaction.213 A key finding from this study is t=
he
extent to which life chances for transgender people are, through a variety =
of
different pathways, essentially compromised. The many manifestations of gender
oppression create a form of structural violence that acts to bound the abil=
ity
of a transgender person to achieve.
Excellence in work is bounded by lack of access to education and
employment. Excellence in
relationships is bounded by persistent social rejection. Excellence in community participat=
ion is
bounded by systemic social exclusion.
The ability to achieve status is bounded by the accumulated effect of
all of the above factors. For=
most
transgender people, the structural violence that creates this persistent
bounding acts to push them downward along the social gradient. This frequently results in overwhe=
lming
poverty, trauma, and severely compromised self-esteem. In the course of this journey, peo=
ple
experience enduring strain, a phenomenon that has been conceptualized as
increased allostatic load53 and bears great similar=
ity to
Geronimus’ concept of early “weathering” within the black
community. 214, 215 However it is
conceptualized, this strain leads to measurable negative health outcomes.
Although transgender people clearly experience a number of adverse health outcomes, the issue of compromised life challenges cannot be raised without its associated context; transgender people’s persistent achievement of survival. Link and Phelan point out how researchers commonly perpetuate their = own context-stripped perspective of stigmatized communities, in this case throu= gh the portrayal of a stigmatized group as victims and not also challengers. ADDIN EN.CITE <EndNote><Cite><Author>Link</Author><Year>200= 1</Year><RecNum>76</RecNum><record><rec-number&g= t;76</rec-number><ref-type name=3D"Journal Article">17</ref-type><contributors><authors><= author>Link, B.G.</author><author>Phelan, J.C.</author></authors></contributors><titles><t= itle>Conceptualizing Stigma</title><secondary-title>Annual Review of Sociology</secondary-title></titles><periodical><full-= title>Annual Review of Sociology</full-title></periodical><pages>363-385</pag= es><volume>27</volume><dates><year>2001</year= ></dates><urls></urls></record></Cite><= /EndNote>27 Given the litany of adv= erse social determinant transgenders face, it is important to emphasize the behaviors and beliefs that allow people to live even within the bounds that= are set on their achievement. What is remarkable about this group is that survi= val is—and is perceived as—a daily and willful act. The achievement of survival is especially evident in the stories of older participants. Although no one in this group is o= ver 55, many have outlived many of their early-life companions and are extremely aware of their role as “elders” in a community that is faced wi= th high levels of violence. These participants know that they must continue to overcome obstacle= s to stay alive. Younger transgend= er people are also aware that they cannot take their continued survival for granted. The words of one 25 year-old participant demonstrate this ever-present challenge. While she talks about her hopes to= find a man and get married soon, she chillingly prefaces her discussion of future aspirations with the caveat that in five years “who knows if I will be alive or dead”.
Taken as a group, the participants use a wide v= ariety of strategies to survive challenges to their health and well-being. In spite of a general lack of social support, friendships or mentorships were a source of both personal support and key survival strategies for many participants. Participants talked about the less= ons they were taught in how to make money, avoid violence, and/or pass as the t= rue gender. For MTFs, mentorship = at times provided orientation on how to successful navigate the dangerous worl= d of sex work. Sex work itself was another survival strategy, particularly for transgender women who experienc= ed exclusion from legal forms of employment. Survival per se (i.e. remaining alive in the face of structural violence) was one challenge for participants. Surviving as transgender= was another. Participants went to= great lengths to express their true gender despite the violence that they faced. = More often than not participants withstood family alienation, discrimination, and violence in order to survive as transgender.
This study demonstrated that the lived experien= ce of transgender people is one of compro= mised survival. Life histories repeatedly demonstrated a simple concept: accepting that you are transgende= r is imperative for your mental health, but conversely, any public display of ge= nder variance puts you at risk for losing everything. Through the twin routes of stigma = and discrimination transgender people in general receive a lesser share of the = life chances distributed among the full population, resulting in their compromis= ed status. This compromised stat= us carries a constant threat of early mortality, a threat which is reinforced = by the many community stories of those who did not survive. But it also engenders the fight for survival. In acts large and s= mall participants demonstrated their skills in survival, engaging in a constant battle against societal opposition to their gender variance.
As briefly mentioned previously, negative stere= otypes about transgender people pervade our social consciousness. Without personal experience with m= embers of this rare population, many people’s knowledge of transgender peopl= e is limited to these stereotypes. This negative stereotyping is key to identifying transgender people as “other,” ultimately perpetuating discrimination against the gro= up and playing into a larger classic cycle of stigma27. The lens of social determinants is particularly valuable for researching groups beset by such stigma. Using this framework researchers a= re forced to look backwards in the causal chain, and to examine the role socie= ty plays in creating outcomes. W= ith this scrutiny, shallow stereotypes start to fall apart, replaced by a fuller understanding of the interaction between individual and social influences.<= span style=3D'mso-spacerun:yes'>
The challenges of sampling hidden populations h= ave been the subject of increasing research over the last decade.28-30, 190-19= 4 The need to gain inform= ation on populations such as HIV-po= sitive people or intravenous drug users has spurred the emergence of new sampling = and estimation methods such as respondent-driven sampling, chain sampling, and capture-recapture estimation.28, 191, 216<= /sup> Most often, social networks play a critical role in providing access to otherwise unreachable people. One of the secondary research ques= tions on this project was to test the viability of the methods proposed to build a community sample. As shown in Chapter 3, demonstrating value in the research, and carrying that value for= ward through the power of social networks was a successful method for gaining ac= cess to this hidden population. Th= ese concepts build directly on the precepts inherent in participatory action research196 and ultimately add to t= he knowledge of successful strategies for accessing hidden populations.
This research was originally posited as explora= tory, and the limitations of existing research in these areas were well documente= d at the outset. One of the most dramatic limitations in existing knowledge is regarding the people who show= an inordinate interest in transgender people.= Some of these people demonstrate their interest as fascination or fe= tishization of sex with transgender partners (i.e. the johns), and others show it throu= gh the strength of their adverse response to transgender people (i.e. through violence or blatant discrimination). The high number of incidents of violence from sexual partners shows = how these groups often overlap. T= his lends strength to the argument that research should look at the phenomena of inordinate interest broadly, and not try to artificially separate out the positive or negative interest.
Gender oppression is clearly woven deeply into = the fabric of our society. The co= ncept of a single public health intervention or even class of interventions chang= ing social mores on this subject is unrealistic. But there are clearly smaller scale interventions that must be initiated to begin this tide of change. These interventions will be more effective if built upon a stronger base of knowledge about the psychology t= hat creates hostility towards transgender people.
The body of research on transgender health is strongest in two areas: clinical management of body modifications (i.e. publications on surgical interventions), and documentation of health risks = and outcomes (i.e. needs assessment surveys).&= nbsp; Additional research must be conducted earlier in the causal chain, specifically around social determinants of transgender health. The issues of stress, trauma, and isolation that emerge in this study are all key health issues for this popu= lation, and each warrant further in-depth study.&n= bsp; I would also advocate for initial research in these veins to continu= e to follow the mode of qualitative inquiry.&nb= sp; While I have framed this research study as exploratory, I am left convinced that immediate research into the areas of stress, trauma, and iso= lation should also be exploratory. W= e are only beginning to understand how these issues affect this population, and research methods should be carefully chosen to reflect this state.
While
additional study is clearly important, information from this research shows
there are actions that can immediately impact transgender health. Recommendations on high impact act=
ions
are presented in the following sections.&n=
bsp;
One of the significant findings from this study= was the extent to which early life gender oppression can exclude transgender pe= ople from the educational system. = In many instances, this gender oppression was experienced within the school itself. This experience of oppression was so great that participants who recalled running away from ho= me in childhood or adolescence described it as escaping school as well as esca= ping family life. It is incumbent = on the educational system to counter any institutionalized practices that undermine the safety of the students. G= ender oppression against transgender people is one such institutionalized risk th= at exists in the educational system. Too often students have no support within their educational system to counter gender oppression, leaving them to conclude that such oppression is acceptable.5 The GLSEN School Climate survey of= 2003 showed how little support students have, and how much difference some suppo= rt can make. LGBT students who d= id not think any school policy protected them from violence and harassment were ne= arly 40% more likely to skip school than those that did. Additionally, eighty-three percent= of harassed students report that faculty rarely or never intervene when they witness these events.155
Unfortunately, a vast majority of students nati= onwide do not have any policy level protections against school-based discriminatio= n, making the need for change that much more urgent.217 Several national organizations have created tools to address and counter transgender discrimination in the educ= ational system.218-223= These tools include trainings, fil= ms, volunteer speakers, and model anti-discrimination policies. These resources emphasize a three-= step process for creating a safe school: create protective policies; train stude= nts and teachers into higher levels of awareness on these issues; and create a policing process to ensure the environment achieves the desired level of sa= fety. The widespread integration of= these tools into our educational system would constitute one of the highest impact changes in respect to transgender health.&= nbsp; Since the educational system plays a key role in early life stress, self-image, and experiences with social exclusion, countering its current toxicity to transgender students is a critical step in keeping transgender youth stable.
As seen in several of the narratives from this =
study,
transgender people are at risk for experiencing significant stress, social
exclusion, and concomitant low levels of social support early in life. These factors can undermine a
person’s base of health, leading some into a period of significant
personal instability. For two=
people
in this relatively small sample of 13 life history participants, these
determinants had the effect of stripping them of so many supports that they
were reliant on sex work for survival by the age of twelve. For others, while they remained
relatively protected by living at home, a different yet still significant l=
evel
of personal instability was created by beatings, abuse, or the deleterious
effects of coping strategies like drug or alcohol use. I have made a choice in representi=
ng
these findings to categorize issues such as abuse and violence under the so=
cial
determinants “Stress” and “Social Exclusion” instea=
d of
under the separate social determinant of “Early Life.” But while they are arguably direct
effects of the categories above, their impact on individuals is heightened
specifically because they occur in early life, a time that has been shown t=
o be
particularly influential in determining individual lifelong health. The strength of the adverse impact=
of
these early life events demonstrates the potential positive impact that cou=
ld
be achieved with services designed to moderate this early life strain. Further, this is a service area th=
at is
sincerely deficient, as demonstrated by Shira Hassan’s concern that t=
here
are no emergency beds for homeless trans youth in
As of Spring 2005, five states, ten counties, a= nd 62 cities in the U.S. had passed anti-discrimination laws that included gender identi= ty or expression.217 From 1975 through 1996, such legis= lation was passed in one or two localities every few years. In 1997, this trend curved sharply upwards, with four to fifteen new localities passing the legislation each year. In all, the National Ga= y and Lesbian Task Force’s Transgender Civil Right’s Project estimates that 27% of the current United States population is legislatively protected from discrimination based on gender identity.224 This legislation most commonly cov= ers four broad areas: public accommodations, employment, housing, and right to private action. However, it i= s only a much smaller subset of these laws, 26 of 77, that also guarantee these protections within the educational system217.
Individuals, organizations, and legislators can= all impact transgender health by directly aiding the efforts to introduce and p= ass protective legislation for gender identity in both the civil rights and educational arenas. While legislation is no insurance against discrimination, its passage alone disru= pts the widespread social message that it is acceptable to discriminate against transgender people. Efforts to disrupt this message through legislation likely have added impact in the current political climate. The passage of 16 state laws codifying LGB discrimination related to marriage during the 2004 presidential election campaign has led many pundits to conc= lude that anti-LGBT sentiments were a watershed issue that determined the outcom= e of the election. Unfortunately, = this highest level of public debate on issues related to LGBT protections ended negatively, reinforcing for many a public climate of discrimination. The National Gay and Lesbian Task = Force issued a report countering this conclusion, showing how 60% of voters actua= lly supported same-sex marriage or civil unions. But the media reporting on this su= bject reached a much wider populace, NGLTF admits that it is “accepted as common wisdom” that same-sex marriage determined the election (p.2).<= !--[if supportFields]> ADDIN EN.CITE <EndNote><Cite><Author>Sherrill</Author><Year>= ;2004</Year><RecNum>141</RecNum><record><rec-num= ber>141</rec-number><ref-type name=3D"Electronic Source">12</ref-type><contributors= ><authors><author>Sherrill, K.</author></authors><secondary-authors><author>Nat= ional Gay and Lesbian Task Force</author></secondary-authors></contributors><titl= es><title>Same-sex marriage, civil unions, and the 2004 presidential election. </title></titles><pages>electronic report</pages><volume>2005</volume><number>March 31</number><dates><year>2004</year></dates>&l= t;publisher>National Gay and Lesbian Task Force</publisher><urls><related-urls><url>http://ww= w.thetaskforce.org/downloads/MarriageCUSherrill2004.pdf</url></rel= ated-urls></urls></record></Cite></EndNote>225 This dramatic reinforcement of a p= ublic climate of discrimination has impacted many, making immediate efforts to counter it that much more needed and valuable.
According to HRC’s WorkNet database, as of Spring 2005, 238 employers currently have non-discrimination policies that include gender identity.226 These employers are a valuable and needed resource for transgender people struggling against the social exclus= ion that often limits their access to basic supports such as employment. Every time another employer makes = this policy change, the climate of social exclusion is opposed, ultimately benefiting transgender people well beyond the employee base of the company. Individuals can dire= ctly impact this process by advocating for non-discrimination policies at their place of employment.
The climate of social exclusion for transgender people has a very personal deleterious effect on individual’s health. Policy changes opposing this climate of social exclusion offer two benefits. They result in direct benefit to a subset of people whose lives intersect with the policy. But perhaps more importantly, chan= ging these policies begins to build a social message that exclusion is not acceptable. Many policy chang= es are initiated by individual efforts, making this a realistic path by which an individual can impact issues related to transgender health.
Legislation protections and workpla=
ce
non-discrimination have been highlighted here due to their far-reaching
effects, but transgender-supportive policy changes are needed at a host of
different levels. For example,
changing the discrimination policies of a local homeless shelter can provid=
e an
immediate and possibly life-saving health benefit to transgender people.
This research was conducted in the unique envir=
onment
of
Living in a world bounded by stress, violence, = social exclusion, and too little social support makes ongoing access to appropriate mental health care a necessary foundational component for transgender health. Too many transgender = people live outside the catchment area of the few existing transgender-focused men= tal health programs. For some, is= sues related to low SES will create an additional barrier to accessing these services. Issues related to l= ow self-esteem can create an additional barrier to seeking mental health services. Some people have li= ved under the strain of social exclusion for so much of their lives that they m= ight be relatively isolated from the concept of mental health.
From the health professional perspective, trans=
gender
people need to have early and consistent access to mental health services
designed to help ease the strain of living with extreme social exclusion.
Current technology makes the idea of a nationally-based phone-in counseling service feasible, and this should be considered as one potential high-impact intervention. The concept comes with many built = in challenges, and should not be moved forward without some level of community= -based consideration and (if appropriate) development. This intervention might not be abl= e to provide the level of in-depth services or trauma recovery that some will ne= ed, but it could provide a critical stabilizing effect for a large group of peo= ple.
As amply demonstrated in this study, extreme so= cial exclusion has widespread destabilizing effects on this population. When transgender people are pushed= down the social gradient, they are in high need of interventions and services to help them survive this transition, and ideally rebound into a higher social gradient. As such, basic life stabilizing services such as housing, food, employment, and medical care ar= e a high priority. Providing these services piecemeal would have a lower impact for those most severely impact= ed by gender oppression, because their daily battle to survive drains the ener= gy needed to navigate complicated social service structures. For this group, the bundling of th= ese services together or the provision of additional people to assist navigation of the social service structure is also a high priority.
The literature review demonstrates areas where significant segments of the transgender population stand out as experiencin= g a higher negative effect of some health outcomes than other underserved populations. These patterns e= merge with HIV, hate-crimes, silicone injection, and some addiction issues. The information in this study star= ts to build a context for these early data. The confluence of strong negative social determinants of health shows how transgender people are routinely left as the most unstable of all unsta= ble people. For example, am= ong the high risk population of sex workers, a transgender sex worker is likely= to experience an additional measure of barriers preventing them from leaving t= hat industry. Barriers to obtaini= ng housing, employment, or even a room at a shelter for the night serve can be= the most extreme for transgender people. As such, these transgender people routinely present with the greatest measure of adverse health effects, such as HIV infection rates or addiction rates. Interventions and serv= ices that are tuned to these experiences must be prioritized. Examples of these would include: interventions to provide alternatives to silicone use, addiction recovery interventions, transgender-tuned HIV services, or interventions to provide = viable alternatives for the many transgender people looking to stop sex work. Successful tuning of these service= s or interventions would emphasize accessibility of the services. Examples of accessibility measures= include: incorporating community members into the planning process; providing the services after-hours and at existing community-gathering locations; or promoting the service through community-based key-influencers.
The social determinants framework serves to mov= e the discussion about transgender health backwards from the calculus of risk behaviors towards a greater understanding of how that risk profile is created. Such contextualizing= is especially important in studying the highly stigmatized population of transgender people. It = is my hope that the lessons about stigma, social bounding, gender oppression, and survival that emerge from this work can be applied to a variety of different contexts, both within and outside the transgender communities. Gender oppression has long been id= entified as a pervasive structural violence that impacts a broad swathe of the population. This work reinfor= ces and adds to that body of knowledge. &= nbsp; Perhaps more importantly, it also operates at a local level, carryin= g a message of urgent need for structural interventions to stabilize transgende= r people. While this research was initiated = within the academic arena it is not bounded by the constraints of discussion and education. I urge readers to = use this information in the spirit that it was developed, as a platform for action. This material challen= ges each of us to use the tools at our disposal to aid one or more transgender people in achieving survival.
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