15 2 Inland Empire Transgender transgender male feminine male androgynous nonbinary female gender variant butch cross-dresser gender queer drag king two-spirit poly-gender male intersex transexual transgender female gender non-conforming masculine female transgender Health & Wellness Profile Riverside University Health System - Public Health   Table of Contents Foreword……………………..………………………………………………………………………………………… 2 Executive Summary….…………………………………………………………………………………………… 3 Acknowledgements ……………………………………………………………………………………………… 4 Introduction…………………………………………………………………………………………...…………..…. 5 Methods……………………………………………………………………………………….……………………… 7 Participant Pro ile Gender Identity…………………………………………………………………………………….……… 9 Age, Race and Sexual Orientation………………………………………………………….………. 13 Income……………………………………………………………………………………………….……….. 14 Education………………………………………………………………………………………….…………. 15 Work Discrimination…………………………………………………………………………...………...…… 16 School Discrimination…………………………………………………………………………..…………….. 18 Health Care Access…………………………………………………………………………………...…………. 20 Behavioral Health Care……………………………………………………………………………..………… 28 Police Interaction……………………………………………………………………………………………….. 30 Sexual Assault and Intimate Partner Violence…………………………………………………... 31 Housing……………………………………………………………………………………………………………….. 32 Needed Services……………………………………………………………………………………………….. 33 Conclusion and Recommendations ………………………………………………………………... 34 Appendices Glossary of Terms………………………………………………………………………………………… 36 Survey Questions and Responses………………………………………………………………….. 38 References….……………………………………………………………………………………………………….. 54 Foreword At its most elemental, the Riverside University Health System strives to ensure and preserve the good health of all Riverside County residents. We know instinctively that future health outcomes are strongly affected by the cultural, social and environmental factors we live within, and critical to achieving the Health System mission is to highlight disparities in those factors within our county’s diverse populations that put them at risk. Our inaugural report on the health and wellness of the Lesbian, Gay, Bisexual, Transgender community sparked substantial productive discussion on how the health and welfare of these critically underserved populations can be improved and we hope that this needs assessment focusing on the transgender population will do so again. With the increasingly robust data this and future reports will bring to light, such conversations can start to lead towards meaningful solutions. Every Riverside County resident should have an equal claim on good health. By giving a voice to this community through stakeholder inclusiveness and rigorous, careful data collection, this report is yet another way to make that goal possible. Cameron Kaiser, MD, MPH Public Health Of icer County of Riverside February 2017 2  Executive Summary The collection and use of data is fundamental to ensuring an equitable distribution of public health resources and the development and provision of accessible health programs. Data on the health and wellness needs of the transgender community is severely lacking. This report and the needs assessment survey it summarizes are among the irst steps in improving our understanding of the transgender community in Riverside and San Bernardino counties. This report is based on 90 survey participants from across Riverside and San Bernardino counties. Transgender: An umbrella term used to describes people who identify with or express a gender different from the gender assigned to them at birth. Key Findings:  Current studies estimate the transgender population of the Inland Empire at nearly 27,000 people.  Respondents to the survey had higher education levels but lower income levels than the general population.  Almost all survey respondents had some form of health insurance (93.3%).  Three quarters of respondents indicated that they had seriously considered committing suicide and over two‐thirds (67.8%) reported having depression or an anxiety disorder.  More than half (56.7%) of respondents have been physically and/or emotionally abused by a partner or someone close to them.  Over a third of respondents said it was “not at all easy” to ind medical (40%) or mental health (39%) providers with suf icient knowledge of and experience with transgender people.  Many respondents reject the concept of a male/female gender binary and have identities that are not exclusively male or female.  A quarter of respondents reported experiencing verbal harassment at work.  Nearly three quarters of respondents reported being bullied or harassed by other students at school.  Over half of respondents said they were very or somewhat uncomfortable seeking help from the police.  Nearly 20% of respondents reported being kicked out of their family home.     “As transgender people we don't want special treatment or favors, we just want to be treated like everyone else and live the same life as everyone else.” 3  Acknowledgements This report was prepared by Aaron T. Gardner, MA, MPH and Erin Curlee, BS Riverside University Health System – Public Health, Epidemiology & Program Evaluation RUHS‐Public Health Contributors: Wendy Hetherington, MPH; Amy Hyong, MS, MPH; Cameron Kaiser, MD, MPH; Sarah Mack, MPH; Rachaline Napier, MPH; Dianne Leibrandt, MPH, MSc; Michael Osur, MBA; Sheena Patel, MPH; Salomeh Wagaw, MPH. Interns: Samantha Aguilar, California Baptist University; Daniel Pagan, MA, MPH, Claremont Graduate University; Aaron Thon, Claremont Graduate University; Rebecca L. Whitaker, California Baptist University. External Review Panel: This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The intent of this independent review was to provide candid and critical comments that would assist the RUHS‐Public Health in making this report as sound, useful, and culturally competent as possible. Thomi Clinton Judith Davis‐Tolbert Chief Executive Of icer Community Activist Transgender Community Coalition County of San Bernardino Department of Public Health Review: Daniel Perez, MSW, MPA Andrea Rodriguez, MS Bonnie Flippin, MBA Division Chief Senior Statistical Analyst Administrative Supervisor Disease Control & Prevention Community Outreach and Innovation Ryan White Program While the reviewers provided many constructive comments and suggestions, they were not asked to endorse the report; nor did they see the inal draft of the report before its release. Individuals and organizations that provided input on early drafts of the survey include: Amy Whelan, National Center for Lesbian Rights; Aydin Kennedy, MSW, St. John’s Well Child and Family Center; Rev. Benita Ramsey, Principal, BRMG, UFCC Get Covered Campaign, Director Rainbow Pride, Pastor UFCC Riverside; Borrego Health Foundation; Clay Decker Cross; Christian Mendez, Operation SafeHouse; Desert Center for Sexuality Awareness; James Williamson, Palm Springs Uni ied School District; Kristen Kelly‐Dolan, SafeHouse of the Desert; Kristie Handzik, Temecula PFLAG; Linda McFarlane MSW, LCSW, Just Detention International; Maria Louise Roman, APAIT; Shelly Ann Ahlerich, Riverside PFLAG; Susan Thronson, Palm Springs PFLAG; Tom Page, Traci W. Lowenthal, Psy.D. Please use the following citation when referencing this report: Riverside University Health System ‐ Public Health. (2017). Inland Empire Transgender Health and Wellness Pro ile, 2015. We appreciate any questions or comments that you may have about this report and welcome recommendations for improving subsequent reports. If you have any comments to share please contact us at: Epidemiology and Program Evaluation Riverside University Health System – Public Health Phone (951) 358—5557 www.rivcohealthdata.org www.shaperivco.org 4  Introduction Transgender and gender non‐conforming individuals face many forms of discrimination that affect their health. To achieve health equity, we need to understand the current health status of all Inland Empire residents. When it comes to transgender health, there is limited information about the health issues affecting this population. Local data collection is a key step to increase our knowledge and understand issues affecting the transgender community. This needs assessment should be considered a irst step in guiding future research and health programs in the Inland Empire and not as a representative description of all people who identify as transgender in the Inland Empire. In 2014, Riverside University Health System – Public Health (RUHS‐PH), along with community partners, published the irst ever LGBT Health & Wellness Pro ile for Riverside County (County of Riverside, 2014). This report highlighted the de icit of data on the health needs of the local transgender population. In response to this lack of data, RUHS‐PH agreed to provide technical assistance to transgender community groups for the creation, distribution, analysis and inal report of a comprehensive transgender needs assessment survey. On behalf of participating community groups, this survey was distributed throughout Riverside and San Bernardino counties in the summer of 2015 to gain a better understanding of the transgender population’s health needs. This document summarizes the indings from this needs assessment survey. The combined counties of Riverside and San Bernardino, commonly referred to as the Inland Empire (IE), has a total population of 4,489,159 residents, spanning over 27,000 square miles. Geographically, the Inland Empire is roughly equal to the states of New Hampshire, New Jersey, Connecticut, Delaware and Rhode Island combined. The collective population of the two counties also exceeds the population of 25 states in the United States (US Census Bureau). The Inland Empire encompasses 52 incorporated cities, 58 school districts and is ethnically diverse; 48% are Hispanic, 35% White, 7% Black or African American, 6% Asian, and 4% all other (American Community Survey, 2015). National or local data are unavailable on the total number of transgender people. However, according to a recent study published by The Williams Institute, 0.6% of the US population is transgender (Flores, Herman, Gates, & Brown, 2016). Using this estimate, the 2015 transgender population of Riverside County is approximately 14,166 individuals and San Bernardino County 12,769. 5  The mission and goals of Riverside University Health System – Public Health align with the four overarching national goals of Healthy People 2020, which are: · Attain high‐quality, longer lives free of preventable disease, disability, injury and premature death · Achieve health equity, eliminate disparities, and improve the health of all groups · Create social and physical environments that promote good health for all · Promote quality of life, healthy development and healthy behaviors across all life stages Providing the technical assistance to community partners in developing this report is one of many steps the RUHS‐PH is taking to promote and protect the health of all County residents and visitors. This report explores the signi icant gaps in transgender health data and services so that county agencies and local non‐pro it organizations can collaborate to close those gaps and work toward health equity. 6  Methods Initial survey questions were developed using the National Transgender Discrimination Survey (NTDS) and the California Health Interview Survey (CHIS) as templates. Drafts of the survey were reviewed by numerous community partners for critical feedback and re inement of the survey instrument. Once inalized, the survey was distributed by website, Facebook, email, and paper, and announced in both the Press Enterprise and The Desert Sun newspapers. The survey was open from May 1, 2015—August 1, 2015. The survey contained 78 questions over 10 domains covering demographics, self‐identity, housing, transportation, discrimination and bias, physical and emotional health, health care access, tobacco, alcohol and other drugs, school, police and the justice system, intimate partner violence, available services and social support. Of the 140 total respondents, 27 did not reside in the Inland Empire, 21 were cis‐gender (gender‐conforming), and two did not complete the survey. After data‐cleaning, the inal study sample included 90 valid respondents (72.2% Riverside County, 27.8% San Bernardino County). The map on the next page (p. 8) shows respondents by city of residence. 7  Map of the Inland Empire Survey Sample The Inland Empire Transgender Health & Wellness Survey Sample by City of Residence  8  drag queen Transgender woman Polygender Woman Agender Queer Trans boy Self body Non binary boy Trans girl Trans female Bi Gender Androgynous Transmasculine Non-binary Intersex Gender fluid Male HOW I IDENTIFY 9  Gender Identity Gender identity can be de ined as an individual’s innermost concept of self as male, female, both or neither. A person’s gender identity can be the same or different than one’s sex assigned at birth. Although gender identity is believed to manifest between ages 3 to 6 years old, many transgender, genderqueer, or gender luid individuals (see Appendix A for a glossary of terms) are not able to embrace their true gender identity until much later in life. This is mainly due to societal pressure to conform to the gender binary (i.e. male/female) and the societal stigma associated with transgender identities (Boundless Psychology, 2016; Eliason and Schope, 2007; Kaufman, 2008). The luid and changing language around identity in transgender communities, allows for complex, layered characteristic expression. Economic status, race, culture, geography, education and age in luence the language respondents use to describe their gender identity. This is demonstrated in how respondents identi ied their gender identity on the survey (see igure below). Other terms used by respondents included agender, transboy, androgynous, bi‐gender, female, gender luid, woman, intersex, male, nonbinary, polygender, queer, self‐body, trans, trans girl/ woman, transmasculine and non‐binary boy. Respondents Self‐iden fied Gender Iden ty  0 5 10 15 20 Percent 25 30 35 40 45 50 FTM / transgender man MTF / transgender woman Genderqueer Gender non‐conforming or gender variant Transgender Transsexual Two‐spirit Feminine male Masculine female or butch Cross‐dresser Drag Queen/King Other (please specify) Note: Respondents could select all terms that applied so percentages do not add to 100%. De initions of these terms are provided in Appendix A. “Please don't forget about gender luidity. Those outside of the gender binary are often considered ‘not really trans’.” 10  Do You Tell People That You Are TRANSGENDER/GENDER NON‐CONFORMING? I tell everyone Those who ask 34.4% 20% Health care providers Family 34.4% 46.7% Work colleagues Close friends 16.7% Casual friends 65.5% Never, I do not tell anyone 18.9% 4.4% Do You Currently or Do You Want TO LIVE FULL TIME IN A GENDER THAT IS DIFFERENT FROM YOUR GENDER ASSIGNED AT BIRTH? 12.2% 8.8% No Not full time but some day 24.4% Yes 54.4% Undecided 11  “Being referred to by improper pronouns constantly even after correction. Asked to use other changing room when out shopping.” Level of “Outness” To be “out” means that people are aware of a person's gender identity or history, sexual orientation, or both. Many studies of LGBT individuals have found that being out can lead to greater self‐acceptance and self‐empowerment. However, the choice to disclose transgender status is a deeply personal decision and great effort should be made to never disclose another person’s gender history. An important aspect of good health care is the ability to be open with your health care provider. Doctors, nurses, physician assistants, psychotherapists and other health care professionals need to know about their patients’ gender identity (and sexual orientation) in order to provide the best care possible. Nearly 2 in 3 survey respondents (65.6%) did not tell their health care providers about being transgender or gender non‐conforming. This could be due to the fact that 58.8% also agreed or strongly agreed that medical personnel would treat them differently if they knew the respondents were transgender. Over half (55.6%) of respondents also agreed or strongly agreed that health care providers are not adequately trained to care for people who are transgender, which can help explain why many respondents choose to keep this information from their health care providers. “This survey assumed that I am "out". I see this as a common problem with social services organizations and supportive services. I am not "out" and do not disclose my sexuality or gender preference in the community due to the discrimination I see others facing.” Gender Expression A third (36.6%) of respondents either currently or want to live full time in a gender different than the gender assigned to them at birth. The rest were either undecided (54.4%) or did not want to live full time as a different gender than the one assigned at birth (8.8%). Many respondents reject the concept of a male/female gender binary and adopt identities that re lect that (e.g. genderqueer, non‐binary). “It always concerns me with the growing transgender population, that on most county and state forms in the gender box only gives Male or Female for choices. They don't take into consideration the growing population of other gender identi iers.” 12  Age, Race & Ethnicity, Sexual Orientation Age Race/Ethnicity Percent Age Range Percent Under 18 2.2% African American 2.2% 18-20 12.2% Asian 1.1% 21-29 40.0% Hispanic 22.2% 30-39 11.1% White 64.4% 40-49 13.3% Multi-Racial 8.9% 50-59 7.8% Unknown 1.1% 60+ 13.3% Ethnic or Racial Background Sexual Orientation 8.9% I don’t use labels   Asexual 14.4% Gay 10.0% 16.7% Lesbian 22.2% Pansexual 15.6% Bisexual 8.9% Questioning This survey trended younger than the general population, with a majority (54.4%) of respondents under 30 years of age and 45.6% over 30. This is in contrast to the general population of the Inland Empire where 43.5% of the population is under 30 and 56.5% are over 30. The needs and experiences of youth under 18 years of age can be very different than those of adults. Future assessments targeting needs of youth should be considered. 21.1% Queer Survey respondents were less ethnically diverse than the general population with nearly two thirds of the respondents identifying as White and less than a quarter identifying as Hispanic, 2.2% African American and 1.1% Asian. Greater effort should be taken in future needs assessment surveys to reach ethnic minorities. Research has shown that the life experiences of gender and sexual minorities who are also ethnic minorities can be substantially different than their White counterparts. Further, recent research conducted by The Williams Institute has indicated that the transgender community may be more ethnically diverse than the general population (Flores, Brown, & Herman, 2016). Sexual Orientation 17.8% Straight Being transgender does not imply any speci ic sexual orientation. Transgender people exhibit the full spectrum of sexual orientations, and may identify as straight, gay, lesbian, bisexual, asexual, or use other labels or no labels at all. 13  Income What were your sources of income in 2014?  How much money did YOU  personally earn in 2014?  Income NonStudent Student $0—$19,999 59.6% 78.9% $20,000—$39,999 15.4% 13.2% $40,000—$59,999 5.8% 7.9% $60,000—$79,999 9.6% 0.0% $80,000 or more 9.6% 0.0% Income Research consistently shows that low income is a signi icant risk factor in disease incidence and severity as well as life expectancy. In general, despite having a higher education level (see page 15) than the general population, non‐student survey respondents reported much lower incomes with 59.6% earning less than $20,000 a year. These responses are consistent with those of the National Transgender Discrimination Survey (Grant, et al., 2011) which also reported lower household incomes but higher education levels than the population as a whole. Other 4.4% Parents 5.6% Student financial aid 8.9% Child support or alimony 1.1% Social security, workers' compensation, disability, veteran benefits or pensions 7.8% Money from a business, fees, dividends, or rental income For Inland Empire residents overall, the median individual income of those 16 years or older in Riverside County is $28,130 and in San Bernardino County $28,145 (American Community Survey, 2014). 14  6.7% Public assistance such as Temporary Assistance for Needy 8.9% Families (TANF); welfare; WIC; food stamps; or SSI. Paycheck(s) or money from one or more jobs 56.7% Education & Employment Have a graduate degree 12.2% Have a Bachelor’s degree 21.1% Have an Associates degree 12.2% Have had some college education 42.2% Have a high school degree or GED 8.9% Have less than a high school degree 3.3% Survey respondents generally had a high level of education. Over three ifths (63.3%) of all respondents under 30 years old indicated they are currently enrolled in school. More than half (51.2%) of all respondents 30 years old and older had a Bachelor’s degree or higher. For those 30 and older this is more than double the education level of the general population of the Inland Empire (22.6%) and higher than California overall (38.1%) (CHIS, 2014). The national goal is to reach a 60% college graduation rate by 2020 (whitehouse.gov). As seen with income (page 14), higher levels of education did not translate to higher levels of employment with survey respondents. Only 18.9% of respondents were employed full time, whereas 52.6% of Inland Empire adults had full time employment (CHIS, 2014). Further, 15.6% of survey respondents directly attribute their transgender status to being unemployed. Employment Status Employed full time 18.9% Unable to work 7.7% Employed part time 6.7% Homemaker 2.2% Unemployed 19.9% Retired 10.0% Student 21.1% Other 3.3% 15  Work Discrimination HAVE YOU EXPERIENCED ANY OF THE FOLLOWING AT WORK BECAUSE OF BEING TRANSGENDER OR GENDER NON‐ CONFORMING?       My access to customers or clients has been restricted or eliminated. 15.6% 3.3% I changed jobs or careers after coming out/disclosing being transgender or gender non-conforming. Co-workers repeatedly I used my old experienced name/ verbal pronoun even harassment. after being corrected. 25.6% 21.1% 14.4%     I was fired.    2.2% Managers or supervisors shared private information about me that they should not have. 3.3% 11.1%   15.6% I was reorganized out of a job. I experienced sexual harassment. 16  I was the victim of physical violence. 12.2% I was harassed by 13.3%   2.2% supervisor(s). Overall Work Discrimination    Was denied access to restrooms that matched my gender identity. 2.2% I was laid off. 4.4%      I was harassed by coworkers.   12.2% Co-workers shared private I was denied information about me that they a promotion. should not have.    11.1%          I have never been employed. 18.9%   I faced unfair scrutiny and/or discipline. Managers or supervisors repeatedly used my old name/pronoun even after being corrected. 3.3% Yes 41.1% No 35.6% Never Employed 18.9% Have you ever been unemployed as a result of being transgender or gender non-conforming? Yes 15.6% 14.4% No “Sometimes the discrimination is not so overt as to be provable. On more than one occasion I did not get a job that I applied for where it was obvious to me that discrimination was involved, but there was nothing provable.” 70.0% I don’t know Four in 10 (41.1%) survey respondents reported experiencing employment discrimination including harassment, being denied promotions or being ired. A ifth (21.1%) of respondents changed jobs or careers after disclosing being transgender or gender non‐conforming and 15.6% attribute their unemployment status to transgender discrimination. “In California, it is unlawful for an employer with five or more employees to discriminate against an employee in the terms, conditions, and privileges of employment based upon the employee’s gender identity, expression, or transgender status….It is also unlawful for an employer, regardless of the number of employees, to verbally or physically harass an employee based on their gender identity, gender expression, or transgender status. Harassment can include intentionally and repeatedly referring to a transgender employee by an incorrect name and pronoun. Coworkers are also prohibited from harassing and discriminating against an employee based upon their transgender status.” From Know your Rights: Transgender People at Work: An information and resource publication for transgender employees in California. Transgender Law Center, www.transgenderlawcenter.org. “I am a veteran and volunteered six years of my life to support and defend this country and despite this I feel like this country would rather turn its back on me than to help me.” 17    School Discrimination Have you experienced any of the following in school? 70.3% How safe do you feel at school/ on campus? Bullied/ harassed by other students at school Somewhat Safe 48.6% 35.1% Not allowed to use the bathroom you identify with Safe/Very Safe 37.8% 13.5% Somewhat Unsafe, Unsafe or Very Unsafe 37.8% 91.9% Teachers or staff bullied or harassed you “After two years on campus, I have not been able to obtain all the services I was promised because the university’s insurance company does not actually have any doctors under their plan.” 27% Uncomfortable stares at school  of participants have missed school in the past 30 days because they  didn’t feel safe. Number of days missed in the past month 8.1% Dropped out of school due to the way people treated you  18  2 Days 5.4% 3 Days 5.4% 4 Days 2,7% 7 Days 5.4% Two‐ ifths (n=37) of respondents were currently enrolled in high school, college or graduate school at the time of the survey. Nationally, transgender students report higher rates of experiencing verbal, physical, and sexual harassment and violence than their gender‐conforming peers. In‐school victimization is associated with harmful effects on psychological well‐being and academic achievement (Kosciew et al., 2012). School‐based protective factors include educators supportive of transgender students, the presence of transgender inclusive gay‐straight alliance clubs (GSAs), anti‐bullying/harassment policies that provide speci ic protections regarding gender identity and transgender‐inclusive curricula. These factors have been shown to increase feelings of school safety, lower rates of victimization and a greater sense of school belonging. These institutional supports are also shown to improve overall psychological well‐being and improve academic achievement (Kosciw et al., 2012). “I skipped many days but never dropped out.” “Indirect harassment, such as classmates using the word ‘tr*nny’ in regular conversation.” Bullying prevention is a national, as well as local issue. A large majority (70.3%) of respondents enrolled in school reported being bullied or harassed by students at school. A third (37.8%) of respondents also reported being bullied or harassed by teachers and other school staff members. “I’ve experienced problems with being misgendered by staff and instructors.” School should be a place where students are able to focus on their education without feeling discriminated against or unsafe. However, 91.9% of survey respondents currently enrolled in school indicated receiving uncomfortable stares while attending school. This can affect a student's ability to perform well in class. “I participate in a transgender discussion group on my university campus.” Safety is key to acquiring a good education. Students who do not feel safe at school will not perform to the best of their ability on homework, tests and other school projects. Nearly 14% of survey respondents reported feeling somewhat unsafe, unsafe or very unsafe at school. Over one quarter also reported missing at least one day of school in the last month, with 18.9% missing more than one. Missing multiple days of school can limit students’ participation in class and can be a risk factor for dropping out. “In high school I was bullied and physically harmed in the bathroom. I have been in ist ights with other students. I was told I had to use the girls locker room and bathroom. I was not allowed to use my preferred name at school.” 19  Health Care Access How easy is it to find a ___________ in your area willing to participate in your health plan? Physician Mental Health Professional Extremely Easy 25.6% 21.1% Very Easy 24.4% 14.4% Moderately Easy 24.4% 22.2% Slightly Easy 12.2% 14.4% Not at all Easy 6.7% 20.0% 6.7% 5.6% of participants go to the Emergency Room/ Urgent Care for health care needs as compared to 2.2%* of the Inland Empire general population. of participants go to a community clinic, government clinic or a community hospital as a usual source of care compared to 24%* of the Inland Empire general population. “I have had lots of doctors deny me service because I am trans. One doctor said she would see me, then once I was there she misgendered me the whole time, said if I don’t show her my genitals then I wouldn’t get my referral and prescription. I felt forced to show her my genitals. If I didn’t do what she wanted then I wouldn’t get what I needed. I have experienced lots of stares and people saying stuff.” *California Health Interview Survey (2015) 20  How easy is it to find a _______ who is willing to provide routine care? Physician  Extremely Easy 25.6% Very Easy 23.3% Sufficient Knowledge How easy is it to find a __________ in your area who has sufficient knowledge and experience on issues related to transgender people? Moderately Easy 24.4% Slightly Easy 12.2% Not at all Easy 8.9% Mental Health Professional  Extremely Easy 25.6% Very Easy 23.3% Moderately Easy 24.4% Slightly Easy 12.2% Not at all Easy 8.9% 7.8% Physician  Mental Health Professional  Extremely Easy 6.7% 6.7% Very Easy 8.9% 8.9% Moderately Easy 14.4% 13.3% Slightly Easy 15.6% 21.1% Not at all Easy 40.0% 38.9% 72.2% of participates usually go to a doctor’s office/HMO/Kaiser for their usual source of care compared to 58%* of the Inland Empire population overall. of participants do not have a usual source of care compared to 15.2%* of the Inland Empire general population. Seven in 10 respondents have a usual place to go when they are sick or need health advice. *California Health Interview Survey (2015) 21  Health Insurance 93.3% 3.3% No 27.8% Employmentbased based  1.1% I Don’t Know Yes 15% 3.3% Private Insurance Insurance  MediCare 20% 2.2% Other Other VA 22  24.4% Medi-Cal Health Care Access An individual’s ability to access health care can be in luenced by ability to pay, transportation, geography, delivery of competent care, patient perceptions and institutional barriers such as discriminatory laws and policies. A person’s access to good quality care can affect their health outcomes. 43.3% Almost all survey respondents have some form of health insurance (93.3%). Though insured at a slightly higher rate than the general population, four in 10 respondents reported a lack of money had kept them from receiving health care in the previous 12 months. According to the California Health Interview Survey 52.8% of the general Inland Empire population delayed care due to cost or lack of insurance (CHIS, 2015). stated that lack of money has kept them from going to the doctor in the past 12 months. Those with health insurance may not use it as needed due to the inadequacy of providers or lack of services available to them. A majority of respondents agree or strongly agree that not enough health care providers are adequately trained to care for transgender people. Respondents also felt there are not enough support groups geared towards helping people who are transgender. “At the VA, medical doctor tells me I’m a married man and need to stay that way.” Unfortunately, seeking care was often perceived as unsafe for survey participants. As other studies have revealed (Grant et al., 2011) transgender and gender non‐conforming people frequently experience discrimination when accessing health care. Participants in this survey reported similar barriers to care (see pages 23—27). Survey participants reported that it is more dif icult to ind a mental health professional than it is to ind a physician or other physical health professional in their area within their health plan. Nearly one‐ ifth of respondents found it only slightly easy or not at all easy to ind a doctor in their area, whereas 34.4% found it only slightly easy or not at all easy to ind a mental health professional in their area.  23  Perception of Accessing Health Services To help us better understand your concerns about accessing health care services please tell us how much you agree or disagree with the following statements. Strongly Agree I will be refused medical services because I am transgender. Medical personnel will treat me differently because I am transgender. Agree 6.7% Neither Agree nor Disagree 16.7% 30.0% There are not enough health professionals adequately trained to care for people who are transgender. There are not enough substance abuse treatment programs for people who are transgender. The community fears/ dislikes people who are transgender. 14.4% 14.4% 14.4% 21.1% 55.6% There are not enough support groups for people who are transgender. Strongly Disagree 26.7% 34.4% 24.4% Disagree 52.2% 6.7% 11.1% 13.3% 23.3% 5.6% 5.6% 2.2% 35.6% 22.2% 34.4% 3.3% 51.1% 30.0% 8.9% 1.1% 24  Perceptions of discrimination and whether one can access quality health services have been shown to not only affect whether and how individuals seek medical care and interact with medical professionals, but affect health outcomes as well (Harcourt, 2006; When Health Care Isn’t Caring, 2010). A health professional’s level of knowledge about transgender health issues and their cultural competency can have a large effect on a person’s decision to disclose gender or sexual minority status (i.e., “come out”) to health providers or whether or not to even obtain services in the irst place (Movement Advancement Project, 2010; Bonvicini & Perlin, 2003). This is part of the lifelong process of coming out (de Vries & Blando, 2004) with potential and signi icant costs to health and well‐being (e.g., Meyer, 2003). Calculations of perceived safety and comfort used in deciding when, what, and how much to reveal about LGBT status can be particularly acute for the youngest and oldest transgender persons and transgender persons of color. Nearly 1 in 4 (23.4%) respondents agree or strongly agree that they will be refused medical services because they identify as transgender. Additionally, over half (58.8%) of respondents agree or strongly agree that they will be treated differently by medical personnel due to being transgender. This feeling of discrimination by medical personnel can keep transgender patients from accessing health care or health services they may desperately need. A strong majority of survey respondents (81.1%) agree or strongly agree that the community around them fears or dislikes them due to being transgender. The perception of discrimination can prevent transgender patients from accessing health care. “There is nothing more humiliating than sitting in a waiting area and having your legal but gender inappropriate name shouted out across the room and .” having to respond to it. Many of us must seek care and are presenting as ourselves long before we are able to get our names legally changed.” A majority of survey respondents strongly agree with the statements, “Not enough health professionals adequately trained to care for people who are transgender” (55.6%) and “Not enough support groups for people who are transgender” (52.2%). Just over one‐third also strongly agree with the statement “Not enough substance abuse treatment for people who are transgender.” Due to these high percentages, it can be concluded that there are not enough health care services that are tailored to transgender patients. “I did bring up my gender identity with my gynecologist recently and her whole body language immediately shifted and she became noticeably uncomfortable.” 25  Experiences in a health care setting As a transgender/gender non‐conforming person, have you experienced any of the following in these spaces? Ever in your life If so, where  Riverside County   San   Bernardino County   Other  Health care professionals were physically rough or abusive. 14.3% 33.3% 25.0% 41.7%  Health care professionals refused to touch me or used excessive precautions. 20.2% 47.1% 17.6% 35.3% I was refused needed health care. 21.4% 38.9% 33.3% 27.8%  Health care professionals used harsh or abusive language. 28.6% 62.5% 16.7% 20.8%  Health care professionals blamed me for my health status. 23.2% 42.1% 21.1% 36.8% Health care professionals used improper pronouns even after being corrected. 42.2% 48.6% 31.4% 20.0%  Denied Services/ Verbally harassed Unequal treatment Or disrespected Doctor’s office or hospital Emergency Room 26  16.9% 2.4% 21.3% 9.6% “I have been called my birth name repeatedly despite me having a legal name change, and they continued to use female pronouns. I was asked why I need hormones, and why the prescription is necessary. I was repeatedly told that the prescription is not important” Ignorance about transgender health issues combined with the perceived danger or discomfort on the part of transgender patients, are factors that can limit access to medical care (Movement Advancement Project, 2010). Anticipated stigma and discrimination (e.g., MetLife, 2010) may lead to deferred or delayed health care utilization with missed opportunities for preventive intervention (Bonvicini & Perlin, 2003). A substantial number of survey respondents reported discrimination and culturally incompetent care in health care settings (pages 23—27). How easy is it to find a doctor in your area who is willing to provide hormone therapy? Extremely Easy 12.2% Very Easy 12.2% Moderately Easy 10.0% Slightly Easy 14.4% Not at all Easy 36.7% Not Applicable 14.4% “My doctor who prescribed my hormones was not very nice & his of ice staff actually said they do not want to work with people like me.” 27  Social Support   WHEN ASKED, “HAVE YOU EVER SERIOUSLY CONSIDERED COMMITTING SUICIDE?” 75% OF PARTICIPANTS STATED “YES” WHEREAS, 6.1% OF THE GENERAL POPULATION HAVE SERIOUSLY CONSIDERED COMMITTING SUICIDE 28  Behavioral Health Care Mental health disorders affect a substantial proportion of the local, state and national population. According to the National Institute of Mental Health (www.nimh.nih.gov), nearly 30% of adults meet criteria for anxiety disorder and nearly 21% for a mood disorder over their lifetime. In comparison, survey participants reported considerably elevated rates of mood and anxiety disorders. Three quarters (74.4%) of respondents indicated that they had seriously considered committing suicide; while over two‐thirds (67.8%) reported having depression or an anxiety disorder. Societal discrimination has a direct impact on the mental health of transgender people. A social context of oppression leads to social and family alienation, reduced levels of social support, low self‐esteem and symptoms of psychological distress. For racial/ethnic minority transgender people the social impact on mental health is ampli ied due to the intersection of racism and transphobia (Hatzenbuehler, 2010). DEPRESSION OR ANXIETY DISORDER YES 67.8% Two‐ ifths of respondents also indicated that it is not easy to ind a mental health professional in their area who has suf icient knowledge and experience on issues related to transgender people. NO 32.2% In order for transgender patients with depression or an anxiety disorder to receive appropriate care, health professionals must gain more knowledge of and experience with issues relevant to transgender people. The stigma associated with these issues must also decrease, as 6.0% of respondents have reported being denied services and 7.2% reported being verbally harassed or disrespected by providers. Have you experienced any mistreatment in a mental/ behavioral health setting? Denied Services/ Unequal Treatment 6.0%  Verbally Harassed or Disrespected 7.2% “The idea that I could be treated negatively IF I disclose my gender identity and sexual orientation terri ies me enough that I don't even seek out mental health services.” 29  Police Interaction 23.4% 52.2% Very/Somewhat Comfortable Very/Somewhat Uncomfortable 20% Neutral As a transgender/gender nonconforming person, how comfortable do you feel seeking help from the police? Of participants who have had an exchange with police Which of the following experiences have you had in your interactions with police? 54.4% of participants have had an interaction with police Officers generally have treated me with respect. 51.0% Officers generally have treated me with disrespect. 36.7% Officers have harassed me. 14.3% 16.7% of all participants have had police and/or sheriff’s deputies use improper pronouns, even after being corrected. 30  Sexual Assault and Intimate Partner Violence Violence and fear of violence can worsen health outcomes and exacerbate health disparities. Victims of abuse and violence are at an increased risk for many negative health and social outcomes such as anxiety, substance use, depression, low self‐esteem, chronic health conditions, academic failure, incarceration and poverty (Garofalo & Bush, 2008; Pitt and Albert, 2008; UNITY, May 2011; UNITY, September 2011). Research indicates that transgender youth and adults experience higher rates of physical, verbal, sexual, and emotional abuse and intimidation than their gender‐conforming peers. Further, victims who are not “out” publicly or have had negative interactions with law enforcement or the courts may be reluctant or unwilling to seek help from these or other services because it would require them to reveal their gender identity and possibly face embarrassment, ridicule or even harassment.   56.7% More than half of respondents have been physically and/or emotionally abused by a partner or someone close to them. Survey respondents reported intimate partner violence at a rate three and a half times (56.7% vs. 16.2%) greater than the general population of the Inland Empire (CHIS, 2009). Many of the concerns and barriers are the same whether the victim/survivor is lesbian, gay, bisexual, transgender, heterosexual or cis‐gender. However, transgender victims often face situations that are not experienced by gender conforming victims (Kaufman, 2008; Pitt and Alpert, 2008).  An abusive partner may threaten to “out” his or her partner’s gender history to family, friends, or co‐workers as a tactic to get that person to stay in the relationship or to coerce the victim in order to get what he or she wants. Transgender people whose families and friends are unsupportive of their identity have fewer sources of support, thereby increasing isolation and making it more dif icult to end abusive relationships.  Victims who are not “out” publicly may be reluctant or unwilling to seek help from the police, the courts and other services because it would require them to reveal their gender history and possibly face embarrassment, ridicule or 25.6% of respondents have been forced or even harassment.  1 in 4 to have sex against their will by a partner or someone close to them.  An abusive partner may threaten to withhold hormone medication as a way to control behavior.  Many transgender individuals have been subjected to abuse from a young age. This baseline of discrimination and violence can increase the risk of trauma later in life (www.nomore.org). 31  Housing Inland Empire Have you experienced any of the following because you are transgender/gender non-conforming? I was denied a home/apartment. 5.6% I moved to a less expensive home/apartment. 14.4% I moved back in with family members or friends. 18.9% I was kicked out of my family home before the age of 18. 6.7% I was kicked out of my family home over the age of 18. 12.2% I have been evicted. 4.4% I became homeless. 8.9% I had to use equity on my house to pay for living expenses. 2.2% I have had sex with people to sleep in their bed/at their homes 4.4% or pay rent. “I am living off of credit cards for daily expenses.” 32  “I am disowned by my parents.” “I was forced to move out of my home due to transphobia and abuse.” “I had to re inance my mortgage to pay for sex reassignment surgery.” Needed Services Survey participants were asked to rank the services they felt were the most needed for transgender people in the Inland Empire. The following are the top 10 services in order of the total number of votes each one received. What are the most important transgender services you think should be offered in your area? 1. Mental Health Services 7. Housing 8. Support Groups 2. Health Services 3. Transportation Support 6. Social Events 9. LGBTQI Senior Housing 33  4. Employment Placement Assistance 5. Legal Support/ Helpline 10. Job Fairs Conclusion and Recommendations Despite recent advances in visibility and equality for transgender people, this report documents the continued discrimination, social stigmatization and harassment, transgender people face. As a result of these chronic stressors, many transgender people struggle with depression, anxiety, low self‐esteem, and suicidal thoughts. This report can be used by local agencies seeking funding and as a tool for health care organizations to assist them in understanding how they can be a resource for this underserved population. Research Recommendations It is essential that local and state health organizations collect and report data on gender identity as part of standard demographic questions. For guidance on how best to ask gender identity questions, please refer to:  Inclusive Questions for Older Adults: A Practical Guide to Collecting Data on Sexual Orientation and Gender Identity. (2013). National Resource Center on LGBT Aging.  Policy Focus: How To Gather Data On Sexual Orientation and Gender Identity in Clinical Settings. (n.d.) The Fenway Institute.  Best Practices for Asking Questions to Identify Transgender and Other Gender Minority Respondents on Population‐Based Surveys. (2014). J.L. Herman (Ed.). Los Angeles, CA: The Williams Institute. Program Recommendations The recommendations below are adapted from First, do no harm: Reducing disparities for lesbian, gay, bisexual, transgender, queer and questioning populations in California (Mikalson et al., 2012). Many have been highlighted by the Riverside University Health System—Behavioral Health, LGBTQ Task Force as particularly relevant to Riverside County.  Health and human service organizations have a duty to create safe, welcoming and af irming environments for transgender individuals and families across all races, ethnicities, cultures, and across the lifespan.  Training of service providers in public mental/behavioral and physical health systems should focus on the speci ic health and safety needs of transgender people. These trainings should meet continuing education unit (CEU) standards and have community‐based endorsement.  Training for school administrators, teachers, police, CBO managers, physical and behavioral health providers and other human service providers should include the physical and mental health challenges, strains and duress endured by members of the transgender community and the community’s cultural diverseness.  Creating safe spaces for transgender youth is critical to addressing harmful school behavior. Gay‐Straight Alliances (GSA) and other such transgender af irming clubs should be supported by school administration and staff. This includes the reducing of barriers to forming and maintaining such clubs at middle and high school campuses. 34   Public schools at all age and grade levels should develop and implement effective anti‐ bullying and anti‐harassment programs. These programs should include language addressing gender, gender identity and gender expression issues.  Review and update non‐discrimination policies within your organization. Adopt transgender ‐ relevant anti‐discrimination policies for the hiring of employees and treatment of clients. These policies should be monitored and enforced.  There are California state laws and regulations already in place which have a direct impact on the mental and physical wellness of the Inland Empire’s transgender population. These laws and regulations should be supported, promoted and enforced.  All domestic violence programs in the Inland Empire should recognize the relationships of transgender persons.  Health and human service providers need to ensure that when referring clients to other programs those programs and services have been determined to be transgender‐sensitive, af irming and culturally competent.  Address and eliminate stigma directed toward the transgender community through social media, event participation and community collaborations. For guidance on how best to provide services to the transgender population see:  Center of Excellence for Transgender Health, University of California, San Francisco. http://transhealth.ucsf.edu/  Transgender Law Center. https://transgenderlawcenter.org/  Services & Advocacy for GLBT Elders (SAGE) & National Resource Center on LGBT Aging: Inclusive Services for LGBT Older Adults: A Practical Guide to Creating Welcoming Agencies. March 14, 2012  American College of Physicians: Fenway Guide to Lesbian, Gay, Bisexual & Transgender Health. 2007.  Gay & Lesbian Medical Association: Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients.  The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient‐ and Family‐Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. Oak Brook, IL, Oct. 2011.  National Association of Gay‐Straight Alliance (GSA) Networks: GSA Advisor Handbook. 2011. www.gsanetwork.org  Transgender Inclusion in the Workplace: Recommended Policies and Practices: Human Rights Campaign (HRC) website. www.hrc.org 35  Appendix A Glossary Asexual: People who do not experience sexual attraction. This does not necessarily exclude romantic attraction. [www.asexuality.org] Cis‐gender: A person whose gender identity and expression matches the gender typically associated with their biological sex. For example: a female who identi ies as a woman. [http:// internationalspectrum.umich.edu/life/de initions] Coming Out: To declare and af irm both to oneself and to others one’s identity as lesbian, gay, bisexual, transgender, queer, etc. It is not a single event but instead a life‐long process. [http:// internationalspectrum.umich.edu/life/de initions] Drag King: Used to refer to female performers who dress as men for the purposes of entertaining others at bars, clubs, or other events. [National Center for Transgender Equality] Drag Queen: Used to refer to male performers who dress as women for the purpose of entertaining others at bars, clubs or other events. It is also sometimes used in a derogatory manner to refer to transgender women. [National Center for Transgender Equality] Gay and Lesbian: Refers to individual people who are romantically and/or sexually attracted to, and/or partner with people of the same gender; lesbians partner with women and gay men partner with men. Gender: The behavioral, cultural, or psychological traits typically associated with one sex. The socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for men and women. [Merriam‐Webster Online Dictionary; World Health Organization] Gender expression: Refers to the ways in which people externally communicate their gender identity to others through behavior, clothing, hairstyle, voice and emphasizing, de‐emphasizing or changing their body’s characteristics. Gender expression is not necessarily an indication of sexual orientation. [http://internationalspectrum.umich.edu/life/de initions] Gender identity: The sense of “being” male or “being” female. For some people, gender identity is in accord with physical anatomy. For transgender people, gender identity may differ from physical anatomy or expected social roles. It is important to note that gender identity, biological sex, and sexual orientation are not necessarily linked. [http://internationalspectrum.umich.edu/life/ de initions] Genderqueer: A term which refers to individuals or groups who “queer” or problematize the hegemonic notions of sex, gender and desire in a given society. Genderqueer people possess identities which fall outside of the widely accepted sexual binary. Genderqueer may also refer to people who identify as both transgender AND queer, i.e., individuals who challenge both gender and sexuality regimes and see gender identity and sexual orientation as overlapping and interconnected. [http://internationalspectrum.umich.edu/life/de initions] Misgender: To refer to someone using a word, especially a pronoun or form of address, that does not correctly re lect the gender with which they identify. 36  Polygender, or poly‐gender: A gender identity that falls under the multi‐gender, nonbinary and transgender umbrellas. Polygender individuals have several gender identities. Some de ine polygender as anyone having more than one gender: they may have two (bigender), three (trigender), or more. Others de ine polygender as strictly people who have more than three genders. Polygender can mean that a person has all these genders at the same time, in a mix. Polygender can also mean that they change from one gender to the next at different times, in which case the word is used interchangeably with gender luid. Some also use the word polygender interchangeably with multigender (http://nonbinary.org). Queer: Used as an umbrella identity term encompassing lesbian, questioning people, gay men, bisexuals, non‐labeling people, transgender folks and anyone else who does not strictly identify as heterosexual. “Queer” originated as a derogatory word. Currently, it is being reclaimed by some people and used as a statement of empowerment. Some people identify as “queer” to distance themselves from the rigid categorization of “straight” and “gay”. Some transgender, lesbian, gay, questioning, non‐labeling, and bisexual people, however, reject the use of this term due to its connotations of deviance and its tendency to gloss over and sometimes deny the differences between these groups. [http://internationalspectrum.umich.edu/life/de initions] Sexual Minority: Refers to a group whose sexual identity, orientation or practices differ from the majority of the surrounding society. Primarily refers to lesbians, gay men, bisexuals and transgender people. Sexual orientation: A person’s emotional, physical and sexual attraction and the expression of that attraction with other individuals. Some of the better‐known labels or categories include “bisexual” (or “multisexual,” “pansexual,” “omnisexual”), “lesbian,” “gay,” “homosexual” or “heterosexual”. Survival sex: Refers to the selling of sex to meet subsistence needs. It includes the exchange of sex for shelter, food, drugs or money (Greene et al., 1999). Transgender: Describes people who identify with or express a gender different from the sex assigned to them at birth. Transphobia: Is the irrational, persistent fear of those who are gender atypical to any degree. It is often accompanied by an inability to deal with gender ambiguity and discomfort with, or hostility towards, people who do not conform to stereotypical gender norms. [www.education.tas.gov.au] *These de initions are meant to be used as reference to better understand the populations under discussion and should not be used to assume another person’s identity. It is important to respect an individual’s self‐identi ication. 37  Appendix B 2015 Inland Empire Transgender Health & Wellness Survey Survey Questions and Responses 38  Do you consider yourself to be transgender or gender non‐conforming in any way? Responses Percent 90 87 96.7 * * 90 Female 49 54.4 Male 40 44.4 * * 90 Yes 78 86.7 No 11 12.2 * * 90 FTM / transgender man 27 30.0 MTF / transgender woman 24 26.7 Genderqueer 23 25.6 Gender non‐conforming or gender variant 25 27.8 Transgender 42 46.7 Transsexual 10 11.1 Two‐spirit 9 10.0 Feminine male 7 7.8 Masculine female or butch * * Cross‐dresser * * Drag Queen/King * * 21 23.3 90 No 11 12.2 Yes 49 54.4 Not full time but someday 22 24.4 Undecided 8 8.9 Yes I don't know/Questioning What gender were you assigned at birth? That is, what was the sex on your original birth certi icate? Unknown Do you currently have a gender identity or presentation that is different from your assigned gender at birth? Don't Know Which, if any, of the following terms do you currently use to describe your gender identity? (Check all that apply) Other (please specify) Do you currently or do you want to live full‐time in a gender that is different from your gender assigned at birth? *less than 5 responses  39  Responses Percent Do you tell people that you are transgender/gender non‐conforming? (Check all that apply) 90 * * Close Friends 59 65.6 Casual friends 17 18.9 Work colleagues 15 16.7 Family 42 46.7 Health care providers 31 34.4 Those who ask 31 34.4 I tell everyone 18 20.0 90 Gay 13 14.4 Lesbian 15 16.7 Bisexual 14 15.6 Straight / Heterosexual 16 17.8 Queer 19 21.1 Questioning 8 8.9 Pansexual 20 22.2 Asexual 8 8.9 I don't use a label 9 10.0 90 White 58 64.4 Hispanic 20 22.2 African American * * Asian * * Multi‐race 8 8.9 Unknown/did not answer * * 90 * * 18‐20 11 12.2 21‐29 36 40.0 30‐39 10 11.1 40‐49 12 13.3 50‐59 7 7.8 60+ 12 13.3 90 Never, I do not tell anyone How do you currently describe your sexual orientation? (Check all that apply) What is your ethnic or racial background? What is your age? 17 or younger In what ZIP code is your home located? (enter 5‐digit ZIP code) *less than 5 responses  40  Responses Percent 90 What is the highest level of education you have completed? * * Less than high school degree 8 8.9 High school degree or GED 38 42.2 Some college 11 12.2 Associate degree 19 21.1 Bachelor degree 11 12.2 Graduate degree 90 Which of the following best describes your current relationship status? 49 54.4 Single, never married 15 16.7 Single, living with partner 13 14.4 Married * * Domestic partnership * * Separated 8 8.9 Divorced * * Widowed 90 In general, how would you rate your overall physical health? 8 8.9 Excellent 28 31.1 Very good 31 34.4 Good 17 18.9 Fair * * Poor * * Unknown/did not answer 90 What is your current employment status? 17 18.9 Employed full time * * Employed full time + Student 5 5.6 Employed part time * * Employed part time ‐ looking for more 6 6.7 Employed part time + Student * * Homemaker * * Multiple part‐time jobs + Student * * On disability 9 10.0 Retired 19 21.1 Student * * Unable to work 11 12.2 Unemployed and looking * * Unemployed and looking + Student * * Unemployed and stopped looking * * Other (please specify) *less than 5 responses  41  How much money did YOU personally earn in 2014? $0 ‐ $9,999 $10,000 ‐ $19,999 $20,000 ‐ $29,999 $30,000 ‐ $39,000 $40,000 ‐ $49,999 $50,000 ‐ $59,999 $60,000 ‐ $69,999 $70,000 ‐ $79,999 $80,000 ‐ $89,999 $100,000 or More Did you have to change jobs or careers when you came out/disclosed that you were transgender or gender non‐conforming? Yes No Unknown What were your sources of income in 2014? (Check all that apply) Paycheck(s) or money from one or more jobs Public assistance such as Temporary Assistance for Needy Families (TANF); welfare; WIC; food stamps; or SSI. Money from a business, fees, dividends, or rental income Social security, workers' compensation, disability, veteran bene its or pensions Child support or alimony Student inancial aid Parents Other (please specify) Have you ever been unemployed as a result of being transgender or gender non‐conforming? Yes No Don't Know In the past 5 years have you lived in any of the following… Homeless shelter Sober living house Halfway or community re‐entry house What is your main mode of transportation? I bike, skate, walk most places I borrow a car or get rides from friends I have my own car / motorcycle etc. I use public transportation such as the bus. Other (please specify) What are your current living arrangements? Living in a house/apartment I RENT alone or with others Living in campus/university housing Living in house/apartment/condo I OWN alone or with others Living with a partner, spouse or other person who pays for the housing Living with parents or family you grew up with Staying with friends or family temporarily Other (please specify) Unknown/did not answer Responses Percent 90 49 12 10 * * * * * * * 54.4 13.3 11.1 * * * * * * * 90 19 69 * 90 51 21.1 76.7 * 56.7 8 8.9 6 7 * 8 5 * 6.7 7.8 * 8.9 5.6 * 90 14 63 13 90 * * * 90 * 11 60 10 5 90 24 * 16 6 32 5 * * 15.6 70.0 14.4 * * * * 12.2 66.7 11.1 5.6 26.7 * 17.8 6.7 35.6 5.6 * * *less than 5 responses  42  Have you experienced any of the following at work because of being transgender or gender non‐conforming? Check all that apply. Responses Percent I was ired I was denied a promotion I was reorganized out of a job I was laid off I experienced verbal harassment I experienced sexual harassment I was harassed by coworkers I was harassed by my supervisor(s) I was the victim of physical violence I faced unfair scrutiny and/or discipline I was denied access to restrooms that matched my gender identity I was denied access to all restrooms My access to customers or clients has been restricted or eliminated Co‐workers repeatedly used my old name/pronoun even after being corrected Managers/Supervisors repeatedly used my old name/pronoun even after being cor‐ rected Co‐workers shared private information about me that they should not have Managers or Supervisors shared information about me that they should not have I have never been employed Other (please specify) None of the above Have you experienced any of the following because you are transgender/ gender non‐conforming? I moved into a less expensive home/apartment I became homeless I have been evicted I was denied a home/apartment I had to move back in with family members or friends I have had sex with people to sleep in their bed/at their homes or to pay rent I had to use equity in my home to pay for living expenses I was kicked out of my family home before the age of 18 I was kicked out of my family home over the age of 18 Other (please specify) I have not experienced any of these How safe do you feel walking in your neighborhood? Very Safe Safe Somewhat Safe Somewhat Unsafe Unsafe Very Unsafe Unknown/did not answer 90 * * * * 23 11 14 12 * 14 * 0 * 13 * * * * 25.6 12.2 15.6 13.3 * 15.6 * 0.0 * 14.4 10 11.1 10 11 17 11 34 11.1 12.2 18.9 12.2 37.8 90 13 8 * 5 17 * * 6 11 5 15 90 11 29 32 8 7 * * 14.4 8.9 * 5.6 18.9 * * 6.7 12.2 5.6 16.7 12.2 32.2 35.6 8.9 7.8 * * *less than 5 responses  43  Responses In general, how would you rate your overall mental or emotional health? 90 Excellent 6 Very good 15 Good 23 Fair 28 Poor 16 Unknown/did not answer * During the past 12 months, have you had a lu shot? 90 No 46 Yes 39 I don't know * Unknown/did not answer * Have you ever been tested for HIV (the virus that causes AIDS)? 90 No 29 Yes 56 I don't know * Unknown/did not answer * What is your HIV status? 90 I am HIV negative 69 I am HIV positive * I don't know my HIV status 17 Declined to answer * In the past 12 months, have you ever been tested for a sexually transmitted 90 disease other than HIV? No 47 Yes 35 I don't know 5 Other (please specify) * Unknown/did not answer * Has a doctor ever told you that you had any of the following 90 Asthma 32 Lung disease other than asthma * Cancer 6 Diabetes 6 Any kind of heart disease * High blood pressure 23 High cholesterol 29 Depression or anxiety disorder 61 Other 12 How important is exercise to you? 90 Extremely important 12 Very important 18 Moderately important 32 Slightly important 18 Not at all important 7 Unknown/did not answer * Percent 6.7 16.7 25.6 31.1 17.8 * 51.1 43.3 * * 32.2 62.2 * * 76.7 * 18.9 * 52.2 38.9 5.6 * * 35.6 * 6.7 6.7 * 25.6 32.2 67.8 13.3 13.3 20.0 35.6 20.0 7.8 * *less than 5 responses  44  In a typical week, how many days do you exercise? Responses Percent Once a week 2 to 4 days a week 5 to 7 days a week I don't regularly exercise Unknown/did not answer Thinking back to the last time you had sex, did you use a condom or any form of barrier protection? No Yes No, married or in a committed relationship Don't remember Never had sex Other (please specify) Unknown/did not answer In the past 7 days, how many times did you eat fast food? Include fast food meals eaten at work, school, at home, or at fast food restaurants, carryout or drive thru. None, I did not eat fast food One time Two times Three times Four or more times Unknown/did not answer Do you currently have health insurance? No, I do not Yes, I do I don't know Unknown/did not answer Type of health insurance Employment‐based Privately purchased VA (CHAMP‐VA) Medi‐Cal (IEHP, Molina) Medicare Medicare and Medi‐Cal Other (please specify) Uninsured Unknown/did not answer Have you ever seriously thought about committing suicide? No, I have never seriously thought about committing suicide. Yes, I have seriously thought about committing suicide. Unknown/did not answer 90 12 32 10 34 * 13.3 35.6 11.1 37.8 * 90 42 26 * * 11 * * 46.7 28.9 * * 12.2 * * 90 14 19 28 11 16 * 90 * 84 * * 90 25 15 * 22 * * 14 * * 90 20 67 * 15.6 21.1 31.1 12.2 17.8 * * 93.3 * * 27.8 16.7 * 24.4 * * 15.6 * * 22.2 74.4 * *less than 5 responses  45  Responses Percent How easy is it to ind a doctor in your area who participates in your health plan? Extremely easy Very easy Moderately easy Slightly easy Not at all easy Unknown/did not answer How easy is it to ind a doctor in your area who is willing to provide routine care? Extremely easy Very easy Moderately easy Slightly easy Not at all easy Unknown/did not answer How easy is it to ind a doctor in your area who is willing to provide hormone therapy? Extremely easy Very easy Moderately easy Slightly easy Not at all easy Not applicable / did not answer How easy is it to ind a doctor in your area who has suf icient knowledge and experience on issues related to transgender people? Extremely easy Very easy Moderately easy Slightly easy Not at all easy Unknown/did not answer How easy is it to ind a mental health professional in your area who participates in your health plan? Extremely easy Very easy Moderately easy Slightly easy Not at all easy Unknown/did not answer How easy is it to ind a mental health professional in your area who is willing to treat you? Extremely easy Very easy Moderately easy Slightly easy Not at all easy Unknown/did not answer 90 23 22 22 11 6 6 25.6 24.4 24.4 12.2 6.7 6.7 90 23 21 22 11 8 5 25.6 23.3 24.4 12.2 8.9 5.6 90 11 11 9 13 33 13 12.2 12.2 10.0 14.4 36.7 14.4 90 6 8 13 14 36 13 6.7 8.9 14.4 15.6 40.0 14.4 90 19 13 20 13 18 7 21.1 14.4 22.2 14.4 20.0 7.8 90 16 17 24 11 15 7 17.8 18.9 26.7 12.2 16.7 7.8 *less than 5 responses  46  Responses Percent How easy is it to ind a mental health professional in your area who has 90 suf icient knowledge and experience on issues related to transgender people? Extremely easy 6 6.7 Very easy 8 8.9 Moderately easy 12 13.3 Slightly easy 19 21.1 Not at all easy 35 38.9 Unknown/did not answer 10 11.1 90 Do you have a usual place to go when you are sick or need health advice? No 24 26.7 63 70.0 Yes * * Unknown/did not answer 90 Where do you usually go for health care? 6 6.7 Community clinic/government clinic/community hospital 65 72.2 Doctor's of ice/HMO/Kaiser 5 5.6 Emergency room/Urgent care 7 7.8 No usual source of care * * Other (please specify) * * Unknown/did not answer 90 In the last 12 months, has a lack of money kept you from going to the doctor? 48 53.3 No, it has not 39 43.3 Yes, it has * * Unknown/did not answer Have you experienced any of the following in a health care setting because you 90 are transgender? 18 20.0 I was refused needed health care 17 18.9 Health care professionals refused to touch me or used excessive precautions 24 26.7 Health care professionals used harsh or abusive language 19 21.1 Health care professionals blamed me for my health status 12 13.3 Health care professionals were physically rough or abusive 35 38.9 Health care professionals used improper pronouns even after being corrected 90 I will be refused medical service because I am transgender 6 6.7 Strongly Agree 15 16.7 Agree 27 30.0 Neither Agree or Disagree 24 26.7 Disagree 13 14.4 Strongly Disagree 5 5.6 Unknown/did not answer 90 Medical personnel will treat me differently because I am transgender 22 24.4 Strongly Agree 31 34.4 Agree 13 14.4 Neither Agree or Disagree 13 14.4 Disagree 6 6.7 Strongly Disagree 5 5.6 Unknown/did not answer *less than 5 responses  47  Responses Percent Not enough health professionals adequately trained to care for people who are 90 transgender 50 55.6 Strongly Agree 19 21.1 Agree 10 11.1 Neither Agree or Disagree * * Disagree 0 0.0 Strongly Disagree 7 7.8 Unknown/did not answer 90 Not enough support groups for people who are transgender 47 52.2 Strongly Agree 21 23.3 Agree 12 13.3 Neither Agree or Disagree 5 5.6 Disagree 0 0.0 Strongly Disagree 5 5.6 Unknown/did not answer 90 Not enough substance abuse treatment for people who are transgender 32 35.6 Strongly Agree 20 22.2 Agree 31 34.4 Neither Agree or Disagree * * Disagree 0 0.0 Strongly Disagree 5 5.6 Unknown/did not answer 90 Community fear/dislike of people who are transgender 46 51.1 Strongly Agree 27 30.0 Agree 8 8.9 Neither Agree or Disagree * * Disagree * * Strongly Disagree 5 5.6 Unknown/did not answer 90 Do you currently smoke cigarettes? 72 80.0 No, I do not 15 16.7 Yes, I do * * Unknown/did not answer Considering all types of alcoholic beverages, how many times during the past 90 month did you have 5 or more drinks on one occasion? 57 63.3 0 times 14 15.6 1 time * * 2 times * * 3 times * * 4 times * * 5 times * * 7 times * * 10 times * * 20 times * * 30 times 5 5.6 Unknown/did not answer *less than 5 responses  48  Responses Percent In the past 30 days have you used any of the following drugs? 90 Tranquilizers or sedatives (without a doctor’s prescription) 5 5.6 Amphetamines (Crystal, Meth, Tina, Crank) * * LSD or some other hallucinogens * * Crack cocaine * * Powder cocaine * * Heroin * * Ecstasy/MDMA * * GHB * * Drugs by injection with a needle (heroin, cocaine, amphetamine) * * Alcohol and pills together to get high * * Unknown/did not answer * * Are you in school? 90 No, I am not in school 49 54.4 Yes, high school * * Yes, I am in college / graduate school 36 40.0 I go to school online * * Unknown/did not answer * * In your life, have you ever been emotionally or physically abused by a partner or 90 someone close to you? (husband, wife, girlfriend, boyfriend, etc.) No 32 35.6 51 56.7 Yes 7 7.8 Unknown/did not answer Have you experienced any of the following in school? (of those currently in 37 school) 26 70.3 Bullied/ harassed by other students at school 14 37.8 Teachers or staff bullied or harassed you 34 91.9 Uncomfortable stares at school? 13 35.1 Not allowed to use the bathroom you identify with * * Dropped out of school due to the way people treated you 6 16.2 Other 37 How safe do you feel at school / on campus? * * Very Safe 11 29.7 Safe 18 48.6 Somewhat Safe * * Somewhat Unsafe * * Unsafe * * Very Unsafe 37 In the past 30 days have you missed school because you didn't feel safe? 27 73.0 No 10 27.0 Yes *less than 5 responses  49  Responses Percent Which of the following experiences have you had in your interactions with the 90 police? 25 27.8 Of icers generally have treated me with respect 18 20.0 Of icers generally have treated me with disrespect 7 7.8 Of icers have harassed me 0 0.0 Of icers have physically assaulted me * * Of icers have sexually assaulted me 41 45.6 I have had no interaction with the police As a transgender/gender non‐conforming person, how comfortable do you feel 90 seeking help from the police? 15 16.7 Very comfortable 6 6.7 Somewhat comfortable 18 20.0 Neutral 19 21.1 Somewhat uncomfortable 28 31.1 Very uncomfortable * * Unknown/did not answer 90 Have you ever been sent to jail or prison for any reason? 80 88.9 No, I have never been sent to jail or prison. 6 6.7 Yes, I have been sent to jail or prison * * Unknown/did not answer Have any of the following people used improper pronouns, even after being corrected? For example: using the pronouns he/his/him for a MTF 90 Transwoman even after being corrected. 40 44.4 Health care professionals (Doctors, Nurses, of ice staff) 15 16.7 Police or Sheriff's deputies * * Judge Have you ever had to get your hormones from another country, such as Mexico? 90 37 41.1 No, I get my hormones locally * * Yes, Mexico 6 6.7 Yes, ordered from another country 5 5.6 Other 40 44.4 N/A I don't take hormones Have you experienced acts of discrimination in Riverside or San Bernardino 90 Counties? 47 52.2 No 31 34.4 Yes 12 13.3 Unknown/did not answer As a transgender/gender non‐conforming person, please check whether you have experienced any of the following in these public spaces. 90 Retail store 5 5.6 Denied service 6 6.7 Denied equal treatment 16 17.8 Verbally harassed or disrespected * * Physically attacked or assaulted 48 53.3 I have not experienced these negative outcomes 8 8.9 Not applicable (N/A) *less than 5 responses  50  Hotel or restaurant Bus, train, or taxi Airplane or airport staff/TSA Doctor's of ice or hospital Emergency Room Mental Health Clinic Responses Percent 90 * * Denied service * * Denied equal treatment 12 13.3 Verbally harassed or disrespected 0 0.0 Physically attacked or assaulted 52 57.8 I have not experienced these negative outcomes 14 15.6 Not applicable (N/A) 90 0 0.0 Denied service * * Denied equal treatment 8 8.9 Verbally harassed or disrespected 0 0.0 Physically attacked or assaulted 51 56.7 I have not experienced these negative outcomes 21 23.3 Not applicable (N/A) 90 0 0.0 Denied service * * Denied equal treatment 8 8.9 Verbally harassed or disrespected 0 0.0 Physically attacked or assaulted 48 53.3 I have not experienced these negative outcomes 25 27.8 Not applicable (N/A) 90 6 6.7 Denied service 9 10.0 Denied equal treatment 19 21.1 Verbally harassed or disrespected 0 0.0 Physically attacked or assaulted 43 47.8 I have not experienced these negative outcomes 12 13.3 Not applicable (N/A) 90 0 0.0 Denied service * * Denied equal treatment 8 8.9 Verbally harassed or disrespected 0 0.0 Physically attacked or assaulted 49 54.4 I have not experienced these negative outcomes 24 26.7 Not applicable (N/A) 90 * * Denied service * * Denied equal treatment 6 6.7 Verbally harassed or disrespected 0 0.0 Physically attacked or assaulted 40 44.4 I have not experienced these negative outcomes 32 35.6 Not applicable (N/A) *less than 5 responses  51  As a transgender/gender non‐conforming person, please check whether you have experienced any of the following in these public spaces. Ambulance/EMT/Medic Responses Percent Denied service Denied equal treatment Verbally harassed or disrespected Physically attacked or assaulted I have not experienced these negative outcomes Not applicable (N/A) Government agency or of icial Denied service Denied equal treatment Verbally harassed or disrespected Physically attacked or assaulted I have not experienced these negative outcomes Not applicable (N/A) Police Of icer Denied service Denied equal treatment Verbally harassed or disrespected Physically attacked or assaulted I have not experienced these negative outcomes Not applicable (N/A) Have you ever been forced to have sex against your will by a partner or someone close to you? (husband, wife, girlfriend, boyfriend, etc.) No Yes Unknown/did not answer I have a strong support system of people in my life Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree Unknown/did not answer Religion and/or spirituality is an important part of my life. Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree N/A Unknown/did not answer 90 0 * * 0 35 43 90 0 0 10 0 37 33 90 * * 12 * 35 35 0.0 * * 0.0 38.9 47.8 0.0 0.0 11.1 0.0 41.1 36.7 * * 13.3 * 38.9 38.9 90 61 23 6 90 27 32 8 13 * 7 90 12 18 12 9 28 * 7 67.8 25.6 6.7 30.0 35.6 8.9 14.4 * 7.8 13.3 20.0 13.3 10.0 31.1 * 7.8 *less than 5 responses  52  I feel connected to the transgender community Responses Percent Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree Unknown/did not answer Would you participate in a transgender speci ic discussion group if one was available in your area? Yes Maybe No Other (please specify) Unknown/did not answer Does your gender identity impact your level of comfort when accessing social and/or health services provided by your county agencies? Yes Maybe No Unknown/did not answer Would you be more comfortable using social and health services if the agency providing the services was identi ied as "Transgender Friendly?" A lot more comfortable Somewhat more comfortable Only slightly more comfortable It wouldn't make a difference Unknown/did not answer Do you participate in any LGBT or Transgender speci ic organizations? No Yes Unknown/did not answer Of the following, please mark the top three most important transgender services you think should be offered in your area. Service Mental Health Counseling Health Transition Support Employment Placement Assistance Support Groups Legal Support/Helpline Social Events Housing LGBTQI Senior Housing Job Fair Job Training 90 12 17 25 17 12 7 13.3 18.9 27.8 18.9 13.3 7.8 90 53 23 * * 7 58.9 25.6 * * 7.8 90 45 15 20 10 50.0 16.7 22.2 11.1 90 57 15 * 6 8 63.3 16.7 * 6.7 8.9 44 48.9 38 8 42.2 8.9 Total Votes 43 37 37 33 29 17 12 10 7 5 * Rank 1 2 3 4 5 6 7 8 9 10 11 *less than 5 responses  53  References Bonvicini, K. A., & Perlin, M. J. (2003). The same but different: Clinician‐patient communication with gay and lesbian patients. Patient Education and Counseling, 51(2), 115‐122. Boundless. “Development of Gender Identity.” Boundless Psychology. Boundless, 08 Aug. 2016. Retrieved 06 Sep. 2016 from https://www.boundless.com/psychology/textbooks/boundless‐psychology‐textbook/gender‐and‐ sexuality‐15/gender‐414/development‐of‐gender‐identity‐297‐12832/ County of Riverside, Department of Public Health. (2014). 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[Fact sheet] Re‐ trieved from www.preventioninstitute.org/unity 55    Riverside University Health System – Public Health Epidemiology and Program Evaluation 4065 County Circle Drive, STE 211 Riverside, CA 92503 Ph: 951.358.5557 http://www.rivcoph.org http://www.shaperivco.org Riverside University Health System – Public Health Epidemiology and Program Evaluation 4065 County Circle Drive, STE 211 Riverside, CA 92503