Two years ago, Austin "A.J." Fonville, 48, went to the emergency room with painful cramps. He had just started taking testosterone as part of his treatment for gender dysphoria and his plan to transition into life as an out trans man.
Fonville, 48, is a black trans man. He said hospital staff misgendered him from the get-go, calling him "ma'am" even though he's identified as male on all his documentation. But the ultimate humiliation came in his interaction with the doctor, who looked at his chart and saw that he was taking testosterone.
"She said, 'I just don’t understand what’s wrong with you people.' I said, 'You people who?' And she just shook her head and walked off," he told me.
That was the first of many similar experiences Fonville has dealt with when he's tried to access health care since beginning to transition, he told me. In one case, a nurse removed the hospital bracelet he was wearing that identified him as a man, changed his gender in the hospital system, and came back with a bracelet that called him a woman.
Fonville is not alone. The National Center for Transgender Equality (NCTE)'s U.S. Transgender Survey, released December 8, found that some 33% of trans people say they were either verbally abused or denied health care because of their gender identity.
The survey also found that while trans people are becoming more visible and accepted in America, they still face far higher barriers in most aspect of their lives than cisgender Americans.
It's the most comprehensive report nationally on the experiences of trans Americans, surveying 27,715 transgender and gender nonconforming people over the age of 18 (roughy 2% of the adult trans population of the U.S.) through online questionnaires, conducted in summer 2015. The only other comprehensive survey of trans people nationally has been the NCTE and the National Gay and Lesbian Taskforce's 2008–2009 Transgender Discrimination Survey.
"There really was no data on trans people except some community needs assessments done in individual communities so that survey became really important. There was no federal data collection. Now there’s a little bit of federal data collection, but not nearly enough. And so this fills a hole with that," Mara Keisling, NCTE's executive director, told me.
Keisling said the fact that the number of trans people who took the survey went up from around 6,400 to nearly 28,000 since 2008–2009 is an indication of the improving visibility and acceptance of trans people in America.
And there's a growing sense of individuals in some trans people's immediate lives being supportive: 60% of people who said they were out to their families said their families were supportive, and 68% who said they were out to their co-workers said they were supportive. Among students who said they were out to their classmates, 56% said their classmates were supportive.
Still, the group's findings provide stark evidence of the disproportionate rates of discrimination and abuse that transgender people continue to face in their daily lives in the United States.
In the year leading up to the survey, 46% of trans people surveyed said they had been verbally harassed, while 10% said they had been sexually assaulted, and 9% said they were physically attacked because they're transgender. In their lifetimes, 47% of trans people said they had been sexually assaulted at some point.
Employment discrimination and poverty
Nearly one-third (30%) of trans people had been fired, denied a promotion, or been harassed or assaulted at work during the year before they took the survey. Of those, 16% said they had lost a job directly because of their gender identity. And 15% of those who had a job in the year before the survey said they had been verbally, physically, or sexually assaulted at work.
In addition to the trauma of assault, the effects of employment discrimination can be far-reaching in a person's life.
"We know that when people have a traumatic, marginalizing event in their lives, whether it's discrimination, violence or even just disrespect, it can have rippling effects throughout their whole life," Keisling said. "It can lead to higher rates of mental and physical illness, in addition to economic insecurity."
What that translates to in practical terms is that 29% of trans people who took the survey are living in poverty. That compares to around 14% of the wider population in the U.S, according to the U.S. Census Bureau. That's backed up by the unemployment rate that the survey captured: 15%, compared to 5% among the wider population at the time the survey was conducted.
And in terms of housing security, it means that trans people are far more likely to experience being homeless at some point in their lives. Close to one-third (30%) of trans people said they had been homeless for some period of time, and 12% said they had been homeless in the year leading up to taking the survey.
For many trans people of color like Fonville, being discriminated against on multiple fronts makes finding work and even just feeling safe walking down the street more challenging.
Trans people of color included in the survey were even more likely to be living in poverty: 43% of Latinxs trans people, 41% of Native American trans people, 40% of multiracial trans people, and 38% of black trans people said they were living in poverty. And the unemployment rate among all trans people of color was 20%, four times the national average at the time of the survey.
"One of those things that is really clear is that when people are facing transphobia and that kind of discrimination and violence and disrespect, if they’re also facing another kind of oppression like racism or ableism, it is multiplied so much worse," said Keisling.
Fonville told me he's applied for eight jobs in the past six months and still hasn't been hired. He says people know he's transgender, because he lives in a small town in North Carolina, and openly tell him they can't hire him because of his gender identity.
After being rejected for a job at a local gas station he asked the manager why he didn't get the job. "He said, 'You know why not,'" Fonville told me.
In 2016, an amendment to the Affordable Care Act brought in specific regulations prohibiting discrimination against transgender people trying to access health care.
But 33% of trans people surveyed said they had at least one negative experience with a health care provider, including verbal abuse or being refused treatment because they are transgender. Around a quarter (23%) were so afraid of being mistreated that they didn't seek health care when they needed it, and 33% didn't seek help because they couldn't afford care. Insurance is also still an obstacle for trans people: 25% said they were denied routine medical or gender transition-related coverage by their insurance company.
That lack of access is one factor that explains another concerning statistic: that 39% of trans people said they experienced serious psychological distress in the month before they took the survey. That compares to an average of 5% of the U.S. population experiencing serious psychological distress–which is measured using a scale that's based on questions about how frequently a person feels hopeless or worthless and how often those thoughts interfere with their life.
"Among the starkest findings is that 40% of respondents have attempted suicide in their lifetime—nearly nine times the attempted suicide rate in the U.S. population (4.6%)," the report reads.
The timing of this survey, in the lead-up to a new and drastically different federal government under Donald Trump, gives us a sense of what's at stake: the rights of a group of Americans who are already living their lives in the grips of widespread abuse and discrimination.
President-elect Trump has said that he believes trans rights should be left to be decided on a state level. In addition to the line-up of transphobic cabinet nominees he's announced so far, that likely means that federal agencies, like the Department of Education and Department of Justice, will no longer issue guidances aimed at setting inclusive standards for how schools, businesses, and government agencies treat trans people.
That means there will be more emphasis on state-by-state legislation. According to the Movement Advancement Project, 23 states have several policies that allow for trans people to be actively discriminated against.
In North Carolina, for example, the transphobic "bathroom bill," or H.B. 2, has meant that trans people are barred from using the restroom that corresponds with their gender identity. The survey found that 59% of trans people had avoided using the bathroom in public, at work, or at school "because they were afraid of confrontations or other problems."
For A.J. Fonville, who's lived in North Carolina for the past 20 years, the law has meant constantly feeling threatened in his daily life. He also said he has suffered from urinary tract infections because he avoids using the bathroom in public places.
"It put a lot of fear into me," he told me. "Before H.B. 2 I had some problems, probably with people who were closer to me, but HB2 gave people permission."
Fonville says he wants the incoming administration to know that he matters as much as every other person in this country.
"We’re an important part of this country. I'm a taxpayer," he said. "We count. It’s not just me. When they're coming at me they’re not just coming at me … I have family and other people who rally behind me. I am not alone. There are people watching."