sexual identity to health care providers and found that many respondents reported previous negative interactions with providers and avoided discussing sexuality with providers (Eliason and Schope, 2001). While many of these studies had sampling limitations, they highlight potential barriers that deserve further scrutiny.

Research with convenience samples of transgender people indicates that lack of access to health care is an important concern for this segment of the LGBT community. Access to transgender-specific health care in accordance with the Standards of Care varies across the United States (Rachlin et al., 2008). One major barrier is that, with some notable exceptions, health insurance and other third-party payers (Medicare, Medical Assistance) exclude coverage of transgender-specific health care, particularly surgery. The cost of medical care, lack of access to specialists, and a paucity of transgender-friendly and -knowledgeable providers are perceived barriers to care. On the other hand, being under the care of a physician is associated with reduced high-risk behavior, such as smoking cessation, medically supervised hormone therapy, and access to clean needles for hormone injection (Sanchez et al., 2009).

The recently conducted National Transgender Discrimination Survey (n = 6,456), described in detail in Chapter 3, reported that 28 percent of transgender respondents experienced verbal harassment in a medical setting, and 50 percent encountered providers that lacked knowledge of some aspect of their health needs (Grant et al., 2010). Qualitative research supports the finding that transgender people often have negative experiences when interacting with health care providers who lack the cultural competence to respond sensitively to their health concerns (Bockting et al., 1998; Clements-Nolle et al., 1999; Sperber et al., 2005). In a survey using a convenience sample of 248 transgender people of color in Washington, DC, 33 percent reported insensitivity or hostility from health care providers; 11 percent reported difficulty accessing transgender-specific health care procedures (counseling, hormone therapy, or surgery to alleviate gender dysphoria), and 70 percent of those taking hormones had acquired them from friends or on the street (Xavier et al., 2005). Participants in this survey indicated multiple needs for general and transgender-specific health care services not currently met. Among 332 transgender women of color in San Francisco, needs for general health care services were high and generally met; however, this was often not the case for social services, substance use treatment, psychological counseling, and transition-related medical services. Further focus group findings (n = 48) indicated that this population was generally dissatisfied with the quality of available health and social services (Nemoto et al., 2005). Similarly, a survey of transgender people in Philadelphia (n = 81) found high levels of need for health and social services that were largely unmet, especially among female-to-males (Kenagy, 2005a).

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