Brief

Vulnerabilities to COVID-19 Among Transgender Adults in the U.S.

April 2020

Using data from the U.S. Transgender Population Health Survey, this study examines characteristics that may increase vulnerability to COVID-19 for the 1.4 million adults in the U.S. who identify as transgender.

Highlights
According to the CDC, those who are over age 65 and those with underlying medical conditions are most at risk of serious COVID-19 illness.
Many transgender people have experienced homelessness, putting them at significant risk during the COVID-19 pandemic.
Home may not be a safe place for many transgender people, who report conflict with their families and high rates of intimate partner violence.
Data Points
319,800
transgender adults have one or more of the following conditions: asthma, diabetes, heart disease, or HIV
217,000
transgender adults in the U.S. are age 65 or older
137,600
transgender adults do not have health insurance
450,400
transgender adults have not gone to a doctor in the last year because they could not afford it
667,100
transgender adults live below 200% of the poverty line
Brief

The 2019 novel coronavirus, which causes COVID-19, has impacted the health, livelihoods, and social lives of people around the world. COVID-19 symptoms include fever, cough, and shortness of breath, with serious COVID-19 illness sometimes causing death.1 The Centers for Disease Control and Prevention (CDC) has described characteristics of those who are most vulnerable to serious COVID-19 illness, including those who are over age 65 and those who are immunocompromised or have other underlying medical conditions, such as heart disease, kidney disease, and asthma.2 In addition, COVID-19 and the response to the pandemic may uniquely harm those who were already economically and socially vulnerable, such as those experiencing homelessness.3 In this factsheet, we utilize weighted proportions from the U.S. Transgender Population Health Survey (“TransPop”), fielded from 2016-2018, and findings from other sources to describe characteristics that may increase vulnerability to COVID-19 for the 1.4 million U.S. adults who identify as transgender.4

Health Vulnerabilities

One salient risk factor for serious illness from COVID-19 is being age 65 or older.5 In 2016, the Williams Institute estimated that approximately 217,000 adults who identify as transgender are age 65 or older.6

Moreover, transgender adults of all ages may have underlying health conditions, which elevate their risk for serious COVID-19 illness.7 Approximately 319,800 transgender adults have one or more of the following underlying health conditions:

  • 208,500 transgender adults have asthma;
  • 81,100 have diabetes;
  • 72,700 have heart disease;
  • 74,800 are living with HIV.

A substantial portion of transgender adults, about 361,400, report being in fair or poor health, a measure that is associated with a variety of poor health outcomes. Additionally, 278,000 transgender adults are current smokers, which also increases the risk for serious COVID-19 illness.8

The CDC also identifies social isolation, financial strain, and job loss as factors associated with elevated risk for suicide.9 587,100 transgender adults have attempted suicide in their lifetimes. The public health response to the COVID-19 pandemic, including shelter-in-place orders and social distancing, may exacerbate existing risk factors for suicide, including among transgender adults.

Access to healthcare is critically important during the COVID-19 pandemic, but approximately 137,600 transgender adults in the U.S. do not have health insurance. Transgender people may also experience discomfort or discrimination in healthcare settings, potentially making them less likely to seek needed care and more likely to receive poor care. We estimate that 483,000 transgender adults feel concerned that if they express their gender identity, they could be denied good medical care, and 77,000 feel unsatisfied with the care that they have received in the past. Cost is also a barrier to accessing health care. We estimate that 450,400 transgender adults have not gone to a doctor because they could not afford it within the last year.

Delays for certain types of surgical care to maximize health care facilities’ capacity to treat patients with COVID-19 could delay transgender individuals’ access to gender-affirming surgical care.10 Lack of access to gender-affirming care when needed is related to a higher prevalence of suicide thoughts and attempts.11

Economic Vulnerabilities

Prior to the coronavirus pandemic, about 667,100 transgender adults in the U.S. lived below 200% of the poverty line. In 2020, 200% of the poverty line was an annual income of $25,520 for an individual living alone. During the time of the TransPop survey (2016-2018), the annual unemployment rate for transgender adults averaged 12.8 percent, whereas the unemployment rate for the U.S. population ranged from 3.9 to 4.9 percent.12 We estimate that 139,700 transgender adults were unemployed at the time the coronavirus pandemic began.13 Recent job losses due to official orders enforcing social distancing practices will likely increase this number and exacerbate existing employment disparities.

Many transgender people have experienced homelessness, putting them at significant risk during the COVID-19 pandemic. Prior to the coronavirus pandemic, 96,400 transgender adults reported experiencing homelessness within the past year. People experiencing homelessness may be unable to carry out social distancing and regular hand washing, two recommended measures to prevent coronavirus infection.14 Moreover, people experiencing homelessness often access shelter and services in congregate settings, which are venues that pose unique risks for the spread of the virus.15

Social Vulnerabilities

Based on data from the 2015 U.S. Transgender Survey (USTS), conducted by the National Center for Transgender Equality, we estimate that 294,800 transgender adults live alone.16 Living alone may increase isolation and certain risks. In particular, older individuals and those with health conditions that put them at risk are recommended to stay home as much as possible.17 Those who live alone and may be disconnected from family and other networks may need special assistance related to health care and daily living.

It is important to note that home may not be a safe place for many individuals, particularly transgender individuals. Many transgender people experience conflict or rejection from their families due to their gender identity. For instance, 801,100 transgender people would say that their relationship with their parents is strained or conflicted.18 Additionally, based on data from the 2015 USTS, we estimate that 755,900 transgender adults have experienced intimate partner violence in their lifetimes.19 Official orders to mitigate the spread of coronavirus, like “stay-at-home” orders, may place transgender people in situations where they must shelter with family members who do not accept their gender identity and may place transgender people at added risk for intimate partner violence.

Methods Note

Except where otherwise noted, we calculated weighted proportions of transgender adults in each reported category using the U.S. Transgender Population Health Survey (“TransPop”; NICHD R01HD090468; PI: Ilan H. Meyer, for more information, see www.transpop.org). These weighted proportions were then multiplied by the estimated total number of adults who identify as transgender in the United States to arrive at the reported population estimates (see Flores, et al., 2016).20  See the Appendix Table, which describes each calculation. The authors wish to thank Winston Luhur for additional analyses conducted with the TransPop data for this fact sheet.

Where noted, we also analyzed data from the 2015 U.S. Transgender Survey (USTS) to create the reported estimates.21 The 2015 USTS was conducted by the National Center for Transgender Equality. (To find out more about the U.S. Transgender Survey, visit http://www.ustranssurvey.org/reports.) Findings from the USTS were then multiplied by the estimated total number of adults who identify as transgender in the United States, (see Flores, et al., 2016).22 See the Appendix Table for each calculation.

Population number estimates were rounded to the nearest 100.

Appendix

Vulnerabilities to COVID-19 Among Transgender Adults in the U.S.

Centers for Disease Control and Prevention. (2020). Coronavirus Disease 2019 (COVID-19): Symptoms of Coronavirus. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html

Centers for Disease Control and Prevention. (2020). Coronavirus Disease 2019 (COVID-19): Information for People who are at Higher Risk for Severe Illness. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/ groups-at-higher-risk.html

Department of Economic and Social Affairs. (2020, April 6). The Social Impact of COVID-19. United Nations, Department of Economic and Social Affairs. https://www.un.org/development/desa/dspd/2020/04/social-impact-of-covid-19/

Flores, A.R., Herman, J.L., Gates, G.J., & Brown, T.N.T. (2016). How Many Adults Identify as Transgender in the United States? The Williams Institute, UCLA School of Law. https://williamsinstitute.law.ucla.edu/publications/ trans-adults-united-states/

Centers for Disease Control and Prevention, 2020, Groups at Higher Risk for Severe Illness.

Flores, et al., 2016.

Centers for Disease Control and Prevention, 2020, Groups at Higher Risk for Severe Illness; The figures presented here for asthma, diabetes, and heart disease may have individuals who are represented in more than one category due to having more than one risk factor.

World Health Organization. (2020, March 24). Q&A on Smoking and COVID-19. World Health Organization. https://www.who.int/news-room/q-a-detail/q-a-on-smoking-and-covid-19

Centers for Disease Control and Prevention. (2019, September 3). Risk and Protective Factors. Centers for Disease Control and Prevention, Violence Prevention, Suicide. https://www.cdc.gov/violenceprevention/suicide/ riskprotectivefactors.html

Stahel, P.F. (2020). How to risk-stratify elective surgery during the COVID-19 pandemic? Patient Safety in Surgery, 14(8). doi: 10.1186/ s13037-020-00235-9; Daniari, S. (2020, March 25). Trans surgeries postponed indefinitely amid coronavirus pandemic. NBC News. https://www.nbcnews.com/feature/nbc-out/trans-surgeries-postponed-indefinitely-amid-coronavirus-pandemic-n1167756

Herman, J.L., Brown, T.N.T., & Haas, A.P. (2019). Suicide Thoughts and Attempts Among Transgender Adults: Findings from the 2015 U.S. Transgender Survey. Williams Institute, UCLA School of Law. https://williamsinstitute.law.ucla.edu/publications/suicidality-transgender-adults/

U.S. Bureau of Labor Statistics. (2020, April 17). Labor Force Statistics from the Current Population Survey. U.S. Bureau of Labor Statistics. https://data.bls.gov/timeseries/LNU04000000?periods=Annual+Data &periods_option=specific_periods&years_option=all_years. The unemployment rate is determined by including only those who are in the workforce in the calculation. Those who are in the workforce but are unemployed and looking for work are considered unemployed for the unemployment rate. Those who are out of the workforce, such as retirees, homemakers, students, and some individuals with disabilities, are not included in the unemployment rate calculation.

The estimated total number of adults who identify as transgender was limited to those who are currently in the workforce (78.1% of adults who identify as transgender are currently in the workforce, per TransPop employment data) then multiplied by the unemployment rate (12.8%) to reach the estimated total number of transgender adults who are unemployed (139,700).

Centers for Disease Control and Prevention. (2020, April 7). Coronavirus Disease 2019 (COVID-19): Homelessness and COVID-19 FAQs. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/faqs.html

Centers for Disease Control and Prevention, 2020, Homelessness and COVID-19 FAQs.

This estimate relies on data from the 2015 U.S. Transgender Survey, which was conducted by the National Center for Transgender Equality. Analysis completed by the authors. (To find out more about the U.S. Transgender Survey, visit http://www.ustranssurvey.org/reports.)

Centers for Disease Control and Prevention. (2020, April 7). Coronavirus Disease 2019 (COVID-19): Older Adults. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html

This finding includes those who do and do not currently live with their parents.

This estimate relies on data from the 2015 U.S. Transgender Survey, which was conducted by the National Center for Transgender Equality. Analysis completed by the authors. (To find out more about the U.S. Transgender Survey, visit http://www.ustranssurvey.org/ reports.)

Flores, et al., 2016.

James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2015). The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality. http://www.transequality.org/sites/default/files/ docs/ USTS-Full-Report-FINAL.PDF

Flores, et al., 2016.