sec_arr Behavioral Health

Behavioral Health

Estimates in the U.S. and internationally indicate that the number of individuals identifying as trans-gender/gender diverse (TGD) are increasing.1 Similarly, the number of individuals identifying as TGD within the workplace appears to be increasing.2 It is reasonable to also expect that the number of police personnel identifying as TGD will continue to increase. Actual numbers of Officers openly presenting as TGD in policing are not known but at least one small study placed the estimate at 0.18%.3 Thus, if there are 850,000 LEOs in the U.S., then approximately 1,530 are TGD. However, TCOPS data show there are 3,700 known TGD LEOs in the U.S. This number is likely to under-estimate TGD LEOs as many may still be closeted and therefore uncomfortable disclosing their status.

When assessing the TGD officer, context is important. For example, psychosocial stressors may be instrumental in a TGD officer’s referral for an FFDE. Stress can often result from a hostile, [trans]phobic culture, which often translates into harassment, maltreatment, discrimination, and victimization.4,5 Stressors may be distal/external (abuse, trauma, discrimination), anticipatory (fear of going to work or school), and proximal/internalized (depression, anxiety, poor self-esteem), which ultimately affects physical and mental health outcomes.6 Thus, interpersonal, environmental, and systemic factors must be examined (e.g., outdated organizational policies, peer marginalization/ ostracization, etc.) when understanding the TGD officer’s recent behaviors and concerns.

In addition to Meyer’s (2003) Minority Stress Theory described above, Interpersonal Theory describes how perceived burdensomeness and a sense of not belonging may lead to the TGD individual feeling “all alone” in their experience. Leading to social isolation, this may increase the likelihood of depression and suicidality.7,8 Lastly Intersectionality Theory, focuses on how systemic factors interact to impact the individual. All three theories stress the significantly adverse impact of discrimination on TGD individuals’ mental health and provide treatment recommendations. Therefore, physicians must understand the unique experiences related to minority stress that TGD individuals encounter and how these experiences relate to both mental health vulnerability and resilience, as well as their ability to access and engage in care.

Not recognizing attendant issues, challenges, and responses from peers when treating the TGD population can be harmful. Being TGD is not a disorder and being TGD should not lead to the presumption that the officer experiences distress or dysfunction related to their gender identity. Gender identity and expression are important aspects of human personhood and as with race, ethnicity, sexual orientation, and other important dimension of human existence, stereotyping and discrimination are harmful. While being TGD is not necessarily causative of distress or dysfunction, some individuals whose gender identity does not align with their sex assigned at birth do experience cognitive conflict and emotional challenges. For many, the marked incongruence can cause a desire to seek change. The dysphoria that can accompany the incongruence may have a serious impact on the individual’s health (including anxiety, depression, and suicidal ideation) and cause dysfunction in achievement, relationships, and the workplace. Symptom severity and its impact on functioning may or may not warrant a formal diagnosis of a mental health disorder.

Gender Dysphoria
Gender dysphoria refers to the discomfort or stress caused by a discrepancy between a person’s gender identity and gender assigned at birth. To meet criteria for the diagnosis, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

While the American Psychiatric Association has made clear that gender identity isn’t inherently linked to mental health problems, gender dysphoria has been associated with higher rates of suicidality and self-harming behaviors, greater psychological distress (including depression and anxiety), and comorbidity with other mental health conditions.9 More generally, research findings – further expounded on below – suggest that TGD individuals exhibit higher rates of mood disorders, substance abuse problems, self-harm, suicidal behaviors, and other high-risk behaviors.8,10 Some studies suggest that self-harming behaviors may also be used by TGD individual as a maladaptive coping mechanism to “numb” the distress associated with gender dysphoria.11

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5)12 provides for one overarching diagnosis of gender dysphoria with separate specific criteria for children and for adolescents and adults. The DSM-512 defines gender dysphoria in adolescents and adults as “a marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months, as manifested by at least two of the following:

  • A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
  • A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
  • A strong desire for the primary and/or secondary sex characteristics of the other gender
  • A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
  • A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
  • A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

As with the diagnostic criteria for adolescents and adults, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Many TGD individuals experience gender dysphoria at some point in their lives. It is important to highlight that while gender dysphoria is a diagnosis listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), TGD identity is not in the DSM-5 and should not be considered a form of psychopathology. For most TGD individuals with or without severe mental illness, their gender dysphoria is alleviated by achieving a satisfactory level of affirmation of their gender identity through social, legal, and/or evidence-informed gender-affirming health services. Many TGD individuals may require both hormone therapy and surgery to alleviate gender dysphoria, while some may need only one of these options, and some may need neither. Physicians should take the opportunity to provide information regarding both medical and non-medical options for gender affirmation, including psychotherapy.

Gender-affirming interventions should be initiated for patients who meet diagnostic criteria for gender dysphoria if co-occurring mental health conditions are reasonably well-controlled and the patient is able to make an informed decision about treatment with clear and realistic expectations. In many cases, gender-affirming health care will help stabilize or resolve co-occurring psychiatric problem.13

Gender Dysphoria and Psychological Adjustment
Gender dysphoria has been associated with higher rates of suicidal ideation and self-harming behaviors, greater psychological distress, and comorbidity with other mental health conditions.9 Some studies suggest that self-harming behaviors may be used by TGD individual as a maladaptive coping mechanism to “numb” the distress associated with gender dysphoria.11 However, a meta-review of 38 studies on gender dysphoria and mental health indicated that, although the levels of psychopathology and psychiatric disorders in TGD individuals at the time of assessment are higher than the general population, they do improve following gender-confirming medical intervention, in many cases reaching normative values.9 Therefore, it is important to recognize that medical intervention and gender confirmation therapies (e.g., hormone treatments, surgeries, etc.) may play a critical and complementary role in promoting mental health adjustment in the TGD LEO.

TGD Mental Health and Outcomes
TGD individuals report higher levels of depression and anxiety, with 48-62% reporting clinical depression symptoms and 26-38% reporting anxiety symptoms.8 These rates are 2-3 times higher than those documented for the general U.S. population.14 TGD women (assigned male at birth) in particular tend to be more likely to experience depression and may be more at risk if they are younger. Hoffman speculates that this is due to the fact that younger TGD women may have fewer coping mechanisms.14 More recent studies continue to affirm these findings,7with TGD individuals reporting greater levels of psychological distress overall, poorer quality of life and lower levels of self-esteem and perceived social support.10

In terms of suicidality, TGD individuals report higher rates of suicide attempts as compared to the general population. About 40% of individuals who are TGD report having attempted suicide in their lifetime, as compared to the 4% found across the general population.7 TGD individuals also report some of the highest suicide attempt rates even as compared to other marginalized groups,7 with them also reporting higher rates of suicidal ideation. Risk factors associated with suicide attempts and completed suicide for TGD individuals include substance abuse, relationship loss, physical health, socioeconomic status, and victimization trauma.15

TGD individuals are also more likely to develop substance abuse disorders as compared to the general population with TGD women showing greater risk for substance abuse as compared to TGD men. 16 For adults, a major factor that has been liked to substance abuse is unemployment, with TGD individuals being twice as likely to be unemployed as compared to the general population. 16 For TGD officers, then, fears concerning employment may tend to heighten and this link with substance use should be recognized as a risk when coping with minority stress.

Research has shown TGD individuals to be at higher risk for experiencing domestic violence as adults as well.17 TGD women in particular are at a higher risk for violence, reporting rates 2-3 times higher than the general population.14 Overall, TGD individuals experience discrimination at dramatic rates. More than 63% report having been the victim of a serious act of discrimination, to include verbal, sexual, and physical victimization as well as systemic injustices.16 In addition, those individuals who are unable to “pass” may be in greater danger of victimization and abuse. TGD LEOs are not immune to the effects of discrimination – one study of TGD LEOs indicated that over 90% of these individuals reported negative experiences including termination or being threatened with termination, verbal abuse, physical abuse, and fearing for their safety.18

Providing a Safe Medical Environment
One study found that the most commonly cited reasons for not seeking treatment included: prior negative experiences with providers, stigma, and fear of refusal of treatment, cost of treatment, fear of certain aspects of treatment (e.g., pressure to take medication), and concerns about stigma or social consequences.19

Given these disparities that exist in both medical and psychological fields for TGD individuals, it is common for misinformed and discriminatory practices to occur in these contexts19 While there is much to consider, empirically-informed suggestions include:

On the individual provider level: 20

  • Providing an affirmative stance in regard to the clients’ identity. This included asking the TGD individual how they view and define their gender and which pronouns they prefer
  • Not assuming that an individual will identify as TGD just because their gender identity is not congruent with their assigned gender at birth
  • Being aware of the disproportionate amount of trauma and violence this population experiences and how that may affect trust between the provider and the client
  • Seeking consultation and training to increase your awareness and knowledge about TGD issues and gender identity
  • Familiarizing yourself with community resources available to TGD individuals
  • Assessing and monitoring for suicidality

On the systemic level recommendations include 21

  • Raising awareness amongst providers (even small efforts can have large outcomes)
  • Increasing culturally competent access to care for TGD officers within departments and health care systems
  • Providing community and/or departmental education to de-stigmatize help-seeking and misinformation about TGD individuals

Contextual Factors and Barriers
The Hippocratic Oath serves as an important foundation when recognizing how to proceed with best practice evaluation of TGD officers. The concepts of confidentiality and non-maleficence are paramount, as many TGD individuals, when approaching a physician for evaluation, bring with them fears and actual experiences of stigma, discrimination, and misunderstanding from healthcare providers in their past. In addition, interpersonal, environmental, and systemic factors create stress that often precede and/or are co-occurring with a TGD officer’s referral for an FFDE. Thus, by understanding context, we believe the physician is best able to properly assess the TGD officer when equipped with more nuanced information on these external factors.

For the evaluating physician, events precipitating an outburst or decline in work product must also be considered. Often, changes in a detail or assignment may result in a lack of support from former work friends, co-workers, and/or supervisors. For example, stress may come from an administration failing to consider the importance of a TGD officer’s network when making changes in a TGD officer’s workload or partnership. TGD officers may also experience harassment from co-workers and/or citizens, and this stress can be exacerbated by failure of coworkers to provide backup and/or support to the TGD officer. Peer socialization on and off duty often plays a critical role for officers in supporting and maintaining their mental health, and actual and perceived experiences of rejection of the TGD officer may create an environment of isolation and fears that can lead to depression, loneliness, and problems with coping/adjustment to the high-stress nature of police work.

Physicians should also recognize the potential TGD individuals face in experiencing intentional acts of sabotage, deceitful behavior, and negative statements by co-workers and superiors. For example, negative performance reviews may be due to supervisor bias and disapproval of the officer’s TGD identity. Negative citizen and/or administrative reports may also be made to the TGD officer’s supervisor from biased, disgruntled, or bigoted teammates or co-workers or citizens. TGD officers may have even faced physical attacks by other employees or their agents, who may be acting to intimidate or dissuade the TGD employee from returning to work. While the TGD officer may have reported such instances to the employer and or jurisdiction where the incident occurred, they often go unreported out of embarrassment or fear of retribution (see Appendix G for further examples).

Even for those TGD officers who have faced little to no workplace stigmatization, marginalization or experiences of prejudice, gender transition is a stressful time for most TGD individuals, especially those who transition later in life. Support networks often dwindle due to the disclosure of the gender transition. Financial stress is also common due to separation or divorce from a spouse and/or their family, and TGD officers also may face challenges regarding child custody or visitation, especially when the officer’s gender identity is made an issue with the court or in the filing of a petition of divorce.

It should also be noted that the TGD officer may also be dealing with stressors surrounding their identities of being both a police officer and a TGD individual. For example, research indicates that incidences of police abuse and misconduct are reported to authorities at much higher rates by TGD individuals.18 This can take of the form of mistreatment by police, including being verbally harassed, or physically or sexually assaulted. As a result, for the TGD officer, they may feel conflicted in their identity as a police officer and as a TGD individual and may witness discriminatory and prejudicial attitudes from peers or administrators that can complicate their adjustment in the workplace and leave them feeling alienated, misunderstood, and forced to choose between these identities. For the evaluating physician, it’s critical that these psychosocial stressors be accounted for when considering the TGD officer’s presenting condition and concerns.

Transition in the Workplace
A useful way of conceptualizing the processes involved in transitioning from assigned gender at birth to the adoption of the identified gender is as parallel continua of social and medical transition manifestations.22 Social transition may, for example, be expressed by dress, use of pronouns or nicknames, or an individual seeking to be identified by their target gender when interacting with others. Medical transition may, for example, take the form of hormone treatments altering the voice or facial hair, or surgeries altering the body in identifiable ways. For purposes of the workplace, these continua range from TGD employees who may not wish to be “out” in the workplace, to those who are expressing varying degrees of alignment with their target gender through social or medical means, to those who are de-transitioning and returning for various reasons towards their assigned birth gender.1,22,23,24

Because there are so many variables that influence how and when an employee may need or want to move along these continua, the best approach is for an employer to maintain open lines of communication and consult with their TGD employee before making changes or decisions impacting the workplace and all employees within the organization.1,2,23,24,25,26 However, similar to the interactive process first established under the ADA, it is incumbent upon the TGD employee to initiate this reciprocal process. Employers will necessarily need to continue the interactive process with their employees to insure they stay current with the employee’s needs and preferences, especially as the employee chooses to make changes that will impact their interactions or performance in the workplace.

It should be noted that employers who wait until an employee presents an individual case of TGD issues within the work environment run the risk of exacerbating the implicit challenges, dilemmas, and potential negative outcomes of poorly handled policies and decisions within their organization.2,27,26 Failure to establish policies, conduct training, and pro-actively set the tone for the organizational culture often results in the leadership reacting after a negative spiral of events and damage to workplace relationships is already in motion.2,27,28

Discrimination and abuse are the reality for many TGD employees. For example, as many as 90% of respondents of a large-scale national survey reported some form of negative consequence after coming out (or being “outed” against their will) in the workplace.29 Other authors have note that negative workplace experiences and outcomes can be mitigated by skillful, caring management, and deliberate attention to respectful policies and workplace culture.8,28

Factors that appear to influence whether an employee experiences more negative or positive outcomes include: the overall culture of an organization, the skillfulness and preparation on the part of leadership, and even the presumptive expectations of the TGD employee.1,3,8,25,27,29 It has been noted by some authors that TGD employees are often surrounded by coworkers who are supportive and empathic but who are not sure how to assist.27,29 It has also been noted that some employees, including those who reported negative experiences related to their transition in the workplace, were able to subsequently identify positive personal outcomes to include better coping strategies, an improve sense of self-efficacy, spiritual growth, knowledge, and a sense of activism.25 Employers have reported that working through the challenges posed by TGD employees in their workplaces resulted in improved organizational reputations, competitive advantages, stronger employee loyalties, and stronger diversity, equity and inclusion (DEI) cultures for all employees in the workplace.2,8,27

Accommodating TGD Employees in the Workplace
Due to the conflicting variations in the international legal and political climates, legal and Human Resource experts recommend approaching the needs of TGD employees based primarily on the self-determinative preferences of such employees.1,2,8,26,30,31,34 Even so, employers will need to be straightforward with their employees when they are under legal constraints and unable to accommodate specific TGD requests on the part of their employee.26,30 For example, a legal name change is quite easy in some states and requires an almost impossible degree of proof of medical transition in others.2 Some matters likely to come up for consideration include: 1) how an employee’s name will appear on organizational documents, email, and security badges; 2) what preferred names, pronouns, and nicknames the employee wants in use in their workplace; 3) legal and organizational regulations related to health benefits and medical leave; 4) the timing and content of communications with supervisors and colleagues related to an employee’s transition; 5) the content and timing of communication with the public or extra-agency groups; and 6) the guidelines governing access to and use of intimate spaces such as restrooms, locker rooms, and dormitories.26,31

Use of and access to intimate spaces within the workplace are a particularly pressing consideration for all employers,26,31 a fact resulting in the publication of specific guidelines by the Occupational Health and Safety Administration stating that “all employees should be permitted to use the facilities that correspond with their gender identity” regardless of their medical transition status.30 The guidelines further state that restroom access must be promptly available, safe, and appropriate. According to the guidelines, gender-neutral facilities are acceptable but no employee (whether TGD or not) may be forced to use or restricted from their use.30The Bostock decision did not address Title VII issues such as dress codes, intimate space access, or exclusions for reasons of religious liberty.34

Organizational Culture and Rules
Subsequent especially to the Bostock decision, legal advisors recommend incorporating TGD policies and procedures into the organizations overall anti-discrimination culture.28 Well-thought-out and mindfully implemented policy changes, insurance coverage for gender transition, organizational trainings, and space adaptations can go far towards setting a healthy tone for the workplace and mitigating potential damage to interpersonal relationships in a workgroup.2,8,26,27,29,31 Updates and particular attention are recommended regarding: 1) the employee handbook; 2) policy and procedure rules; 3) hiring practices; 4) employee training; 5) setting expectations for respect for everyone in the workplace; 6) tracking ongoing successes and deficits and adapting as necessary.2 TGD employees who have reported positive experiences identify several factors which influenced their opinion, most notably a knowledgeable and proactive Human Resource staff, the manner in which information was disseminated, educational and emotionally intelligent meetings and training events. Employees also noted that their personal support system and counseling support from knowledgeable employee assistance program (EAP) professionals were helpful.8

Crimes and Harassment against TGD individuals
Research shows that TGD individuals in the U.S. face persistent and pervasive discrimination and violence. According to the 2015 U.S. Transgender Survey – the largest national survey of TGD persons in the U.S., with over 27,000 respondents – 46% of respondents had been verbally harassed in the previous year, and 9% had been physically attacked as a result of being TGD.(James 2016) Nearly half (47%) had been sexually assaulted at least once during their lifetime. At work, 30% of respondents reported being fired, denied a promotion, or experiencing harassment including physical or sexual assault

According to research, TGD African Americans are disproportionately impacted by violence among LGBT individuals. Among respondents to the 2015 U.S. TGD Survey, 44% of Black respondents reported being verbally harassed, and more than half (53%) were sexually assaulted at least once in their life.32 Another study of anti-LGBTQ violence found that 71% of reported homicides were people of color, 52% were TGD or gender nonconforming, and 40% were TGD women of color.33

Key Concepts
As platforms for communication and related social dialogue have expanded, society’s past limited perspectives have given way to deeper and richer understandings of how we view gender. Historically, gender has been narrowly conceived of in binary terms. It was also thought to follow a linear developmental pathway. Such overly simplistic understandings of the multi-causal and dimensional nature of gender have done harm to TDG individuals and have limited effective assessment and intervention. But as conceptualizations of gender began to change around the 1600s, and through advances in biology and modern medicine since the early 1900s, medical and psychological communities have progressed in their understanding of these issues. Concurrently, language and conceptualizations have evolved in society and brought visibility to TGD individuals who were not previously identified, understood, represented, protected, or provided proper care. This section outlines and articulates critical concepts and key terms necessary for understanding, acknowledging, and communicating with TGD individuals in ways that are inclusive, equitable, affirmative, and which allow for the provision of competent care.

Gender or Sex?
People tend to use the terms “sex” and “gender” interchangeably. But while connected, the two terms are not equivalent (see Gender Spectrum at Generally, sex is defined as a set of biological attributes characterized by chromosomes, genes, hormones, and reproductive/sexual anatomy. A newborn’s sex is assigned as either male or female (some U.S. states and other countries offer a third option) based on the baby’s observed genitals. Once a sex is assigned, the child’s gender is presumed. For most people, this is cause for little, if any, concern or further thought because their gender aligns with gender-related ideas and assumptions associated with their sex. Nevertheless, while gender may begin with the assignment of sex, it doesn’t end there. A person’s gender is the complex interrelationship between three dimensions: body, identity, and social gender.

Most societies view sex as a binary concept, with two rigidly fixed options: male or female, based on a person’s reproductive anatomy and functions. But a binary view of sex fails to capture even the biological aspect of gender. While people are often taught that bodies have one of two forms of genitalia (classified as “female” or “male”), there are intersex traits that demonstrate that sex exists across a continuum of possibilities. This biological spectrum by itself should be enough to dispel the simplistic notion that there are just two sexes. The relationship between a person’s gender and their body goes beyond one’s reproductive functions. Research in neurology, endocrinology, and cellular biology points to a broader biological basis for an individual’s experience of gender.13 In fact, research increasingly points to the brain as playing a key role in how one experiences gender.

Bodies themselves are also gendered in the context of cultural expectations. Masculinity and femininity are equated with certain physical attributes, labeling as more or less a man/woman based on the degree to which those attributes are present. This gendering of bodies affects how one feels about themselves and how others perceive and interact with them.

Gender Identity
According to the American Academy of Pediatrics, “By age four, most children have a stable sense of their gender identity.” This core aspect of one’s identity comes from within. Gender identity is an inherent aspect of a person’s make-up. Individuals do not choose their gender, nor can they be made to change it. However, the words persons use to communicate their gender identity may change over time; naming one’s gender can be a complex and evolving matter. Because of limited language for gender, it may take a person quite some time to discover or create the language that best communicates their internal experience. Likewise, as language evolves, a person’s name for their gender may also evolve. This does not mean their gender has changed, but rather that the words for it are shifting.

Social Gender
Social gender includes gender expression, which is the way one communicates gender to others through such things as clothing, hairstyles, and mannerisms. It also includes how individuals, communities and society perceive, interact with, and try to shape a person’s gender. Social gender includes gender roles and expectations and how society uses those to try to enforce conformity to current gender norms.

Practically everything is assigned a gender – toys, colors and clothes are some of the more obvious examples. Children are taught about gender from the moment they are born; given the prevalence of the gender binary, children face great pressure to express their gender within narrow, stereotypical definitions of “boy” or “girl.” Expectations regarding gender are communicated through every aspect of their lives, including family, culture, peers, schools, community, media, and religion. Gender roles and expectations are so entrenched in culture that it’s difficult to imagine things any other way.

Gender congruence is the feeling of harmony in one’s gender:

  • experiencing comfort in one’s body as it relates to one’s gender
  • naming of one’s gender that adequately corresponds with one’s internal sense of who we are
  • expressing oneself through clothing, mannerisms, interests, and activities
  • being seen consistently by others as we see ourselves

Finding congruence is an ongoing process throughout each life as we continue to grow and gain insight. It is most often found through exploration. For some, finding congruence is fairly simple; for others, it is a much more complex process. But the fundamental need to find gender congruence is true for all, and any degree to which it is not experienced it can be distressing.

Personal Gender
While the dimensions of gender and the desire for congruence are common to all, ultimately gender is personal. Each dimension of gender is informed by a unique intersection of identities, experiences, and personal characteristics. People are more than body, gender identity and gender expression: it is also our race, ethnicity, class, faith, sense of geographic place, family history, and more.

Gender Is Different Than Sexual Orientation
One final distinction to make is the difference between gender and sexual orientation, which are often incorrectly conflated. In actuality, gender and sexual orientation are two distinct, but related, aspects of self. Gender is personal (how one sees oneself), while sexual orientation is interpersonal (who one is physically, emotionally and/or romantically attracted to).

When one confuses gender with sexual orientation, one is likely to make assumptions about a young person that have nothing to do with who they are. For example, when someone’s gender expression is inconsistent with others’ expectations, assumptions are frequently made about that person’s sexual orientation. The boy who loves to play princess is assumed to be gay, and the girl who buys clothes in the “boys’” section and favors a short haircut may be assumed to be a lesbian. These could be faulty conclusions. What someone wears and how they act is about gender expression. You cannot tell what a person’s sexual orientation is by what they wear (for that matter, one can’t know what their gender identity is either, unless they tell you).

Our society’s conflation of gender and sexual orientation can also interfere with a young person’s ability to understand and articulate aspects of their own gender. For example, it’s common for a TGD youth to wonder if they are gay or lesbian (or any sexual orientation other than heterosexual) before coming to a fuller realization of their gender identity. How one comes to understand one’s gender and sexual orientation – and the choices made to disclose and express these parts– are distinct paths.



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  31. Smith A. (2016). Anxiety over transgender women in restrooms persists. News and Features: Legal Issues. Society for Human Resource Management (SHRM): 2009-present. local-updates/pages/anxiety-over-transgender-women-in-restrooms-persists.aspx
  32. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality. 2016.
  33. National Coalition of Anti-Violence Programs. (2018). Lesbian, Gay, Bisexual, Transgender, and HIV-Affected Hate and Intimate Partner Violence in 2017.
  34. U.S. Equal Employment Opportunity Commission (EEOC). Annual Report on the Federal Workforce for Fiscal Year (FY) 2020. 2020. Available at:

Additional resources: 

Blair Woods J, Galvan FH, Bazargan M, Herman JL, Chen Y. Latina transgender women’s interaction with law enforcement in Los Angeles County. Policing: J Policy Practice. 2013;7(4):379-391. https://doi. org/10.1093/police/pat025.

Herman JL, Brown TN, Wilson BD, Meyer IH, Flores AR. (2016). Prevalence, characteristics, and sexual victimization of incarcerated transgender people in the United States: results from the National Inmate Survey (NIS-3). American Public Health Association. Denver, CO.

Lambda Legal. (2014). Police: Protected and Served? New York, NY. protected-and-served.

Ristori J, Cocchetti C, Romani A, et al. Brain sex differences related to gender identity development: genes or hormones? Intl J Molecular Scie. 2020;21(6): 2123.

Santos GM, Rapues J, Wilson EC, et al. Alcohol and substance use among transgender women in San Francisco: Prevalence and association with human immunodeficiency virus infection. Drug Alcohol Review. 2014;33(3):287-295.