TAVA Survey Results
Transgender People in the U.S. Military: Summary and Analysis of the 2008 Transgender American Veterans Association Survey
Whitepaper prepared for The Palm Center1
and the Transgender American Veterans Association2
by Karl Bryant, PhD3 * and Kristen Schilt, PhD4 *
This paper reports findings from a survey of transgender service members and veterans designed and administered by the Transgender American Veterans Association (TAVA). TAVA was founded in 2003 with the goal of ensuring that transgender military veterans receive fair, equitable, and dignified treatment from Veterans Association (VA) Hospitals.1 The resulting survey data produced compelling findings indicating that transgender service members and veterans, like many transgender people in the U.S., face various forms of discrimination based on their transgender status. Transgender people in particular faced discrimination while serving in the military, as well as when they accessed or tried to access services through VA Hospitals.
EXECUTIVE SUMMARY OF KEY FINDINGS
This survey produced the first major empirical data on transgender people in the military. The key findings from the 827 surveys filled out by U.S. military veterans and active-service personnel included:
TAVA designed their survey to capture a broad swath of the life experiences, both military and non-military, of transgender service members and veterans. The survey collected data on demographics (e.g. gender identity, income), military history (e.g. rank, years served), discrimination in the military, discrimination outside of the military (e.g. employment, housing), and experiences with VA Hospitals. The final survey instrument had 117 fixed answer and open response questions and was administered on-line from the 13th of December 2007 to the 1st of May 2008.
Collecting a random sample of transgender people is not possible, as the numerical bounds of the population are unknown. Transgender people also are widely dispersed geographically (meaning there are no transgender enclaves to sample from) and are often hidden due to societal stigma. These issues preclude gathering a random sample of the population of transgender people through traditional means (mailings, telephone calls, etc.).To get participants, TAVA used a convenience sampling method. TAVA listserv members were invited to take the survey; in addition, the survey was featured prominently on TAVAs website, as well as on the websites of many LGBT organizations, and on transgender-related websites and blogs. The non-randomization of the data collection means it is not possible to state with confidence that the findings are representative of the U.S. transgender population. However, as there is so little data on transgender people in the military, these data still provide an important first step toward illuminating the experiences of members of this group.
The data from this survey face several sources of potential bias. First, as the survey was administered on-line, there was no way to verify if participants were actually transgender service members or veterans. Second, on-line surveys create a bias toward higher socio-economical classes, as lower income individuals are less likely to have access to the Internet. Finally, the advertising of the survey on LGBT websites limits participants to those who feel comfortable accessing such sites. As such, there is a potential exclusion of transgender people who are deep stealth a community term that refers to people who have undergone a gender transition and maintain no ties to a transgender and/or LGBT community.
A NOTE ON OUR TERMINOLOGY
Terminology about individuals who live in a gender other than the one they were assigned at birth has been changing rapidly in the last twenty years. Historically, these individuals have been referred to as transsexuals a term developed by the psychological community in the 1940s. With the rise of gender activism in the 1990s, transgender came into more common usage as an umbrella term for a wide variety of gender identities that could be labeled by society as non-traditional. Transgender, as such, could include people who seek to live in a gender other than that which they were assigned at birth, feminine men, and masculine women. The terms female-to-male (sometimes abbreviated FTM) and transmen often are used to refer to female-bodied individuals (e.g. people assigned female at birth) who personally identify as male or masculine. The terms male-to-female (sometimes abbreviated MTF) and transwomen often are used to refer to male-bodied individuals (e.g. people assigned male at birth) who personally identify as female or feminine. The term transgender also can include male-to-female and female-to-male crossdressers individuals who wear clothing not commonly associated with their birth gender, occasionally or frequently, but do not plan on undergoing gender transitions. Intersex people individuals born with a variety of conditions where reproductive and sexual anatomy does not fall within the common definitions of male and female may also consider themselves transgender.
To fully understand the experiences of transgender people requires a working knowledge of the distinctions between sex, gender, and sexual orientation. Male and female are biological sex categories generally linked to a set of anatomical markers, including chromosomes and reproductive capacities. Gender identity is peoples sense of themselves as men, women, and/or somewhere in between this gender binary. Gender expression is how people present themselves to the world as masculine, feminine, androgynous, or a combination of any or all of these elements. Finally, sexual orientation refers to the object of peoples sexual desire (e.g. homosexual, heterosexual, bisexual). As transgender peoples experiences reveal, these elements biological sex, gender identity, gender expression, and sexual orientation are not static, and do not always fall into a set and predictable pattern. Rather, someone can be assigned male at birth, but have a gender identity and gender expression as a feminine woman. And, she may identify as heterosexual, lesbian, bisexual, or some other sexual identity entirely.
|BACKGROUND ON TRANSGENDER PEOPLE IN THE MILITARY
While there are very few studies that focus specifically on transgender people serving in the U.S. military, existing research indicates that military policies and practices negatively impact transgender, transsexual, and intersex-identified people in the U.S. armed forces. For example, one report suggested that:
On an institutional level, the U.S. military has taken the traditional stand that non-traditional gender identities fall under the aegis of disease, in particular psychopathology, and that individuals claiming such identities are therefore to be removed from service or to be
prevented from entering the service wherever and whenever possible.
This approach to non-traditionally gendered people manifests in formal policy. For instance, the Army Medical Services Standards of Medical Fitness include transsexualism and transvestism (a psychiatric label often applied to crossdressing) among its causes for rejection for appointment, enlistment, and induction. U.S. military recruitment policies and practices deem transgender individuals mentally ill, and thus unsuitable for service. Further, individuals who attempt to transition from male to female or female to male during military service may be discharged under enlistment violations, as well as through rules relating to homosexuality or cross-dressing or through being classified as psychologically unfit or having a personality disorder. Various formal and informal recruitment policies, enlistment rules, healthcare policies, and military case lawconcerning crossdressing and gender transitioning negatively impact the lives of transgender and non-traditionally gendered service members. These policies and practices severely limit transgender service members ability to freely express non-normative gender identities, and can result in extremely punitive actions.
|DEMOGRAPHICS ON TAVA SURVEY PARTICIPANTS
Survey participants resided in diverse geographic regions from all over the United States. Most were mid-life to older adults and had been or were currently married. The participants also represented diverse socioeconomic characteristics. About half of the participants reported an annual income of over $40,000, with the most typical source of income being from full-time employment. Most participants (54%) owned their own homes; those who did not own their domiciles were typically renters (34% of total).
FIGURE ONE: Branch of Service
Survey participants ranged across all branches of the service, with the highest proportion having served in the Army (38%) or Navy (29%). They also represented the full spectrum of ranks. Large proportions of participants who reported an enlisted rank were in the junior enlisted (48%) or junior non-commissioned officer (39%) ranks. Of those who reported officer ranks, junior officers made up the largest proportion (69%). Nearly half of the participants (47%) had served in a combat zone. The vast majority (86%) were honorably discharged, with the second highest reported discharge type being disability-medical discharge (8%).
As Figure Two shows, the majority of the sample identified as female. In terms of how respondents related to the broader category of transgender, the majority of participants located themselves on the MTF continuum between non-operative, pre-operative, and post-operative.  21% identified as crossdressers, with the majority being male-bodied. The remaining participants located themselves somewhere on the FTM continuum (9%), some other gender variant identity (4.8%), or no longer identified as transsexual or transgender (1.5%).
|FIGURE TWO: Gender Identities
As Figure Three shows, participants alternated between living as male full time, living as female full time, and alternating between male, female, and androgynous. Most transwomen lived as female full time, and most transmen lived as male full time. The majority of crossdressers alternated between male and female.
FIGURE THREE: Gender Expressions
Because people generally enlist in the military in their late teenage years, they often have not had the opportunity or financial ability to undertake any medicalized aspects of a gender transition a process that can be extremely expensive, especially if body modification surgeries are involved. Additionally, as discussed above, military regulations and culture prevent people from expressing transgender or other non-traditionally gendered identities. This means that most transgender and gender variant people serving in the military are seen in the eyes of the institution as the sex/gender they were assigned at birth (this claim is bolstered by the survey finding that of 660 respondents who identified as transsexual, 97% said they were unable to transition before leaving the military). So, the typical military experience for transmen and gender variant female-bodied people is that they are seen as women while serving, and the typical military experience for transwomen and gender variant male-bodied people is that they are seen as men while serving. As we discuss below, this forced gender expression has important fallout in terms of military experiences, including forms of discrimination and other negative treatment specific to transgender service members and veterans.
|EXPERIENCES OF DISCRIMINATION OUTSIDE OF THE MILITARY
Mirroring existing research that indicates that transgender people experience diverse forms of discrimination related to their gender identities,survey participants reported that they too experienced discrimination, violence, and other forms of negative treatment in several areas of their lives. As Figure Four shows, nearly one third of the survey participants reported having experienced some form of discrimination in the workplace, with approximately the same amount (31%) reporting that they believed they had not been hired for a job specifically because they were transgender. A full 15% reported that they had been fired from a job for being transgender (with 40% of those people having been fired more than once). Nearly 10% reported experiencing open, blatant discrimination from an employer or prospective employer; they were explicitly told that they were being fired (or not hired) because they were transgender. There was an important gender difference concerning experiences of employment discrimination: transmen were more likely to report facing discrimination when they presented as female, while transwomen reported more discrimination after their gender transitions.
FIGURE FOUR: Forms and Prevalence of Discrimination and Violence
Survey respondents also reported experiencing discrimination outside of the workplace, with about one third (31%) reporting some form of non-employment related discrimination. The most common form of discrimination outside the workplace was difficulty obtaining IDs, a widely reported experience faced by many transgender people; 21% of the survey participants reported that they had experienced difficulty obtaining identification documents.
In addition to discrimination, this group reported a high percentage of experiences with interpersonal violence. 26% reported having been the victim of physical violence, and 16% reported having been raped. For both reported experiences of discrimination and reported cases of violence, MTF and FTM participants reported higher incidences than did either male or female crossdressers. However, there were respondents in all categories (MTF, FTM, and Crossdressers) who reported having experienced each form of discrimination and violence discussed above.
|TRANSGENDER SERVICE MEMBERS AND THE “DON’T ASK, DON’T TELL” POLICY
Participants responses indicated that they are impacted by the U.S. militarys current dont ask, dont tell (DADT) policy on homosexuality, even though that policy (the implementation of title 10 United States Code § 654 or Policy Concerning Homosexuality in the Armed Forces) is not designed to regulate service eligibility by transgender people. A full 38% reported that when they were in the military, people suspected or directly asked if they were gay. In addition, 14% had been questioned by an officer about their sexual orientation. For younger respondents (aged 18-35), all of whom had served under DADT, this finding was even more pronounced: 61% reported that when they were in the military, people suspected or directly asked if they were gay; 20% had been questioned by an officer about their sexual orientation.
Such effects varied significantly by gender. Transmen were almost two times more likely to report they were suspected of being gay than transwomen (72% vs. 37%). They were three times more likely than transwomen to have been asked by an officer about their sexual orientation (33% vs. 11%). These numbers suggest being in the military as a pre-transition transman is a very different experience than being in the military as a pre-transition transwoman, and that DADT policies and homophobic military cultures differentially impact these two subpopulations.
What accounts for this gender difference may be the societal leeway for gender crossing. For example, during childhood girls can adopt masculine dress and behavior with little sanction, but boys cannot adopt feminine dress and behavior. While female-bodied people face pressure to conform to feminine norms in adolescence and adulthood, they are still able to adopt masculine gender expressions, such as wearing pants, having short haircuts, and not wearing makeup. Male-bodied people, in contrast, face stigma, ridicule, and violence if they adopt feminine gender expressions, such as wearing dresses or make-up. These differences mean that pre-transition transmen can be masculine-appearing women in the military more readily than pre-transition transwomen can be feminine-appearing men. However, as masculine women fit many peoples stereotypes of lesbians, pre-transition transmen who do adopt a masculine appearance seem to face more open questioning of their sexual orientation. Thus, while masculine female-bodied people are generally more tolerated than feminine male-bodied people, this may create a situation where pre-transition transmen (who appear to others as masculine women) are more likely to be targeted by anti-homosexual policies than are pre-transition transwomen, who face many more pressures to appear as normatively masculine men.
The gender differences found in this survey match findings about the differential impact of DADT on women versus men reported in other research. While women make up only 14% of the Army and 20% of the Air Force, in some years they account for up to half of discharges via DADT in those branches of the military. Thus, just as women in the military are disproportionately discharged through DADT, pre-transition transmen (who may appear socially as masculine women) are disproportionately suspected of and questioned about being gay.
|TRANSGENDER VETERANS’ EXPERIENCES WITH THE VETERANS ADMINISTRATION
Only 29% of the sample currently used a VA hospital. Transgender veterans who used the VA tended to be middle aged or older, and not working for pay. 70% of those using the VA fall between the ages of 46-65. 46% were retired, living on social security, or living on some form of non-employment-related income. 35% were unemployed due to disability. Only 23% were working full-time for pay. Nearly two thirds (63%) of those who used the VA had an annual income of less than $30,000, with over one third (35%) making less than $15,000 a year.
13% of those using VA hospitals identified somewhere on the FTM spectrum, while 82% identified somewhere on the MTF spectrum. This gender breakdown reflects the disproportionate amount of men in the military and the small percentage of transmen in this survey (about 10% of the total sample). Transgender veterans living in the Mid North (OH, KY, IL, IN, WI, MN, MS) were twice as likely to use the VA than those living in North or South. As with the general survey sample, participants who used the VA were most likely to have served in the Army (36%). Mirroring the total survey sample, most of those using VA hospitals were honorably discharged (84%) or discharged due to disability (14%).
As Figure Five shows, those who did access care from the VA received a variety of services both related to and not related to being transgender.
FIGURE FIVE: Examples of Treatments Accessed at VA Hospitals
|10% of the sample reported being turned away from the VA due to being transgender. About a third of those using the VA hospital had broached the subject of medical gender transitions with the VA staff. Generally, these individuals sought hormone therapy, genital surgery, and for transmen chest reconstruction surgery (double mastectomy) and hysterectomies. The majority reported having these requests denied. Most veterans reported being told simply no. A few doctors and staff members cited VA policy. As one respondent noted, [I was told] federal legislation forbids the VA from performing SRS (sex reassignment surgery). Only two people had a specific policy section quoted to them to back up the doctors claims. Showing the lack of formal policy, other respondents received different messages from different doctors. Ive gotten mixed responses. One doctor told me it has been done in the past. Most tell me it isnt allowed. One cursed me. Several responses also noted stigmatizing responses to their questions. [I was told] the VA does not turn men into women.
Few respondents reported being turned down for procedures that are considered medically necessary for their birth gender: pap smears for female-bodied people and prostate exams for male-bodied. Veterans were much more likely to be denied surgeries related to GID, such as hysterectomies, mastectomies, and orchiectomies. Respondents reported organizational discrimination in a lack of clear and consistent practice, and little support for gender transitions. In addition, there were many reports of interpersonal discrimination, via lack of respect from VA doctors (22%), non-medical staff (21%), and nurses (13%). These cases of interpersonal discrimination ranged from what many veterans describe as typical refusing to change to gender-appropriate pronouns, failure to use a new name consistently to the extreme refusing to look at transgender patients, referring to them in dismissive ways, refusing to treat them for general medical care. One FTM respondent noted, I was told by a religious clerk that I should just go away because I was an insult to the brave real men who were there for treatment. Another MTF respondent noted, I am asked about my genitals and my plans for SRS regardless of whether or not it has relevance to my treatment. Other transgender veterans reported having their medical privacy violated by VA doctors and nurses. In many of these cases, doctors and nurses violated the Hippocratic Oath do no harm by singling out and stigmatizing their transgender patients. Illustrating this, one MTF respondent recounted the following experience: A nurse pulled my partner out in the hall of the VA Hospital where I was an in-patient [and said], You know that is really a man, dont you? While these are just a few examples, they clearly show the discriminatory experiences transgender veterans are facing in VA hospitals discrimination based on their non-traditional gender identities. This discrimination is not unique to transgender veterans many transgender people face similar issues of access to care and stigmatization by medical staff in their daily lives.
In summary, this survey of the experiences of transgender service members and veterans in the U.S. reveals a wide variety of discrimination both inside and outside the military. Both MTFs and FTMs report being passed over for jobs or being openly fired, being denied necessary ID changes, and being victims of personal and sexual violence due to their transgender status. Crossdressers report less overt forms of discrimination, though they are extremely vulnerable, too, if they are discovered crossdressing by employers.
Within the military, transgender service members are prohibited from freely expressing non-traditional gender identities by military culture and formal organizational policies. Yet, in direct violation of DADT, transmen and transwomen still report being directly questioned about their sexual orientation even when they have not made any surgical or hormonal changes to their birth gender. Female-bodied people report being openly questioned about being gay by fellow soldiers and officers at a significantly higher rate than male-bodied people supporting research that suggests that DADT is being differentially enforced upon female soldiers.
Transgender veterans report a variety of experiences with the VA hospitals. While the majority of participants did not currently use the VA hospital, those who did report an array of experiences with organizational and interpersonal discrimination from doctors, nurses, and non-medical staff. Further, people who sought medicalized aspects of gender transitions from the VA hospital were typically denied this care. While experiences varied between VA hospitals, as well as from doctor to doctor, these findings suggest that the VA hospital is at a best a precarious environment for transgender veterans, and at worst, a location of stigma and discrimination.
|RESEARCH IMPLICATIONS AND RECOMMENDATIONS
Survey responses make clear that transgender service members are negatively affected by the current DADT policy, even though the policy does not directly apply to them. Transgender and other service members expressing non-traditional gender identities are often perceived as lesbian, gay, or bisexual, thus increasing the likelihood that they will be investigated under DADT. DADT targets these service members regardless of their actual sexual orientation. Further, DADT disproportionately affects service members who are female, female-bodied, or on the FTM continuum. In sum, the experiences of transgender service members clearly show that DADT is not being implemented as designed.
While repealing DADT might alleviate some of the scrutiny to which transgender service members are subject, such a policy shift would not be sufficient. Beyond the effects of DADT, there is clear evidence that transgender service members are negatively impacted by existing military policy and culture. The current U.S. military orientation to transgender service members which is both pathologizing and punitive is not the only possible approach. In fact, the UK, Canada, Israel, and Thailand all have integrated militaries, with provisions for transgender military service. Canadas Department of National Defence pays in certain cases for sex reassignment surgeries. Existing research suggests that allowing medical gender transitions for service members would not create a financial burden on the military, as the percentage of people accessing such services would be quite small a finding that has led some city agencies, and some Fortune 500 companies, to add medical coverage for gender transition-related surgeries and other procedures for transgender employees. With other countries increasingly allowing the open service of transgender members, and other sectors of the U.S. business world making similar adjustments, the U.S. military will soon be the anomalous case if it does not develop policy to keep pace.
Data from this survey show that in both active duty and veteran contexts, transgender people are currently hindered from expressing their desired gender identities. Yet, the World Professional Association for Transgender Health (WPATH) the leading organization of health professionals specializing in transgender patient populations defines its Overarching Treatment Goal as lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfillment. The U.S. Military and Veterans Administration should develop policies and procedures including, for example, adopting WPATHs Standards of Care as clinical guidelines for providing services to transgender persons that more fully allow transgender service members and veterans to express their gender identities.
In the case of transgender veterans seeking medical care (whether it be transgender-related healthcare needs or not), the data shows that those who access VA hospitals are among the most vulnerable within the larger transgender veteran population. They tend to be older, unemployed or underemployed, and lower income or living in poverty. They likely access services at VA institutions in part because of a lack of viable alternatives. This constellation of marginalities may mean that these service members rely, without any other options, on VA services.
A typical mission statement of the VA Hospital reads like this one from the Washington, D.C. VA Medical Center:
We are dedicated to providing high quality, comprehensive health care to veterans in an environment that fosters trust, respect, commitment, compassion and excellence. We serve as a major resource for health services, education and research that benefit our patients, their families, the community, the network and the nation.
These survey findings suggest that many VA Hospitals have a long way to go toward meeting this goal. As members of the U.S. military who have served their country, transgender veterans should have the same access to professional medical care, for both transgender-specific and general medical needs, as any other veterans. Following well established protocols for providing medical services to transgender patient populations would establish guidelines for doctors and would allow veterans seeking transgender-specific care to know what services they could expect to access consistently. Patients and doctors (as well as other medical and non-medical VA staff) could be held accountable to such standards of practice. Such institutional guidelines could also provide uniformity across VA hospitals, which would help mitigate against the kinds of uneven and unpredictable services across institutions that survey participants described.
Finally, as a minimal step toward remedying the many instances of interpersonal discrimination evidenced in the survey data, VA staff should be educated in respectful ways of interfacing with transgender clients. All VA personnel should receive diversity and sensitivity training as a first step toward providing appropriate, respectful treatment to the transgender veterans who seek healthcare at VA institutions.
|Appendix A: Survey Participant Characteristics
General Demographic Characteristics
Gender Identity, Expression, and Sexual Orientation
Military Service Characteristics
 1000 respondents took all or part of the survey. However, not all indicated that they had served in one or more branches of the U.S. military. For the analysis presented herein, we include response data only from the 827 respondents who completed all or part of the survey and who also indicated that they had served (or were currently serving) in the U.S. Air Force, Army, Marines, Navy, Coast Guard, Air National Guard, National Guard, or Reserves (any branch).
 The exact size of the transgender population is a topic of great debate. Conservative estimates place them as about .008% of the population, while other estimates place them at closer to .04%. For a wider discussion of this issue, see Lynn Conway. 2001. How frequently does transsexualism occur? Accessed online on February 9, 2008 at http://ai.eecs.umich.edu/people/conway/TS/TSprevalence.html.
 Most research conducted with transgender people uses a convenience sampling method, due to the impossibility of generating a random sample. Transgender people typically are recruited from support and social groups, or from listserves and on-line communities. For other examples of this method, see Anne Bolin. 1988. In search of eve: Transsexual rites of passage. South Hadley, MA: Bergin and Garvey; Anne Lawrence. 2003. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Archives of Sexual Behavior 32: 299-315; Henry Rubin. 2003. Self made men: Identity and embodiment among transsexual men. Nashville, TN: Vanderbilt University Press; Kristen Schilt. 2006. Just one of the guys? How transmen make gender visible at work. Gender & Society 20 (4): 465-490; Kristen Schilt and Catherine Connell. 2007. Do workplace gender transitions make gender trouble? Gender, Work and Organization 14 (6): 596-618.
 The link to the survey spread virally, as many different people reposted the call for participants. This makes it impossible to provide an exhaustive list of all the locations where potential participants could find the survey link.
 See Joanne Meyerowitz. 2002. How sex changed: A history of transsexualism in America. Cambridge: Harvard University Press.
 For more information about the development of this term, see Jamison Green. 2004. Becoming a visible man. Nashville: Vanderbilt University Press.
 For the only peer reviewed publication addressing transgender people in the U.S. Military, see George R. Brown. 1988. Transsexuals in the military: Flight into hypermasculinity, Archives of Sexual Behavior 17(6): 527-537.
 Tarryn M. Witten. 2007. Gender identity and the military Transgender, transsexual, and intersex-identified individuals in the U.S. armed forces. Santa, Barbara, CA: The Palm Center. p. 5.
 Witten, Gender identity and the military. p. 8.
 See, e.g., U.S. v. Guerrero, 33 M.J. 295 297-298 (C.M.A.) 1991; U.S. v. Modesto, 39 M.J. 1055 (A.C.M.R.) 1994.
 Witten, Gender identity and the military.
 For more information on the full demographic profile of survey participants, see Appendix A.
 The largest proportions resided in the Mid North states (OH, KY, IL, IN, WI, MN, MI; 18%), Northeast states (NY, PA, DE, MD, WV, VA, NJ, DC; 16%), Southeast states (TN, NC, SC, GA, AL, MS, FL; 14%), or California (11%).
 46 years or older.
 84% had been married at some point; 43% were currently married to a person of the opposite sex.
 All percentages over 10% have been rounded to the nearest whole number in this paper.
 These operative categories reference whether or not people have undergone or plan to undergo surgical body modifications in their gender transitions. Non-operative typically means that a person has opted not to undergo any surgical modifications. Pre-operative typically means a person is planning to undergo one or more surgical modifications. Post-operative indicates that a person has undergone one or more surgical body modifications and considers their transition complete. These categories often are assumed to reference what is termed as sex reassignment surgery, or genital reassignment surgery. However, in this survey, the types of surgeries were not specified.
 In this figure, crossdresser is abbreviated CD, transwoman is abbreviated MTF, and transman is abbreviated FTM.
 See, e.g., Kristen Clements-Nolle, Rani Marx, and Mitchell Katz. 2006. Attempted suicide among transgender persons: The influence of gender-based discrimination and violence. Journal of Homosexuality 51(3): 53-69; Paisley Currah, Richard M. Juang, and Shannon Price Minter (Eds.). 2006. Transgender rights. Minneapolis, MN: University of Minnesota Press; Richard Green. 1985. Spelling relief for transsexuals: Employment discrimination and the criteria of sex. Yale Law & Policy Review 4:125-140; Claudine Griggs. 1998. S/he: Changing sex and changing clothes. New York: Berg; Pooja S. Gehi and Gabriel Arkles. 2007. Unraveling injustice: Race and class impact of medicaid exclusions of transition-related healthcare for transgender people. Sexuality Research & Social Policy 4(4): 7-35. Arnold H. Grossman and Anthony R. DAugelli. 2006. Transgender youth: Invisible and vulnerable. Journal of Homosexuality 51(1): 111-128; Emilia L. Lombardi, Riki Anne Wilchins, Dana Priesing, and Diana Malouf. 2001. Gender violence: Transgender experiences with violence and discrimination. Journal of Homosexuality 42(1): 89-101; Rita M. Melendez and Rogério Pinto. 2007. Its really a hard life: Love, gender and HIV risk among male-to-female transgender persons. Culture, Health & Sexuality 9(3): 233-245; Shannon Minter. 2003. Employment discrimination against transgender people: Case law, statutes, and workplace policies. Accessed Aug 8, 2008 at < http://www.abanet.org/labor/lel-aba-annual/papers/2003/minter.pdf>; T. Nemoto, D. Operario, J. Keatley, and D. Villegas. 2004. Social context of HIV risk behaviours among male-to-female transgenders of colour. AIDS Care 16(6): 724-735; Jodi Sperber, Stewart Landers and Susan Lawrence. 2005. Access to healthcare for transgendered persons: Results of a needs assessment in Boston. International Journal of Transgenderism 8(2-3): 75-91; Rebecca L. Stotzer. 2008. Gender identity and hate crimes: Violence against transgender people in Los Angeles County. Sexuality Research & Social Policy 5(1): 43-52; Stephen Whittle. 2002. Respect and equality: Transsexual and transgender rights. Portland, OR: Cavendish Publishing.
 Because identification documents (e.g., birth certificates, drivers licenses, passports, etc.) often include gender as a marker of identity, and because these documents are required to negotiate many aspects of daily life (driving, making purchases, flying on commercial airlines, crossing borders, interfacing with governmental and other formal institutions, securing employment, etc.), having identification documents that match ones gender identity and expression is crucial. Lack of such documents can lead to limited mobility, harassment, violence, and incarceration. In the U.S., the ability to obtain identification documents that match ones gender identity and expression is dependent on a labyrinth of state and local statutes and policies. For more on the challenges identification documents pose for people expressing transgender and other non-traditionally gendered identities, see e.g., Julie A. Greenberg. 2006. The roads less traveled: The problem with binary sex categories pp. 51-73 in Currah, Juang and Minter (Eds.). Transgender rights.
 See, e.g., Barrie Thorne. 1993. Gender play: Girls and boys in school. New Brunswick, NJ: Rutgers University Press.
 See, e.g., Judith Halberstam. 1998. Female masculinity. Durham, NC: Duke University Press.
 See, e.g., Thom Shanker. June 23, 2008. Dont ask dont tell hits women much more. The New York Times. Section A, p. 14.
 38% of the sample reported that they had at one time (currently or in the past) used the VA for primary care.
 For more information, see Transgender health and the law: Identifying and fighting health care discrimination. Accessed Aug 8, 2008 at <http://www.transgenderlawcenter.org/pdf/Health%20Law%20fact%20sheet.pdf>
 For more information, on this cost/benefit analysis, see Philadelphia Daily News. 2001. San Francisco will pay for workers sex changes. Section A, p. 14; Althea Chang. 2008. Unusual perks: Goldman sachs covers sex changes. Accessed August 8, 2008 athttp://money.cnn.com/2008/02/08/news/companies/gender.fortune/index.htm
 Walter Meyer et al. 2001. The harry benjamin international gender dysphoria association’s standards of care for gender identity disorders, sixth version. Accessed Aug 8, 2008 at <http://wpath.org/Documents2/socv6.pdf>, P. 1.
 This statement is available at: http://www.washingtondc.va.gov/aboutus/mission.asp
 N and denominators in the frequency columns indicate the number of individuals who responded to the item. Percentages reflect percent of those who responded to the item.