Secretary Alex Azar

Department of Health and Human Services

Hubert H. Humphrey Building, Room 509F

200 Independence Avenue SW

Washington, DC 20201

 

Re: RIN 0945-AA11, “Nondiscrimination in Health and Health Education Programs or Activities”

Dear Secretary Azar:

Human Rights Watch is an independent organization working to investigate, expose, and address human rights violations around the globe. We write to oppose the proposed rule on Nondiscrimination in Health and Health Education Programs or Activities, and to urge the Department of Health and Human Services to instead renew its efforts to eradicate discrimination on the basis of sex – including discrimination against transgender people – in healthcare settings.

In July 2018, Human Rights Watch published the report “You Don’t Want Second Best”: Anti-LGBT Discrimination in US Health Care.[1] The report documents the difficulties that lesbian, gay, bisexual, and transgender (LGBT) people encounter in accessing healthcare services in the United States. In November 2018, Human Rights Watch published the report "Living at Risk”: Transgender Women, HIV, and Human Rights in South Florida.[2] Based on our research, we believe the proposed rule would exacerbate discrimination against transgender people in medical settings and would negatively affect their health and rights.[3] The proposed rule would narrow the Department’s definition of discrimination based on sex; among other changes, it would exclude discrimination based on gender identity as a form of sex discrimination. In doing so, it would leave transgender people vulnerable to discrimination and refusals of service by insurers and healthcare providers, jeopardizing their health and rights.  

  1. The Proposed Rule Does Not Sufficiently Protect Patients

In the Final Rule issued in 2016, the Department of Health and Human Services observed that transgender individuals experience stark health disparities and often are unable to obtain insurance coverage, are not protected under covered entities’ nondiscrimination policies, are harassed in healthcare settings, are refused care, and delay or forego needed healthcare because of concerns about mistreatment.[4] The Department determined at the time that the Final Rule would help ameliorate these concerns and would benefit the health and well-being of women, transgender people, and the wider society.[5] It specifically found that “[b]y prohibiting discrimination on the basis of sex, Section 1557 [of the Affordable Care Act] would result in more women and transgender individuals obtaining coverage and accessing health services.”[6]

A substantial body of research indicates that these conditions persist. Moreover, the potential benefits of the existing regulations have not yet been realized, as they have been enjoined by a federal court and the Administration has not enforced them or established alternative means of protecting transgender people from discrimination in healthcare. The Administration’s decision to roll back the Final Rule does not address the weighty concerns that initially motivated rulemaking in this area, and leaves transgender individuals vulnerable to discrimination, mistreatment, and refusals of care by insurers and providers alike.

The failure to protect patients is exacerbated by other recent law and policy changes that weaken protections and permit insurers and providers to discriminate. Last year, Human Rights Watch expressed opposition to the Proposed Rule on Protecting Statutory Conscience Rights in Health Care; Delegations of Authority.[7] The Department ultimately adopted a version of this rule, expanding exemptions for religious and moral objectors and jeopardizing the ability of women and LGBT people to obtain the healthcare services they need. The Department’s approach to nondiscrimination protections jeopardizes transgender health on two fronts; it substantially expands “exemptions” to nondiscrimination provisions by arguing these are necessary to preserve the rights of religious and moral objectors, while simultaneously rejecting or repealing the underlying nondiscrimination protections themselves.[8] The cumulative result of these regulatory changes is more pervasive discrimination and significantly reduced access to care. The changes facilitate discrimination against groups who already face persistent mistreatment and bias in healthcare settings.

  1. LGBT People, Especially Transgender People, Already Face Stark Health Disparities and Barriers to Accessing Care; Federal Protection is Necessary

When LGBT people experience health problems, they may encounter a variety of barriers to obtaining the care they need. A nationally representative survey in 2017 found that 25 percent of transgender respondents were uninsured, compared to only 8 percent of cisgender respondents.[9] Transgender people also face high rates of discrimination and mistreatment in medical settings. The same survey found that 21 percent of transgender respondents had been subject to harsh or abusive language by healthcare providers in the year preceding the survey.[10] Over the same period, 29 percent of transgender respondents reported that a healthcare provider had refused to see them because of their gender identity or sexual orientation.[11] Similarly, a survey of almost 28,000 transgender people in 2015 found that 33 percent of respondents had experienced a negative interaction with a healthcare provider because of their gender identity in the year preceding the survey.[12]

When LGBT people experience discrimination or refusals from healthcare providers, this can prevent them from obtaining the care they need. One survey found that 41% of LGBT people outside of major metropolitan areas felt it would be “very difficult” or “not possible” to find an alternative provider if they were refused care at a hospital.[13]

The discrimination and mistreatment that transgender people experience throughout healthcare settings make expansive nondiscrimination protections important. In interviews, patients and advocates noted that they not only encountered discrimination from medical providers, but from administrative staff. Jeynce Poindexter, a victims advocate at the LGBT organization Equality Michigan, observed in an interview with Human Rights Watch: “The initial interaction in the emergency room, where you have to give your ID, info, insurance, that’s mainly where the complaints come from… There’s lots of misgendering, harmful terminology, intentional disrespect.”[14] Connie L., a 31-year-old transgender woman in Miami, recalled: “This woman shouted for ‘Kevin’ to come to the desk. I shrunk in my seat, hoping she would see the note on the chart about my gender change. But she just kept yelling for Kevin. I finally had to get up and cross the room in a walk of shame. Will I ever go back there? No way.”[15]

Other Human Rights Watch interviewees faced humiliation or discrimination from providers themselves. In 2018, Renae T., a transgender woman in Memphis, Tennessee, told Human Rights Watch about an incident where a nurse was treating her for cardiomyopathy (a heart condition), left the room, and audibly told another nurse to come look at the patient’s breasts.[16] Judith N., a transgender woman in East Tennessee, described a pre-employment medical examination in which a doctor abruptly ended the appointment without giving her the exam as soon as he saw that she had shaved her legs.[17] Karen W., a transgender woman in Biloxi, Mississippi, recounted that she had been admitted and then ignored when seeking care at the emergency room at a local hospital.[18]

In some instances, transgender people are refused care outright because of their gender identity. Jessica Shea, a clinical social worker in Memphis, described how a religiously affiliated psychiatric practice turned away a transgender child:

They accepted the person at first, but when they found out it was a trans client, the doctor said we don’t see trans clients here. They got in the door, but then got turned away. It often takes months to get an appointment here, and the family felt they had invested a lot of time to get in, and was then turned away. It was the doctor there.... Once he found out the child was a trans child he said they would not be able to accommodate them for the psych evaluation. The family was told they don’t provide services to trans clients.[19]

Other services that were offered to the general public were similarly withheld from transgender individuals. One interviewee in Memphis recounted the story of a transgender woman who “had a yeast infection, and five to six doctor’s offices told her we don’t treat trans patients. But a prescription for Diflucan isn’t gendered! Unless you’re talking about HRT or surgery, health care isn’t different for trans people. It’s a body that needs care.”[20]

Such discriminatory incidents can deter people from returning for further medical care. As Carla B., the mother of a transgender teenager, told Human Rights Watch in 2017: “I said these are [my son’s] name and his pronouns and he was sitting there, and the doctor uses his birth name and pronouns.... After the doctor left, [my son] cried for a solid ten minutes, and said I don’t want to come back here ever again.”[21]

Discrimination in health care can compound the isolation and discrimination in society that also contribute to health disparities. Researchers have found that the added stressors that members of marginalized groups experience – called minority stress – can adversely affect both physical and mental health.[22] Levels of minority stress are influenced by the environment in which people live. Research shows that, in parts of the country with greater social and legal equality, LGBT people have better health outcomes and smaller disparities in comparison with their cisgender, heterosexual counterparts.[23]

Conversely, laws targeting LGBT people can contribute to stress. One recent study found that the passage of state-level religious refusal laws, for example, was associated with a 46 percent increase in the number of LGBT residents of the state reporting mental distress.[24]

Consistent with these findings, research has established that transgender people are at heightened risk of physical and mental health conditions.[25] Existing data from the United States indicates that transgender people are more likely to be overweight, be depressed, report cognitive difficulties, and forego treatment for health problems than their cisgender counterparts.[26] In the United States, the National HIV/AIDS Strategy designates transgender women as a “high-risk” and “key” population as a recent meta analysis found 14 percent of transgender women are HIV positive, with higher prevalence rates among transgender women of color.[27] This is grossly disproportionate to the overall prevalence of HIV in the US, which is under one percent.[28]

Despite these clear patterns regarding transgender health needs and challenges securing access to care, state-level nondiscrimination laws and policies are limited, leaving many transgender people in the US without sufficient protection.[29] Public insurance also varies considerably from state to state. While Medicaid expressly covers transition-related care in 19 states and the District of Columbia, it is silent on the issue in 24 states, and excludes transition-related care in seven states.[30] Rolling back federal protections would leave people especially vulnerable in states that lack comprehensive protections against gender identity discrimination in health care. In 2018, for example, the Iowa Supreme Court ruled that excluding transition-related care from public insurance violated the Iowa Civil Rights Act; in 2019, the legislature amended the Iowa Civil Rights Act to expressly permit such discrimination.[31] Federal protection is necessary to meaningfully prevent discrimination in healthcare for transgender people throughout the United States.

  1. The Proposed Rule Would Exacerbate Documented Barriers to Accessing Health Care

Through interviews, Human Rights Watch has identified some of the many barriers that transgender people encounter when seeking healthcare services. The proposed rule would exacerbate each of these concerns. 

First, as described above, transgender people face widespread discrimination, even when accessing routine health services. Existing nondiscrimination protections at the federal level ensure that individuals who need care receive that care, regardless of their gender identity or expression. The proposed rule would permit discrimination by providers, allowing them to decide whether to provide care based not on the patient’s healthcare needs, but on their identity or expression. A foreseeable consequence is that some providers will feel emboldened to discriminate, and transgender individuals will be less certain that they will receive or can insist on fair treatment in the absence of clear protections.

Second, transgender people are often unable to obtain healthcare to meet specific needs related to their gender identity, and the current rule helps mitigate this situation by improving insurance coverage and ensuring that services available to cisgender patients are also available to transgender patients. Transgender people who medically transition, for example, may seek access to hormone replacement therapy (HRT) or gender-affirming surgeries as part of their transition.[32] Transgender women may have a greater need for HIV-related health care, including preventive care such as pre-exposure prophylaxis (PrEP), a daily pill that significantly lowers the risk of HIV infection. Some transgender people who decide to have children may seek out fertility specialists or utilize assisted reproductive technologies as part of the process. A change to the existing federal rule could jeopardize access to these services when a patient is transgender.

In interviews with Human Rights Watch, many LGBT individuals and service providers said there were few, if any, LGBT-friendly healthcare providers in their area – rendering a federal obligation to provide care even more important. As the head of one community center in rural Michigan said, “I do not know of any trans-affirming healthcare providers in the area. And I’ve talked to many trans people in the area.”[33] Interviewees told us that as a result of the lack of providers in rural areas, transgender individuals would drive two hours from Tennessee to attend a weekend support group for gender-expansive youth in Birmingham, Alabama;[34] would travel two hours from Mississippi to meet with a trans-affirming doctor in Memphis, Tennessee;[35] and would drive from East Tennessee to North Carolina for regular hormone injections.[36]

The lack of providers was especially acute in rural areas, but certain services were difficult to find in metropolitan areas as well. As one mother of a transgender child noted:

In Knoxville, we have a lot of hospitals, a lot of doctor’s offices, but even with all of that, finding hormone therapy is very difficult. So difficult. Gynecologists don’t do hormones, GPs don’t do hormones, you have to see an endocrinologist. And that can be cost prohibitive, or maybe you don’t find one you like.... It’s hard to find medical care for trans people even in a city around here—and that’s just for hormones. Finding a GP where you can go in the office that you’re comfortable in, where the doctor is good, the office is good—that’s hard for anyone, even if you’re not trans. But having them treat you like a normal human being when you’re trans is even more difficult. If you’re in a rural area, you’re up a creek.[37]

While some of the scarce services were related to gender-affirming treatment, others were general medical services available to cisgender people that providers denied to transgender people. Interviewees noted that breast surgeries that were available to cisgender individuals, for example, were not similarly available to transgender individuals.[38] One sexual and reproductive health services provider estimated that in Memphis, Tennessee, with a population of 650,000, only four medical practices provide hormone replacement therapy – in contrast with menopausal hormone therapy for cisgender women, which she described as virtually identical to HRT and much more widely available.[39]

When protections are piecemeal, transgender patients may not know whether services are available to them. One doctor in a rural state noted that her hospital had extensive services for transgender youth, but was not allowed to market or advertise those services because administrators were concerned about repercussions from the state legislature.[40] The mother of a transgender child who had struggled to find a pediatric endocrinologist said, “The ones in this area, they’ve told us they’re not certain about displaying something saying they’re LGBT-friendly, out of fear of how people would react.”[41] Judith N., a transgender woman in East Tennessee, said “I spent years looking for access to therapy and hormones and I just couldn’t find it.”[42] When a limited number of providers were known to the community to be competent and welcoming, they could be overwhelmed with demand.[43] Having federal protections in place can help establish a presumption that healthcare services are offered without discrimination.

By permitting insurers and providers to limit coverage and services without repercussion, the proposed rule would adversely affect those who cannot afford or access alternative options. When providers are limited, other forms of disadvantage and marginalization can make access practically impossible, particularly where lengthy travel or out-of-pocket expenses are required. Data from the 2015 U.S. Transgender Survey indicated that 15 percent of transgender respondents were unemployed and 29 percent were living in poverty.[44] Of those who had held or applied for a job in the previous year, 27 percent reported experiencing employment discrimination because of their gender identity or expression.[45] Without employment, individuals may have a more difficult time maintaining insurance and affording health care. In the same survey, a third of the transgender respondents indicated that they had foregone medical care they needed in the past year because of concerns about cost.[46] When accessible options are few and far between, a provider’s hostility or unwillingness to see a transgender patient is not only an indignity and inconvenience, but may prevent the patient from obtaining treatment at all.

The proposed rule would exacerbate these barriers. Individuals would not only need to find accessible, affordable services in their areas, but would need to ensure that their insurers would cover those services and that their providers would deliver those services without discriminating based on gender identity. A foreseeable outcome is that many transgender individuals will simply be unable to obtain the care they need. Without adequate healthcare, workers are less able to contribute to the economy, tenants are less able to maintain stable housing, and parents are less able to care for their children.

Third, LGBT people, and especially transgender people, may be reluctant to seek out the care they need when they anticipate discrimination or have been subject to discrimination in healthcare settings in the past. Data suggest that discrimination deters many LGBT people from seeking care. In a nationally representative survey, eight percent of LGBT respondents had delayed or foregone medical care because of concerns of discrimination in healthcare settings—and those who had previously experienced discrimination were six times more likely to avoid going to a doctor’s office than those who had not experienced discrimination.[47] In a National Center for Transgender Equality survey, twenty-three percent of respondents did not seek care they needed because of concern about mistreatment based on gender identity.[48]

Clara B., the mother of a transgender teenager in Knoxville, told Human Rights Watch: “The dentist is a good example—[my son] hasn’t gone back in two years. They’re very religious people and [my son] said, ‘I don’t know how they feel about me and I don’t want to go.’ We’ve yet to agree on finding another dentist.”[49] Judith N., a transgender woman in East Tennessee, described how she had foregone medical care, attributing her decisions to “the combination of not having money anymore and the [low-quality] insurance that goes with it, and then worrying about how I’ll be treated.”[50]

As these examples suggest, many transgender people are already reluctant to seek out care because of how they are treated, and delay or forego that care as a result. The proposed rule would take the position that such discrimination is permissible, further deterring transgender people from seeking care.

  1. Rights at Stake

The Right to Health

Under international law, everyone has the right “to the enjoyment of the highest attainable standard of physical and mental health” without discrimination on the basis of sex, age, or other prohibited grounds.[51] The right to health is also inextricably linked to provisions on the right to life and the right to non-discrimination that are included in the International Covenant on Civil and Political Rights (ICCPR), which the US has ratified.[52]

The Committee on Economic, Social and Cultural Rights, the United Nations body charged with interpreting and monitoring the implementation of the International Covenant on Economic, Social, and Cultural Rights (ICESCR), has identified four essential components to the right to health: availability, accessibility, acceptability and quality.[53] In General Comment 22, the Committee further affirmed that “[n]on-discrimination, in the context of the right to sexual and reproductive health, also encompasses the right of all persons, including LGBTI persons, to be fully respected for their sexual orientation, gender identity and intersex status.”[54] Even though the US is not a party to the ICESCR, the Committee’s interpretation represents a useful and authoritative guide to the steps governments should take to realize and protect the right to health and other human rights. The proposed rule will reduce the availability and accessibility of healthcare services, particularly for transgender people, in communities across the US.

When states enact laws allowing healthcare providers to discriminate, they undermine the right to health. Individuals may be denied services outright; have difficulty finding services of comparable quality, accessibility, or affordability; or avoid seeking services for fear of being turned away.

The Committee on Economic, Social and Cultural Rights has noted that the right to health is threatened both by direct discrimination and by indirect discrimination, in which laws appear neutral on their face but disproportionately harm a minority group in practice.[55] To promote the right to health, the Committee has thus urged states to “adopt measures, which should include legislation, to ensure that individuals and entities in the private sphere do not discriminate on prohibited grounds.”[56]

The Right to Non-Discrimination

Non-discrimination is a central principle of international human rights law.[57] As a party to the ICCPR, the US is obligated to guarantee effective protection against discrimination in the enjoyment of rights, including discrimination based on sex, sexual orientation, and gender identity.[58] Existing protections, if implemented fully, would be a positive step toward fulfilling this obligation. Adopting the proposed rule would eliminate a clear nondiscrimination protection without any alternative proposal to ensure transgender people are able to access healthcare on equal terms with others.

  1. Conclusion

Human Rights Watch has documented a range of barriers that transgender people face when seeking healthcare services in the United States. These findings are consistent with research by academic experts and nongovernmental organizations, as well as government data, including the findings cited by the Department when it issued the Final Rule protecting transgender individuals from discrimination in 2016. We believe that withdrawing explicit protection for transgender people will exacerbate existing health disparities and fail to uphold US commitments under international human rights law. For these reasons, Human Rights Watch urges the Department to reject the proposed rule and support inclusive nondiscrimination protections.

Sincerely,

Ryan Thoreson

Researcher, LGBT Rights Program

Human Rights Watch

 

[1] Human Rights Watch, “You Don’t Want Second Best”: Anti-LGBT Discrimination in US Health Care (2018), https://www.hrw.org/sites/default/files/report_pdf/us_lgbt0718_web.pdf.

[2] Human Rights Watch, “Living at Risk”: Transgender Women, HIV, and Human Rights in South Florida (2018), https://www.hrw.org/report/2018/11/20/living-risk/transgender-women-hiv-and-human-rights-south-florida.

[3] While this Comment primarily examines how the rollback of the rule would jeopardize the rights of transgender people, the rollback would also adversely affect LGB and pregnant people who are protected under existing regulations.

[4] “Nondiscrimination in Health Programs and Activities; Final Rule,” 45 CFR 92, Federal Register Vol. 81, No. 96, May 18, 2016, https://www.gpo.gov/fdsys/pkg/FR-2016-05-18/pdf/2016-11458.pdf.

[5] Ibid. at 31461.

[6] Ibid. at 31460.

[7] Human Rights Watch, “Human Rights Watch Letter to US Secretary of Health and Human Services Alex Azar,” March 27, 2018, https://www.hrw.org/news/2018/03/27/human-rights-watch-letter-us-secretary-health-and-human-services-alex-azar.

[8] See Human Rights Watch, “All We Want is Equality”: Religious Exemptions and Discrimination against LGBT People in the United States (2018), https://www.hrw.org/sites/default/files/report_pdf/lgbt0218_web_1.pdf.

[9] Kellan Baker & Laura E. Durso, “Why Repealing the Affordable Care Act is Bad Medicine for LGBT Communities,” Center for American Progress, March 22, 2017, https://www.americanprogress.org/issues/lgbt/news/2017/03/22/428970/repe... affordable-care-act-bad-medicine-lgbt-communities (accessed August 11, 2019).

[10] Shabab Ahmed Mirza & Caitlin Rooney, “Discrimination Prevents LGBTQ People from Accessing Health Care,” Center for American Progress, January 18, 2018, https://www.americanprogress.org/issues/lgbt/news/2018/01/18/445130/discrimination-prevents-lgbtq-people-accessing- health-care (accessed August 11, 2019).

[11] Ibid.

[12] Sandy James et al., Executive Summary of the Report of the 2015 U.S. Transgender Survey, National Center for Transgender Equality (2016), https://transequality.org/sites/default/files/docs/usts/USTS-Executive-S... (accessed August 11, 2019).

[13] Shabab Ahmed Mirza & Caitlin Rooney, “Discrimination Prevents LGBTQ People from Accessing Health Care,” Center for American Progress, January 18, 2018, https://www.americanprogress.org/issues/lgbt/news/2018/01/18/445130/disc... health-care (accessed August 11, 2019).

[14] Human Rights Watch interview with Jeynce Poindexter, Equality Michigan, Detroit, MI, January 16, 2018.

[15] Human Rights Watch interview with Connie L., Miami, Florida, February 6, 2018.

[16] Human Rights Watch interview with Renae T., Memphis, TN, January 12, 2018.

[17] Human Rights Watch interview with Judith N. (pseudonym), Johnson City, TN, December 10, 2017.

[18] Human Rights Watch telephone interview with Karen W. (pseudonym), Biloxi, MS, October 4, 2017.

[19] Human Rights Watch interview with Jessica Shea, Memphis, TN, January 11, 2018.

[20] Human Rights Watch interview with Holly Calvasina, Choices, Memphis, TN, January 10, 2018.

[21] Human Rights Watch interview with Carla B. (pseudonym), Knoxville, TN, December 9, 2017.

[22] Brief of Ilan H. Meyer, PhD., and Other Social Scientists and Legal Scholars Who Study the LGB Population as Amici Curiae Supporting Respondents, Masterpiece Cakeshop v. Colorado Civil Rights Commission, No. 16-111 (U.S. 2017), p. 23-24.

[23] Ibid.

[24] Mary Elizabeth Dallas, “‘Religious Refusal Laws May Take Mental Health Toll on LGBT Americans,” US News & World Report, May 23, 2018, https://health.usnews.com/health-care/articles/2018-05-23/religious-refu... (accessed August 11, 2019).

[25] See Centers for Disease Control and Prevention, “About LGBT Health,” March 24, 2017, https://www.cdc.gov/lgbthealth/about.htm (accessed August 11, 2019).

[26] Carl G. Streed, Ellen McCarthy & Jennifer S. Haas, “Association Between Gender Minority Status and Self-Reported Physical and Mental Health in the United States,” JAMA Internal Medicine, Vol. 177, No. 8 (2017), 1210-1212.

[27] US Centers for Disease Control, “HIV Among Transgender People,” https://www.cdc.gov/hiv/group/gender/transgender/index.html (accessed August 11, 2019);“HIV among Transgender People Fact Sheet,” https://www.cdc.gov/hiv/pdf/group/gender/transgender/cdc-hiv-transgender... (accessed August 11, 2019); US Office of National HIV/AIDS Strategy, “National HIV/AIDS Strategy for the United States, Updated to 2020,” https://files.hiv.gov/s3fs-public/nhas-update.pdf (accessed August 11, 2019).

[28] Avert, “HIV and AIDS in the United States of America,” https://www.avert.org/professionals/hiv-around-world/western-central-eur... (accessed August 11, 2019).

[29] Movement Advancement Project, “Healthcare Laws and Policies,” http://www.lgbtmap.org/equality-maps/healthcare_laws_and_policies (accessed August 6, 2019).

[30] Ibid.

[31] Michael Ollove, “Iowa, Other States Diverge on Transgender Healthcare,” The Gazette, July 17, 2019, https://www.thegazette.com/subject/news/nation-and-world/iowa-other-states-diverge-on-transgender-health-care-aidan-zingler-gender-dysphoria-reassignment-surgery-20190717 (accessed August 6, 2019).

[32] Human Rights Watch, “Living at Risk”: Transgender Women, HIV, and Human Rights in South Florida (2018), https://www.hrw.org/report/2018/11/20/living-risk/transgender-women-hiv-and-human-rights-south-florida.

[33] Human Rights Watch interview with Mary Jo Schnell, OutCenter, Benton Harbor, MI, January 17, 2018.

[34] Human Rights Watch telephone interview with Paula R. (pseudonym), September 7, 2017.

[35] Human Rights Watch interview with Gail Stratton, Oxford, MS, January 13, 2017.

[36] Human Rights Watch interview with Judith N. (pseudonym), Johnson City, TN, December 10, 2017.

[37] Human Rights Watch telephone interview with Sarah H. (pseudonym), Knoxville, TN, October 20, 2017.

[38] Human Rights Watch interview with Holly Calvasina, Choices, Memphis, TN, January 10, 2018; Human Rights Watch interview with Kayla Gore, OutMemphis, Memphis, TN, January 10, 2018; Human Rights Watch interview with Renae T., Memphis, TN, January 12, 2018.

[39] Human Rights Watch interview with Holly Calvasina, Choices, Memphis, TN, January 10, 2018.

[40] Human Rights Watch telephone interview with Paula R. (pseudonym), September 7, 2017.

[41] Human Rights Watch interview with Carla B. (pseudonym), Knoxville, TN, December 9, 2017.

[42] Human Rights Watch interview with Judith N. (pseudonym), Johnson City, TN, December 10, 2017.

[43] Human Rights Watch interview with Sam P. (pseudonym), Johnson City, TN, December 10, 2017; Human Rights Watch interview with Renae T., Memphis, TN, January 12, 2018.

[44] Sandy James et al., Executive Summary of the Report of the 2015 U.S. Transgender Survey, National Center for Transgender Equality (2016), p. 3, https://transequality.org/sites/default/files/docs/usts/USTS-Executive-S... (accessed August 11, 2019). Comparable rates for the general population of the United States were 5 percent and 12 percent, respectively. Ibid.

[45] Ibid.

[46] Sandy James et al., The Report of the 2015 U.S. Transgender Survey, National Center for Transgender Equality (2016), p. 98, https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report... (accessed August 11, 2019).

[47] Shabab Ahmed Mirza & Caitlin Rooney, “Discrimination Prevents LGBTQ People from Accessing Health Care,” Center for American Progress, January 18, 2018, https://www.americanprogress.org/issues/lgbt/news/2018/01/18/445130/disc... health-care (accessed August 11, 2019).

[48] Sandy James et al., Executive Summary of the Report of the 2015 U.S. Transgender Survey, National Center for Transgender Equality (2016), https://transequality.org/sites/default/files/docs/usts/USTS-Executive-S... (accessed August 11, 2019).

[49] Human Rights Watch interview with Carla B. (pseudonym), Knoxville, TN, December 9, 2017.

[50] Human Rights Watch interview with Judith N. (pseudonym), Johnson City, TN, December 10, 2017.

[51] Committee on Economic, Social and Cultural Rights (CESCR), “Substantive Issues Arising in the Implementation of the International Covenant on Economic, Social and Cultural Rights,” General Comment No. 14, The Right to the Highest Attainable Standard of Health, E/C.12/2000/4 (2000), para. 12.

[52] International Covenant on Civil and Political Rights (ICCPR), adopted December 16, 1966, G.A. Res. 2200A (XXI), 21 U.N. GAOR Supp. (No. 16) at 52, U.N. Doc. A/6316 (1966), 999 U.N.T.S. 171, entered into force March 23, 1976, ratified by the United States on June 8, 1992, art. 10.

[53] Committee on Economic, Social and Cultural Rights (CESCR), “Substantive Issues Arising in the Implementation of the International Covenant on Economic, Social and Cultural Rights,” General Comment No. 14, The Right to the Highest Attainable Standard of Health, E/C.12/2000/4 (2000), para. 12.

[54] UN Committee on Economic, Social and Cultural Rights, “General Comment No. 22 (2016) on the Right to Sexual and Reproductive Health,” UN Doc. E/C.12/GC/22, May 2, 2016, para. 23. The “I” in “LGBTI” stands for “intersex.”

[55] UN Committee on Economic, Social and Cultural Rights, General Comment No. 20: “Non-Discrimination in Economic, Social and Cultural Rights”, U.N. Doc. E/C.12/GC/20, July 2, 2009, para. 10.

[56] Ibid., para. 11.

[57] International protections for the right to non-discrimination include: ICCPR, arts. 2, 4, 26; ICESCR art.2(2); Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), adopted December 18, 1979, G.A. res. 34/180, 34 U.N. GAOR Supp. (No. 46) at 193, U.N. Doc. A/34/46, entered into force September 3, 1981, art. 2; International Convention on the Elimination of All Forms of Racial Discrimination (ICERD), adopted December 21, 1965, G.A. Res. 2106 (XX), annex, 20 U.N. GAOR Supp. (No. 14) at 47, U.N. Doc. A/6014 (1966), 660 U.N.T.S. 195, entered into force January 4, 1969, ratified by the United States on October 21, 1994, art. 5; International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families (Migrant Workers Convention), adopted December 18, 1990, G.A. Res. 45/158, annex, 45 U.N. GAOR Supp. (No. 49A) at 262, U.N. Doc. A/45/49 (1990), entered into force July 1, 2003, art. 1(1), art. 7.

[58] ICCPR, art. 26. The Human Rights Committee frequently expresses concern about discrimination based on gender identity in its concluding observations on state compliance with the ICCPR. See UN Human Rights Committee, Concluding Observations: Azerbaijan, U.N. Doc CCPR/C/AZE/CO/4 (November 16, 2016), paras. 8-9; UN Human Rights Committee, Concluding Observations: Burkina Faso, U.N. Doc CCPR/C/BFA/CO/1 (October 17, 2016), paras. 13-14; UN Human Rights Committee, Concluding Observations: Colombia, U.N. Doc CCPR/C/COL/CO/7 (November 17, 2016), paras. 16-17; UN Human Rights Committee, Concluding Observations: Costa Rica, U.N. Doc CCPR/C/CRI/CO/6 (April 21, 2016), paras. 11-12; UN Human Rights Committee, Concluding Observations: Denmark, U.N. Doc CCPR/C/DNK/CO/6 (August 15, 2016), paras. 13-14; UN Human Rights Committee, Concluding Observations: Ecuador, U.N. Doc CCPR/C/ECU/CO/6 (August 11, 2016), paras. 11-12; UN Human Rights Committee, Concluding Observations: Ghana, U.N. Doc CCPR/C/GHA/CO/1 (August 9, 2016), paras. 43-44; UN Human Rights Committee, Concluding Observations: Jamaica, U.N. Doc CCPR/C/JAM/CO/4 (November 22, 2016), paras. 15-16; UN Human Rights Committee, Concluding Observations: Kazakhstan, U.N. Doc CCPR/C/KAZ/CO/2 (August 9, 2016), paras. 9-10; UN Human Rights Committee, Concluding Observations: Kuwait, U.N. Doc CCPR/C/KWT/CO/3 (August 11, 2016), paras. 12-13; UN Human Rights Committee, Concluding Observations: Morocco, U.N. Doc CCPR/C/MAR/CO/6 (December 1, 2016), paras. 11-12; UN Human Rights Committee, Concluding Observations: Slovakia, U.N. Doc CCPR/C/SVK/CO/4 (November 22, 2016), paras. 14-15; UN Human Rights Committee, Concluding Observations: South Africa, U.N. Doc CCPR/C/ZAF/CO/1 (April 27, 2016), paras. 20-21.