Research & Study Results

The Trans PULSE Project is committed to ensuring our research findings are relevant and accessible to community members, while also providing results in a way that will have a meaningful impact on health, service delivery, and policy reform.

We are currently making the results of the project available in a variety of different formats. Our continued goal is to reach a diverse audience and have a broad influence; as such we have tried to target our publications and knowledge dissemination strategies to various groups of people. The diversity of audiences we hope to reach include but are not limited to policy-makers, health care professionals, social service workers and staff, and most significantly community members, lobbyists, advocates and allies.

Factors Impacting Transgender Patients’ Discomfort with Their Family Physicians

A Respondent-Driven Sampling Survey

Representing approximately 0.5% of the population, transgender (trans) persons in Canada depend on family physicians for both general and transition-related care. However, physicians receive little to no training on this patient population, and trans patients are often profoundly uncomfortable and may avoid health care. This study examined factors associated with patient discomfort discussing trans health issues with a family physician in Ontario, Canada.
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Statistics from Trans PULSE to Inform Human Rights Policy

The purpose of this report is to summarize key research results from the Trans PULSE Project that may be useful in discussions, debates or policy creation related to transgender human rights in multiple jurisdictions. As Trans PULSE results have been used by the Canadian Human Rights Commission, and are heavily cited in the Ontario Human Rights Commission’s 2014 policy on gender identity and discrimination, we sought to create a summary of research findings that have been of greatest interest with regard to human rights issues. Read more

Intervenable Factors Associated with Suicide Risk in Transgender Persons

A Respondent Driven Sampling Study in Ontario, Canada

Across Europe, Canada, and the United States, 22–43 % of transgender (trans) people report a history of suicide attempts. We aimed to identify intervenable factors (related to social inclusion, transphobia, or sex/gender transition) associated with reduced risk of past-year suicide ideation or attempt, and to quantify the potential population health impact.
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Intersecting Impacts of Transphobia and Racism on HIV Risk among Trans Persons of Colour in Ontario, Canada

Minority stress theory suggests enhanced HIV risk for those experiencing social marginalization, while an intersectionality framework posits that forms of marginalization may interact. The purpose of this paper is to understand how race/ethnicity- and gender-based discrimination may impact HIV risk among transgender or transsexual (trans) people.

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Barriers to Well-being for Aboriginal Gender-diverse People

Results from the Trans PULSE Project in Ontario, Canada

Despite health inequities experienced by Aboriginal and transgender (trans) communities, little research has explored the well-being of Aboriginal trans (gender-diverse) people. This paper aims to describe barriers to well-being in a sample of Aboriginal gender-diverse people in Ontario, Canada.

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Sex and Gender Diversity Among Transgender Persons in Ontario, Canada

Results From a Respondent-Driven Sampling Survey

Recent estimates suggest that as many as 1 in 200 adults may be trans (transgender, transsexual, or transitioned). Knowledge about dimensions of sex and gender in trans populations is crucial to development of inclusive policy, practice, and research, but limited data have been available, particularly from probability samples.

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‘Community Control’ in CBPR

Challenges Experienced and Questions Raised from the Trans PULSE Project

Newer forms of community-based participatory research (CBPR) prioritize community control over community engagement, and articles that outline some of the challenges inherent in this approach to CBPR are imperative in terms of advancing knowledge and practice. This article outlines the community control strategy utilized by Trans PULSE, an Ontario-wide research initiative devoted to understanding the ways in which social exclusion, cisnormativity (the belief that transgender (trans) identities or bodies are less authentic or ‘normal’), and transphobia shape the provision of services and affect health outcomes for trans people in Ontario, Canada. Read more

Avoidance of Public Spaces by Trans Ontarians

The Impact of Transphobia on Daily Life

The ability to leave the house and access public or shared spaces such as public transit, washrooms, restaurants, and schools is taken for granted by many non-trans people. However, trans people experience much prejudice, discrimination, and violence related to being trans. The fear of such harassment or violence is also bad for our health, and may result in avoiding public spaces. We found that two-thirds of trans Ontarians had avoided a public space or situation because of a fear of harassment, being “read” (perceived as trans), or outed. About half had avoided three or more spaces or situations. Washrooms were the most commonly avoided space (57% had ever avoided a public washroom). Read more

Reported Emergency Department Avoidance, Use, and Experiences of Transgender Persons in Ontario, Canada

Results From a Respondent-Driven Sampling Survey

Transgender, transsexual, or transitioned (trans) people have reported avoiding medical care because of negative experiences or fear of such experiences. The extent of trans-specific negative emergency department (ED) experiences, and of ED avoidance, has not been documented.

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Breast and Cervical Cancer Screening Among Trans Ontarians

A report prepared for the Screening Saves Lives Program of the Canadian Cancer Society

The objective of this report is to provide requested information on perceived need for, and access to, Pap tests and mammograms for trans (transgender, transsexual and transitioned) people in Ontario, using data from the Trans PULSE Project.

Among FTM trans people who had not had hysterectomies, 56.2% reported perceived need for a Pap test in the past year, of whom 83.1% were able to access one. In other words, an estimated 46.7% of FTMs who had not undergone hysterectomies had accessed a Pap test in the past year. Ten FTMs who had not had chest surgery (mastectomy) reported perceived need for a mammogram in the past year, of whom 7 were able to access one. Among MTF trans people who were on estrogen, 12 of 16 participants who perceived need for a mammogram were able to access one.  Read more

Suicidality among Trans People in Ontario/ La suicidabilité parmi les personnes trans en Ontario

Implications for social work and social justice

Abstract: While transgender and transsexual (trans) communities have been documented to experience high rates of suicidality, little attention has been paid to how this may vary based on experiences of social injustice. Using survey data from the Trans PULSE Project (n=433), we estimated that suicidal thoughts were experienced by 36% of trans Ontarians over the past year, and that 10% attempted suicide during that time. Moreover, we documented that youth and those experiencing transphobia and lack of support are at heightened risk. Suicidality varied greatly by medical transition status, with those who were planning to transition sex, but who had not yet begun, being most vulnerable. Recommendations are made for improving wellbeing in trans communities, through policy advocacy, service provision, access to transition care, and fostering accepting families and communities.

Résumé: Bien qu’on ait déjà établi que les membres des communautés transgenre et transsexuels (trans) connaissaient des taux de suicidabilité élevés, on n’a que très peu porté attention jusqu’ici à la façon dont ces taux pouvaient varier en fonction d’expériences d’injustice sociale. Read more

Nonprescribed Hormone Use and Self-Performed Surgeries

“Do-It-Yourself” Transitions in Transgender Communities in Ontario, Canada

Objectives. We examined the extent of nonprescribed hormone use and self-performed surgeries among transgender or transsexual (trans) people in Ontario, Canada.

Methods. We present original survey research from the Trans PULSE Project. A total of 433 participants were recruited from 2009 to 2010 through respondent-driven sampling. We used a case series design to characterize those currently taking nonprescribed hormones and participants who had ever self-performed sex-reassignment surgeries.

Results. An estimated 43.0% (95% confidence interval = 34.9, 51.5) of trans Ontarians were currently using hormones; of these, a quarter had ever obtained hormones from nonmedical sources (e.g., friend or relative, street or strangers, Internet pharmacy, herbals or supplements). Fourteen participants (6.4%; 95% confidence interval = 0.8, 9.0) reported currently taking nonprescribed hormones. Five indicated having performed or attempted surgical procedures on themselves (orchiectomy or mastectomy). Read more

Sexual Health of Trans Men Who Are Gay, Bisexual, or Who Have Sex with Men

Results from Ontario, Canada

Recent reports have addressed the sexual health of female-to-male transgender or transsexual people who are gay, bisexual, and/or have sex with men (trans GB-MSM) using urban convenience samples. The Trans PULSE Project conducted a multimode, respondent-driven sampling survey in Ontario, Canada, in 2009–2010. Weighted estimates were calculated for trans GB-MSM (n = 173) for sexual orientation, behavior, partners, and HIV-related risk, as well as for psychosocial stressors and sexual satisfaction. An estimated 63.3% (95% CI [50.4, 73.5]) of trans men were GB-MSM (173/227). Results indicate great diversity in sexual behavior and experiences. Implications for sexual health promotion, counseling, and medical care are addressed. Read more

Joint Effort

Prison Experiences of Trans PULSE Participants and Recommendations for Change

Trans Ontarians experience high rates of unemployment, workplace discrimination, and poverty which can make them more vulnerable to incarceration. Approximately one-quarter of trans people in Ontario report being harassed by police because they are trans, while about a quarter of racialized, and a third of Aboriginal, trans people report police harassment because of their race or ethnicity. The limited research conducted on the prison experiences of trans people in Canada suggests that trans people who live in poverty, who are sex workers, and who use drugs frequently report police harassment, and may constitute the majority of trans people who are arrested and imprisoned. We also know that Aboriginal and Black people are over-represented in Canadian prisons.

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Experiences of Transphobia among Trans Ontarians

Transphobia has been described as an “irrational fear of, aversion to, or discrimination against people whose gendered identities, appearances, or behaviours deviate from societal norms”. This includes transgender, transsexual, transitioned, transgender, and gender-queer people, as well as some two-spirit people. Transphobia exists within a context of cisnormativity, the expectation that all people are- and should be- cisgender, or non-trans. Transphobia includes acts of exclusion, discrimination, and violence, as well as attitudes that trans people may themselves internalize. Here we present information about the types and levels of transphobia experienced by trans people in Ontario.

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Experiences of Racism among Trans People in Ontario

We know that like transphobia, racism and ethnicity-related discrimination are bad for our health. The concept of minority stress can help us to understand how experiences of racism and ethnicity-related discrimination, in addition to transphobia and other forms of social oppression, can lead to negative physical and mental health outcomes. We understand racism to include both structural inequalities based on socially-constructed racial categories, and exposure to specific discriminatory events, though we will focus on the latter here. To date, research has not described experiences of racism and ethnicity-related discrimination among trans people in Ontario or Canada. Therefore, we sought to describe these experiences and their overall burden among non-Aboriginal white, non-Aboriginal racialized, and Aboriginal trans Ontarians.


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Trans Ontarians’ Sex Designations on Federal and Provincial Identity Documents

A report prepared for the Canadian Human Rights Commission

The objective of this report is to provide requested information on social gender transition and the status of sex designations on government-issued identity documents for trans (transgender, transsexual and transitioned) people, using data from the Trans PULSE Project.

An estimated 48.0% of trans people who had socially transitioned to live full-time as men or women had no government-issued identification that reflected their lived gender. While a full discussion of the implications is beyond the scope of this report, this does represent a special situation in that the complete absence of identification matching one’s lived gender creates barriers to everyday activities of life.

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Impacts of Strong Parental Support for Trans Youth

A report prepared for Children's Aid Society of Toronto and Delisle Youth Services

The aim of this report is to provide preliminary data on the health impacts of parental support for trans (transgender or transsexual) youth aged 16 to 24 in Ontario.

Trans PULSE data have considerable implications for parents/caregivers and for those working with trans youth in schools and services. First and foremost, our findings show clear associations between the support that trans youth experience from their parents and numerous health outcomes. The most significant differences show that trans youth who have strong parental support for their gender identity and expression report higher life satisfaction, higher self-esteem, better mental health including less depression and fewer suicide attempts, and adequate housing compared to those without strong parental support. These findings draw a direct relationship between strong parental support and the reduction of significant risk factors for trans youth. Read more

High Heterogeneity of HIV-Related Sexual Risk Among Transgender People in Ontario, Canada

A Province-Wide Respondent-Driven Sampling Survey

Background  Studies of HIV-related risk in trans (transgender, transsexual, or transitioned) people have most often involved urban convenience samples of those on the male-to-female (MTF) spectrum. Studies have detected high prevalences of HIV-related risk behaviours, self-reported HIV, and HIV seropositivity.
Methods  The Trans PULSE Project conducted a multi-mode survey using respondent-driven sampling to recruit 433 trans people in Ontario, Canada. Weighted estimates were calculated for HIV-related risk behaviours, HIV testing and self-reported HIV, including subgroup estimates for gender spectrum and ethno-racial groups.
Results  Trans people in Ontario report a wide range of sexual behaviours with a full range of partner types. Read more

Prevalence of and Risk and Protective Factors for Depression in Female-to-Male Transgender Ontarians

Trans PULSE Project

Although depression is understudied in transgender and transsexual communities, high prevalences have been reported. This paper presents original research from the Trans PULSE Project, an Ontario-wide, community-based initiative that surveyed 433 participants using respondent-driven sampling. The purpose of this analysis was to determine the prevalence of, and risk and protective factors for, depression among female-to-male (FTM) Ontarians (n=207). We estimate that 66.4% of FTMs have symptomatology consistent with depression. In multivariable analyses, sexual satisfaction was a strong protective factor. Conversely, experiencing transphobia and being at the stage of planning but not having begun a medical transition (hormones and/or surgery) adversely affected mental health in FTMs.

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Depression in Male-to-Female Transgender Ontarians

Results from the Trans PULSE Project

High prevalences of depression have been reported in male-to-female (MTF) transgender communities. We explored factors associated with depressive symptomatology among MTF spectrum trans people in Ontario, using data from the Trans PULSE Project Phase II respondent-driven sampling survey (n=433 participants, including 191 MTFs with data needed for this analysis). We estimated the prevalence of depression at 61.2%. Factors associated with higher odds of depressive symptomatology included living outside of Toronto, having some college or university (vs. completed), being unemployed, and experiencing higher levels of transphobia. Increasing social support was associated with reduced odds of depressive symptomatology. Multivariable analyses suggested complex relationships between these factors, passing, and childhood abuse, which require additional study.

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Gay, Bisexual & MSM Trans Guys: No Assumptions!

A report prepared for the Gay Men's Sexual Health Summit

About two-thirds of trans guys are GB-MSM, and are attracted to or sexually involved with cis or trans men. Trans guys already exist within gay men’s communities, gay bathhouses, and gay men’s bedrooms. Yet, their sexual health concerns are rarely made visible.

Our results show wide diversity among GB-MSM trans guys with regard to relationship types, sexual activities, psycho-social factors, and HIV-related risk. Thus, no assumptions can safely be made about how an “average” GB-MSM trans guy may act, what he may do in bed (or not do in bed), or what other psycho-social stressors he may or may not have to deal with.

Sexual health and HIV-related prevention and testing programs and materials need to incorporate trans guys’ issues and needs, and to reflect the potential for gay or queer bodies to be trans bodies.

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Challenging the Binary

Gender Characteristics of Trans Ontarians

Gender-related terms represent concepts that are important in how people self-identify and are rooted in social, institutional, and medical histories. Sex and gender have historically been binary—male and female—and these terms have been applied to appearance, identities, and anatomies. The assumption of two and only two categories that neatly apply to all aspects of an individual is reinforced by social, medical, religious and legal systems. A sex/gender label is generally carried throughout a person’s life and any presentation desire to change this or expand its boundaries can come at great personal costs, whether financial, emotional, or social. The information gathered by Trans PULSE challenges this binary and suggests that gender presentation and identity are more complicated with a range of diverse presentations. It also makes clear the need for further education for service providers, educators, and the rest of society.

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We’ve Got Work to Do

Workplace Discrimination and Employment Challenges for Trans People in Ontario

A key to good health and quality of life is being fully included as a valued member of society, having access to a safe employment setting free of harassment and which provides meaning on a daily basis, and being able to rely on a secure income from one’s employment. There is a considerable negative impact when these social determinants of health are absent, compromised, or threatened. Recent results from the U.S. have documented high levels of discrimination and harassment in employment settings, but until now similar data have not been available in a Canadian context. While some non-explicit employment protections are in place for trans people in Canadian law, employment discrimination still exists. Trans PULSE findings showed that while 71% of trans people have at least some college or university education, about half make $15,000 per year or less. In light of this we sought to better understand the unique barriers to employment faced by trans Ontarians, and the discrimination they experience in the workplace.

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Ontario’s Trans Communities and Suicide

Transphobia is Bad for our Health

Recently, the news has been filled with reports of anti-gay bullying and high suicide rates among lesbian, gay and bisexual youth. Unfortunately, there has been little discussion about the situation for trans people regarding suicide. Just-released data from a large U.S. study found that 41% of trans participants had ever attempted suicide in their lifetime, but they did not include information on who might be currently at risk. Trans PULSE has taken a unique snapshot of trans people across Ontario, Canada- people with a range of identities, relationships with their bodies, and personal beliefs about the necessity of physical  transition. The information on suicide we present here was collected using a unique research method that allowed us to take the most statistically accurate picture of trans people possible in Ontario. We caution that this information is alarming. This situation demands immediate action on the part of our community, policy-makers, service providers and educators. It also underscores the need for parents and families come together to support trans people in Ontario.

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Estimating Unmet Need for OHIP-funded Sex Reassignment Surgeries

A Report Prepared for the Ministry of Health and Long-term Care of Ontario

The objective of this report is to provide information from Trans PULSE Project data to inform health systems planning with regard to sex reassignment surgeries covered under the Ontario Health Insurance Program (OHIP). Hormonal care and non-listed medical procedures are thus not included, though they represent important additional components of transition-related care.

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Who are Trans People in Ontario?

Our knowledge about who trans people really are is unfortunately still very limited. Many studies have focused on only those who attend certain clinics, or seek out hormone treatment or sex reassignment surgeries.(1,2) More recent studies have tried to capture what trans people “look like” by surveying people in other venues.(3) Trans PULSE has taken a unique snapshot of trans people across Ontario – people with a range of identities, relationships with their bodies, and personal beliefs about the necessity of physical transition. The information we present was collected using a unique research method that would allow us to take the most statistically accurate picture of trans people possible in Ontario.

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“I Don’t Think This Is Theoretical; This Is Our Lives”

How Erasure Impacts Health Care for Transgender People

For people who are transgender, transsexual, or transitioned (trans), access to primary, emergency, and transition-related health care is often problematic. Results from Phase I of the Trans PULSE Project, a community-based research project in Ontario, Canada, are presented. Based on qualitative data from focus groups with 85 trans community members, a theoretical framework describing how erasure functions to impact experiences interacting with the health care system was developed. Two key sites of erasure were identified: informational erasure and institutional erasure. How these processes work in a mutually reinforcing manner to erase trans individuals and communities and produce a system in which a trans patient or client is seen as an anomaly is shown. Thus, the impetus often falls on trans individuals to attempt to remedy systematic deficiencies. The concept of cisnormativity is introduced to aid in explaining the pervasiveness of trans erasure. Strategies for change are identified.

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Trans PULSE Project Summary 2008

Why is this survey important?

A survey of this many trans people has never been done before – in Ontario or anywhere else in the world! In order for services to  change we need to hear the real experiences of what it is like to be trans or to transition in Ontario. We’ve chosen particular kinds of questions to make sure that the results are useful to trans communities and able to improve our quality of life. This survey is important because it is driven and owned by trans people, allies and partners who are committed to improving our communities.

Report on Phase I & Plans for Phases II and III

Phase I of our research involved gathering a wide variety of perspectives on health and health issues  from trans people in Ontario. Overall, 89 participants took part in seven soundings held in summer 2006 in Toronto, Guelph, and Ottawa. These were trans-only spaces, facilitated by trans investigators from our research team. The soundings provided insight into the current health priorities of trans community members, the challenges confronted when trying to become or stay healthy, and some frequent barriers to accessing health care and social services.