Experiences of Discrimination,Harassment,and Violence in a Sample of Italian Transsexuals Who Have Undergone Sex-Reassignment Surgery

Abstract

The present study aims to provide an overview of experiences of discrimination, harassment, and violence in a sample of Italian transsexuals who have undergone sex-reassignment surgery (SRS). Lack of support for gender transition from family members was also assessed, before and after SRS. Data were collected in the context of a multicentric study (Milan, Florence, and Bari) on SRS outcome. Patients who underwent SRS were contacted and asked to fill out a questionnaire concerning experiences of discrimination, harassment, violence, and crime they might have experienced in previous years. Seventy-two participants took part in the research: 46 were male-to-female (MtF; 64%) and 26 were female-to-male (FtM; 36%). Thirty-six percent of the total sample (with no differences between MtF and FtM) experienced at least one episode of harassment, violence, or discrimination. The workplace was reported to be the social area with the highest risk of discrimination and harassment (22% of participants). Reports of more than one incident of discrimination, harassment, and violence characterized the majority of participants in the MtF sample. Compared with previous studies carried out in other countries, a much larger proportion of participants could count on a supportive family environment before and after transition. Our results show that Italian society at large is prejudiced against transsexuals, but at a more “micro” level, having a trans person as a family member might result in a protective and tolerant attitude.

Keywords

transgenderism discrimination violence LGBT sex-reassignment surgery

Introduction

Several studies, carried out both in the United States and in Europe, have shown that transgender¹ people—more so than any other sexual minority group (Browne & Lim, 2008)—are often victims of discrimination, harassment, or violence as a result of social stigma (Bockting et al., 2013). This can take the form of overt physical violence and lead to murders perpetrated by both strangers and known people (Harper & Schneider, 2003; Prunas et al., 2015).

The issue of transphobic violence has indeed reached alarming proportions in Italy which, according to a recent report from Transgender Europe (2015), is the second European country in the number of homicides of transgender people between 2008 and 2014; in spite of these figures, there is paucity of research in the field.

A National U.S. survey on violence against transgender people revealed that 48% of respondents had been victims of assaults, including sexual assault and rape, and 78% had experienced verbal harassment (Wilchins, 1997). Other studies conducted in the United States found that 43% of participants had been victims of violence or crime, with 75% attributing the motive to either transphobia or homophobia (Xavier, 2000).

Research carried out in Europe showed similar figures. In 2006, a large U.K. survey found that 73% of transgender people had experienced some kind of harassment in public places, and that 10% had experienced violent behavior (Whittle, Turner, & Al-Alami, 2007). Another research report from the United Kingdom found that transgender people are, compared with lesbian, gay, bisexual persons, at higher risk of becoming victims of hate crimes: twice as likely to experience physical violence and 3 times as likely to experience harassment (Browne & Lim, 2008). Similar results were also found in a large survey carried out across several European countries (Turner, Whittle, & Combs, 2009).

The most recent study has been carried out by the European Union Agency for Fundamental Rights (2014), involving participants from 28 countries and, for the first time, the large sample of participants allowed comparisons between different subgroups of trans people (i.e., transsexuals, cross dressers, transgender, gender variant, and queer). The survey showed that more than half of the whole sample of respondents (54%) felt discriminated against or harassed in the year preceding the survey because they were perceived as trans. People at higher risk of feeling discriminated against were of a young age, jobless, or from a lower income class. Work was found to be the area of social life in which the likelihood of being discriminated against was higher, with 37% of trans respondents reporting discrimination when looking for a job and 27% discrimination at work. Breaking down the whole sample in subgroups, transwomen (i.e., natal males who identify themselves as women) and -people who self-identified as transgender were found to be particularly at risk for discrimination when looking for a job and at work. Looking at respondents’ nationalities, 22% of the Italian respondents reported a prevalence of discrimination in the workplace, while 43% of them felt discriminated against when looking for a job.

These results are in line with previous studies carried out in the United States (Grant et al., 2011; Lombardi et al., 2001). In particular, several reports focusing specifically on MtF and FtM transsexual participants showed that up to 57% of transsexual people reported losing a job, difficulty getting a job, or job discrimination (Clements, Katz, & Marx, 1999; Reback, Simon, Bemis, & Gaston, 2001; Sugano, Tooru, & Operario, 2006; Sykes et al., 1999).

Health care was also found to be an area of discrimination as around 20% of all respondents who accessed health care services (22%; 17% in Italy) or social services (19%) in the year preceding the survey felt health care providers discriminated against them because of being trans (European Union Agency for Fundamental Rights, 2014).

The general results showed that the annual incidence rate of violence or harassment is around one incident per two trans respondents, which is twice as high as the incidence rates for lesbian, gay, and bisexual respondents. This means that one in two trans persons indicate that they were attacked or targeted through insults, threats, or violence in the year preceding the survey.

First of all, the phenomenon of violence against lesbian, gay, bisexual, transgender, intersex² (LGBTI) minorities has reached alarming proportions in the country, although there is an unexplainable paucity of research in this area. According to Amnesty International (2013), for example, the Observatory for Security against Discriminatory Acts of the Ministry of the Interior reported 40 cases of hate crimes motivated by sexual orientation from 2010 to March 2013 in Italy. The non-governmental organization (NGO) Gay Helpline (offering free legal and psychological counseling to victims of discrimination and violence) received information about 750 cases of verbal and physical attacks targeting LGBTI individuals in 2011.

Second, although violence motivated by race, ethnicity, nationality, or religion is a specific crime in Italy (according to Law n. 205, June 25, 1993, also known as “Legge Mancino”), a violent act committed on the grounds of gender identity and sexual orientation is not prosecuted as a hate crime. According to the Penal Code (Art. 61), “general aggravating circumstances” may apply when a crime is perpetrated either for trivial purposes or with cruelty, but such circumstances have been applied only on rare occasions to crimes against the LGBT community (Prunas et al., 2015). This lack of legislation implies that transphobic motives are unlikely taken into consideration in the investigation, prosecution, and sentencing of a crime and, as a consequence, no official data on the prevalence of hate crimes against the trans community in Italy are available as of yet.

It is also remarkable that the gender transition process in itself can be more difficult in Italy compared with other European and extra-European countries. Indeed, although Italy was one of the first countries with a specific legislation regulating gender transition³ (Godano et al., 2009), such a law appears outdated nowadays and not aligned with the European Union (EU) directives and the Current Version of the World Association for Transgender Health (WPATH) Standards of Care (Coleman et al., 2011). Court approval is still mandatory for undergoing SRS at the end of 12 continuous months of living in a gender role congruent with one’s gender identity. This period is still defined in the Italian courts as “real life experience.”

Finally, the present study focuses specifically on transsexual people with the aim of providing a full picture of quality of life and global functioning after SRS, not limited to satisfaction with surgery results and functional outcome after surgery.

Method

Data were collected in the context of a study aimed at assessing outcome of SRS in Italian transsexuals, between November 2012 and March 2015. The research was carried out in three different centers providing hormonal and/or surgical treatment for people suffering from gender dysphoria, in line with clinical guidelines provided by the WPATH (Coleman et al., 2011).

The three centers are located in Milan (Northern Italy), Florence (Central Italy), and Bari (Southern Italy). Researchers in these three sites contacted all the patients who had previously received SRS by telephone or email to ask for their participation in the study. The questionnaires were either completed in a paper-and-pencil format or by means of an online survey platform. All questionnaires were completed anonymously to ensure confidentiality, and the surveys were taken after participants provided a written informed consent.

No remuneration was offered for study participation. The study was approved by the Institutional Review Board (IRB) of Milan-Bicocca State University.

Measures

Participants were asked to fill in a questionnaire aimed at assessing post-surgical satisfaction, sexually and in overall quality of life, which included questions concerning experiences of discrimination, harassment, violence, and crime of which they may have been victim in previous years. The experiences assessed included the following:

being fired or losing a job because of transsexualism

experiencing harassment or discrimination at work from a co-worker, manager, or boss, because of transsexualism

experiencing harassment or discrimination from a doctor, nurse, or other health care provider because of transsexualism

being a victim of violence or crime because of transsexualism

For each of the previous experiences, participants were invited to respond by means of a dichotomous scale (happened/never happened) and, in the case of a positive answer, they were invited to provide a brief description of the event.

The level of support from family members before and after SRS was also assessed by means of a 5-point Likert-type scale from “very supportive” to “very unsupportive” (with the additional option of “not applicable”).

The questionnaire was originally developed by Anne Lawrence (2003) and then adopted in her study on SRS outcome (Lawrence, 2003, 2005).

Participants

Seventy-two participants took part in the study and returned the questionnaire fully completed by hand or online; the response rate was 37% (i.e., 37% of all potential participants in the three centers who were asked for participation completed the survey). It must be pointed out, however, that no data on the total number of SRSs carried out in the country are available; therefore, no conclusion can be drawn about the representativeness of this sample to the overall population of Italian transsexuals who underwent SRS. The only national study available so far (Caldarera & Pfäfflin, 2011) provides figures up to 2008, but results are tentative and marked by some relevant methodological drawbacks.⁴

Among the respondents, 46 were self-identified as male-to-female (MtF) transsexuals (64% of the total sample) and 26 were self-identified as female-to-male (FtM) transsexuals (36% of the total sample).

Mean age was 39.65 years (SD = ±12.31; age range = 18-72 years) in the MtF sample and 34.77 years (SD = ±7.79; age range = 21-50 years) in the FtM sample; the age difference between the two groups reached statistical significance (Student’s t = 1.82; p < .05).

In the MtF sample, 30 (65%) participants had a paid job at the time of study participation, eight (17%) were looking for work, three (7%) were full-time students, five (11%) were housewives or retired. In the FtM sample, 16 (62%) participants had a paid job, eight (30%) were looking for work, two (8%) were full-time students.

Mean time since SRS was 6.13 years (SD = ±7.24; range = 1-34 years) for MtF and 4.15 years (SD = ±5.37; range = 1-22 years) for FtM.

All MtF participants underwent vaginoplasty, but only one participant in the FtM sample underwent phalloplasty (i.e., surgical construction of a penis); all other participants in the FtM sample underwent hysterectomy, ovariectomy, and mastectomy (i.e., surgical removal of uterus, ovaries, and breast, respectively).⁵

The distribution of participants by center was as follows: Milan 45%, Florence 33%, and Bari 22%.

Data Analysis

All analyses were performed using SPSS 22.0 (IBM, Amonk, NY). Descriptive statistics were used to describe the sociodemographic characteristics of the sample and the frequencies of experiences of harassment, discrimination, and violence. Given the small sample size and the small numbers in contingency tables, for categorical data Fisher’s exact test was used to assess the presence of significant differences in the prevalence of the variables of interest (harassment, discrimination, and violence) between the MtF and the FtM sample. Finally, Student’s t test and chi-square test were used as appropriate to assess the association between sociodemographic variables and experiences of harassment, discrimination, and violence.

Results

Lack of support from family members before and after SRS

Data on the supportiveness/unsupportiveness of family environment in the two samples, before and after surgery, are shown in Table 1. To allow comparison with previous studies, results from Lawrence’s (2003) study referring to a large sample of MtF participants are also provided.

Table 1.

Support From Family Members Before and After Transition.

	Overall (n = 72)	MtF (n = 46)	FtM (n = 26)	Results From Lawrence (2003) in MtF (%)
Before SRS^a
Very unsupportive	6 (8%)	4 (9%)	2 (8%)	27
Somewhat unsupportive	2 (3%)	2 (4%)	0	18
Neither	17 (24%)	8 (17%)	9 (35%)	6
Somewhat supportive	20 (28%)	16 (35%)	4 (15%)	22
Very supportive	26 (36%)	15 (32%)	11 (42%)	28
After SRS^b
Very unsupportive	4 (5%)	4 (9%)	0	—
Somewhat unsupportive	2 (3%)	1 (2%)	1 (4%)	—
Neither	8 (11%)	3 (6%)	5 (19%)	—
Somewhat supportive	16 (22%)	12 (26%)	4 (15%)	—
Very supportive	40 (56%)	24 (52%)	16 (61%)	—

Note. MtF = male-to-female; FtM = female-to-male; SRS = sex-reassignment surgery.

For one participant in the MtF group, the question was not applicable.

For two participants in the MtF group the question was not applicable.

Given the small sample size, to allow a statistical comparison between the MtF and the FtM group, the participants who defined their family members as “somewhat” to “totally unsupportive” of their gender transition were aggregated to form a single group. The prevalence of a so-defined unsupportive family environment showed no difference between the MtF and FtM sample, either before or after surgery (before SRS: Fisher’s exact test = 0.702, p > .05; after SRS: Fisher’s exact test = 1.0, p > .05).

In the MtF sample, the comparison between before and after SRS showed that for four of six participants whose family members were unsupportive before surgery, the situation did not change after surgery. For another participant, the level of support from family improved dramatically after surgery, and for the last one the situation even worsened (from “somewhat” to “very unsupportive”).

As for the FtM sample, the situation improved for two participants after surgery, dramatically in one case (from “very unsupportive” to “very supportive”) and slightly in the other (from “very unsupportive” to “somewhat unsupportive”).

Experiences of harassment, discrimination, violence, and crime

Table 2 summarizes experiences of harassment and discrimination in the two samples.

Table 2.

Experiences of Discrimination, Harassment and Violence in MtF and FtM Transsexuals.

	Overall (n = 72)	MtF (n = 46)	FtM (n = 26)	Fisher’s Exact Test, p
Ever been fired because of transsexualism	11 (15%)	10 (22%)	1 (4%)	0.048, p < .05
Ever experienced harassment or discrimination at work because of transsexualism	16 (22%)	13 (28%)	3 (11%)	0.142, n.s.
Ever experienced harassment or discrimination from a health care provider because of transsexualism	10 (14%)	8 (17%)	2 (8%)	0.311, n.s.
Ever been a victim of violence or crime because of transsexualism	10 (14%)	8 (17%)	2 (8%)	0.311, n.s.
At least one of the above experiences	26 (36%)	19 (41%)	7 (30%)	1.489, n.s.

Note. MTF = male-to-female; FtM = female-to-male.

In both samples, the highest number of episodes of discrimination and harassment occurred in the workplace, with a prevalence of up to 28% in the MtF sample, with no significant difference between MtF and FtM (Fisher’s exact test = 0.142, p > .05).

Experiences of harassment and discrimination from health care providers were reported by 17% of the MtF sample and 8% of the FtM sample, with no significant differences between the two samples (Fisher’s exact test = 0.311, p > .05).

The same prevalence rates, 17% of the MtF sample and 8% of the FtM sample, were reported for being a victim of violence and crime.

To obtain a global picture of the prevalence of participants in the two samples who were ever victims of any of the aforementioned experiences, a summary variable was created showing that 36% of the total sample experienced at least one episode of harassment, violence, or discrimination (41% in the MtF sample and 30% in the FtM sample). In the FtM sample, having ever been victims of violence, harassment, or discrimination because of transsexualism showed no association with the participants’ age (Student’s t = −0.999, df = 24, p > .05), time since social transition (Student’s t = −0.628, df = 24, p > .05), level of education or having/not having a paid job (continuity corrected χ² = .031, df = 1, p > .05); however, the time since undergoing SRS was significantly longer for those who had been victims of violence, harassment, or discrimination compared with those who had not (8.29 ± 7.78 years vs. 2.63 ± 3.29 years; Student’s t = −2.652, df = 24, p < .05). In the MtF sample, having ever been victims of violence, harassment, or discrimination showed no association with the participants’ age (Student’s t = −0.957, df = 44, p > .05), time since SRS (Student’s t = −0.679, df = 44, p > .05), time since social transition (Student’s t = 0.451, df = 44, n.s.), level of education or having/not having a paid job (c.c. χ² = .841, df = 1, p > .05).

In only the MtF sample, we also compared participants who reported one episode of violence, harassment, and discrimination (20%) against those who reported multiple episodes (22%). No difference was found between the two groups in age or job status. It was not possible to carry out the same comparison in the FtM group because of the small sample size.

Finally, the participants who reported having ever been victims of crime or violence were asked to further specify, by means of a series of options, the type of events they experienced. The results are summarized in Table 3. No difference in prevalence was found between the two groups for any type of violence examined.

Table 3.

Episodes of Crime Reported by Participants in the Two Samples.

	MtF (n = 8)	FtM (n = 2)	Fisher’s Exact Test, p
Assault (not sexual)	6	1	0.409, n.s.
Rape or sexual assault	2	0	0.532, n.s.
Robbery	2	0	0.532, n.s.
Burglary or theft	1	0	1, n.s.
Extortion or blackmail	1	0	1, n.s.
Abduction or kidnapping	0	0	—
Unjustified arrest	1	0	1, n.s.
Vandalism	0	1	0.361, n.s.

Note. MTF = male-to-female; FtM = female-to-male.

Discussion

This is the first multicentric study conducted in Italy on experiences of discrimination, harassment, and violence in transsexual clients who underwent SRS.

Our results show that 36% of the total sample reported at least one episode of discrimination and harassment at work, discrimination by a health care provider, or violence. These results provide more optimistic figures compared with other European studies (European Union Agency for Fundamental Rights, 2014) and reports from Italy (Transgender Europe, 2015).

No difference was found in the overall prevalence rate between MtF and FtM transsexuals, a result at odds with previous surveys showing that transwomen are generally at higher risk (European Union Agency for Fundamental Rights, 2014; Kenagy, 2005; Stotzer, 2009). Yet, once the prevalence of specific types of discrimination and harassment was compared between the two samples, one difference emerged with MtF transsexuals reporting more frequently the experience of having been fired because of their transsexualism. Such result might be explained by gender inequality, that is, the valuation of masculinity over femininity. From this perspective, while transmen have to face less censure as they are conforming to the socially respected traits of masculinity, transwomen are at higher risk of being intensely harassed or discriminated in the workplace for both abandoning masculinity and choosing femininity (Schilt & Westbrook, 2009).

Generally speaking, the workplace emerged as a social area with high risk for discrimination and harassment with 22% of the participants reporting experiences of harassment and discrimination connected to being transsexual at work. This result is in line with previous surveys carried out in the United States and in Europe (European Union Agency for Fundamental Rights, 2014; Lombardi, Wilchins, Priesing, & Malouf, 2001). For instance, the 2011 Report of the National Transgender Discrimination Survey (Grant et al., 2011) showed that the workplace is a major area of discrimination for transgender people, which might take the form of unemployment or underemployment, harassment, and mistreatment, job loss or denied promotions, both in MtF and in FtM respondents.

Also, in line with previous research (Lombardi et al., 2001), reports of more than one experience of discrimination, harassment, and violence were characteristic in the majority of participants in the MtF sample.

The number of experiences of discrimination, harassment, and violence showed no relationship with the participants’ age or socioeconomic status, suggesting that such episodes might be actually explained as a result of one single system of inequality (Meyer, 2012; that is, belonging to a sexual minority group). However, another possible explanation is that it might be connected to a sample bias (as discussed in limits of the study).

Our data also allowed us to assess the supportiveness/unsupportiveness to gender transition among family members before and after SRS. This is particularly important as previous studies on the long-term outcomes of SRS indicated that adequate support from family can play a key role in predicting the well-being of transsexuals after surgery, especially in MtF transsexuals (Carroll, 1999; Eldh, Berg, & Gustafsson, 1997), although later studies did not provide further support to these results (Lawrence, 2003).

Our data show that only around 10% of participants had to face an unsupportive family environment before and after SRS surgery; no difference was found between MtF and FtM transsexuals. This prevalence rate is considerably lower than what was found in previous studies in the United States by means of the same assessment instrument; Lawrence (2003) found in a large sample of post-surgery MtF transsexuals that 45% of them described their family environment as at least somewhat unsupportive to their gender transition, providing no data on possible attitude change after the surgery. Such a discrepancy is probably explained by cultural differences between Italy and the United States: Sociologists and economists have in fact shown that family ties tend to be much stronger in Italy (and in other countries in the Mediterranean basin) than in Northern European countries and in the United States (Alesina & Giuliano, 2013; Reher, 1998). Therefore, the family-oriented nature of the Italian society may reflect in a more favorable attitude toward a family member who decides to undergo gender transition, but research is needed to support this hypothesis. Another possible explanation is that Lawrence’s (2003) study was published over 10 years ago, and the differences with the current study might be connected to a change in the attitude toward transgender people. Finally, it should be pointed out that this result might again reflect a selection bias, as those who obtain SRS might actually be those whose families show the most supportive attitude.

Our results also show that, for the majority of participants who could not rely on a supportive family environment before SRS, the situation did not improve at all after surgery, and therefore the unsupportive attitude does not “naturally” change once the gender transition is carried out. This result might call for the need for specific psychological interventions directed toward the unsupportive family to be carried out in the context of the transsexual person’s transition.

Italian transsexuals are exposed to discrimination, harassment, and violence as much (if not even more) than those in any other European country but, living in a family-centered society, they can generally rely on a more supportive attitude from their family members than in other European or extra-European countries in which family ties tend to be weaker. Overall, our results show that the Italian society at large is still prejudiced against transsexuals, but at a more “micro” level, having a trans person as a family member can result in a protective and tolerant attitude.

This study suffers from several methodological limitations.

First of all, the sample under investigation cannot be considered representative for all transsexual clients but rather for transsexual clients requesting SRS according to the International Standards of Care. This is not at all a complete picture of the trans population which is characterized by high levels of heterogeneity and cannot be simply reduced to a single group of individuals undergoing standardized hormonal treatments and SRS (Giami & Beaubatie, 2014).

Second, although the rate of returned questionnaires (37%) is comparable with that of previous studies of the same kind (Lawrence, 2003), it is plausible that the participants studied may not constitute a representative sample of all those at the three centers who have undergone SRS, nor of the overall population of Italian transsexuals who ever underwent SRS. No reliable data have ever been provided on the exact number of SRSs carried out in the country, and estimates currently available are in fact tentative and marked by some relevant methodological drawbacks (Caldarera & Pfäfflin, 2011).

Finally, non-respondents were not contacted to assess the presence of relevant differences from respondents. Persons who experienced positive results might have been more likely to reply and take part in the current research because of their feelings of gratitude; on the contrary, some individuals who experienced unsatisfactory surgical outcomes may have committed suicide, become isolated, or been victims of violence (Prunas et al., 2015); these factors could possibly have biased our results toward more positive outcomes.

In spite of these shortcomings, our findings call for the need to introduce in Italian legislation the notion of hate crime as a crime perpetrated on the grounds of gender identity. In recent years, the Parliament has rejected several times draft laws aimed at extending the scope of existing legislation on hate-motivated violence to include sexual orientation and gender identity (Senato della Repubblica Italiana, 2013). Such a new law might encourage trans people to report any discrimination incident they experience to authorities.

Furthermore, future research should provide further data on larger samples of transsexual participants and also broaden the scope of the present study by providing data on Italian transgender participants who do not self-identify as transsexuals and do not come to clinical attention.

Footnotes

Acknowledgements

The authors are heartily grateful to Mr. Ray Valido for editing the English version of the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Author Biographies

Antonio Prunas, PhD, is a psychologist and sex therapist and associate professor in Clinical Psychology at the Department of Psychology, University of Milan-Bicocca, Milan, Italy.

Elisa Bandini, MD, is a psychiatrist and research assistant at the Department of Biomedical, Experimental and Clinical Sciences, Careggi University Hospital, Florence, Italy.

Alessandra D. Fisher, MD, PhD, is endocrinologist and research assistant at the Department of Biomedical, Experimental and Clinical Sciences, Careggi University Hospital, Florence, Italy.

Mario Maggi, MD, is a full professor of endocrinology at the University of Florence, and Head of the Department of Biomedical, Experimental and Clinical Sciences, Careggi University Hospital, Florence, Italy.

Valeria Pace, PhD, works as a psychologist at the Gender Dysphoria Unit, Department of Psychiatry, Bari University Hospital, Bari, Italy.

Luca Quagliarella, PhD, works as a psychologist at the Gender Dysphoria Unit, Department of Psychiatry, Bari University Hospital, Bari, Italy.

Orlando Todarello, MD, is a full professor of Psychiatry at the University of Bari and Head of the Psychiatric Unit at Bari University Hospital, Bari, Italy.

Maurizio Bini, MD, is the head of the Unit for Disorders of Fertility at Niguarda Ca’ Granda Hospital, Milan, Italy.

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