Aurora Adams came out as a woman last year.
But her path to such a pivotal moment has been a complicated, lonely journey -- marked by years of depression and anxiety that continue to take a toll on her mental health.
Born male, Adams can hardly remember a time when she didn't feel ostracized for expressing interests that others viewed as feminine. School was a source of constant stress.
"I'd get locked out of classroom doors. I'd be shoved into the girls' locker room. I'd be told by people that I should kill myself," recalled Adams, 27. "And that just happened again and again and again."
Today, Adams is still trying to find acceptance, and regain her health - as are many others in Minnesota's lesbian, gay, bisexual, and transgender communities.
Editor's note: This story is part of a series that explores health disparities among certain groups of Minnesotans and the growing importance of data to understand the causes. The report was done in collaboration with the Healthy States project, American Public Media's focus on information, insight and experiences in health.
Researchers say chronic stress associated with harassment and discrimination is making sexual and gender minorities much more vulnerable to suicide and other health problems than the general population.
Just how much is unclear. The state of Minnesota collects a vast amount of data about the health of its citizens, including mortality rates from various causes, rates of communicable disease and of chronic illnesses like diabetes.
But although a ground-breaking Minnesota Department of Health report, delivered to the Legislature earlier this year, documented the many ways that racial and ethnic minorities experience poorer health than whites, it did not assess the health of the LGBT community. It did note that there is evidence that sexual and gender minorities suffer from health problems to a greater degree than others, but said more data is needed.
Lesbian, gay, bisexual, and transgender people are becoming more socially accepted in Minnesota, particularly since the state legalized same-sex marriage. But some say they still have a long way to go to overcome prejudice, discrimination and other social hurdles.
41 percent of transgender people have tried to take their lives at some point.
Adams is trying to do so at a supervised housing facility in Maplewood, where she has been since March, after seeking help from an emergency room for her suicidal thoughts. It was her third hospitalization.
Last July, she attempted to kill herself by mixing prescription medications and alcohol. A few months earlier, she entered a hospital after deliberately harming herself by cutting and burning her skin.
Adams doesn't blame her suicide attempt or thoughts on her struggles over her gender identity, what researchers describe as a person's inner sense of their own gender. But she acknowledges that it is a factor in how people treat her.
At the time she attempted suicide, Adams was unemployed and worried that she might soon be homeless. She had just walked away from her job at a cable company call center without giving notice. She said it was stressful work that was especially hard to manage as she began to assert her true self.
"Every single day I'd be on the phone and as you can tell probably by my voice people might gender me masculine on the phone," she said. "And that hurts, especially when you tell the customer or the person you're speaking with, 'you know, I'm actually a woman, so please gender me female,' and they don't."
In the few weeks before Adams left her job, after she told people she considered herself a woman, many of her colleagues were supportive. But she said plenty of others had no regard for her privacy.
"Asking 'have you had the surgery yet?' is very not okay in such a setting," she said. "And it's too high of a number for the amount of times I was asked that at my job. I mean, I very quickly started eating alone or going into the restroom stall and crying. The amount of stress and anxiety that comes with it is astronomical."
While more research is needed, the limited data that are available suggest that suicide attempts are pervasive among transgender people.
A 2011 national survey of more than 6,400 transgender people found that a staggering 41 percent had tried to take their lives at some point.
But comparing the survey's suicide attempt rate to other populations is not possible because few mainstream studies have included questions about sexual orientation or gender identity. The data are so lacking that there are no good estimates of how many people identify as lesbian, gay, bisexual, or transgender in the United States.
"People actually just don't feel like there's a place for them to exist safely in the world, and so the conclusion that they kind of come to is that they shouldn't exist"
Ed Ehlinger, commissioner of the Minnesota Department of Health, said the lack of data has made it difficult for public health officials to determine to what extent members of the LGBT community have poorer health than the general population.
To assess that, research must answer key questions, among them: Does the population have higher rates of chronic diseases related to the stress they experience in their daily lives? Do members of the LGBT community have more cancers due to their higher smoking rates? How different are health experiences within the population, which includes a very diverse group of people? That information is scant.
"We're a very heterosexist society," Ehlinger said. "We really think in terms of gender identity, male/female."
But Ehlinger said asking more detailed questions about gender and sexual orientation isn't as simple as it sounds.
"We need to have agreement on what we're asking," he said. "We have to have agreement on what the definition[s] of those terms are. And then, we have to be able to share that information from one electronic system to another."
That effort will likely take years, Ehlinger said. But there is some momentum.
In a 2011 report, the Institute of Medicine recommended collecting sexual orientation and gender identity data in government health surveys, federally-funded research, and electronic medical records. Some research conducted in Minnesota already collects that data.
The College Student Health Survey asks tens of thousands of students at 40 post-secondary schools about their sexual orientation and gender identity. But the population of transgender students who have participated in the randomized survey has been too small to analyze.
The Minnesota Student Survey, conducted every three years in the state's public schools, added a sexual orientation question in 2013. But the survey does not request information about gender identity.
LGBT advocates are aware of the data collection challenges, but they're not letting that hinder their campaign to be properly counted.
They have forged ahead with their own data gathering efforts, where they can.
In Minnesota, some of what is known about health disparities in the LGBT population comes from a relatively new survey conducted at the Twin Cities Pride Festival.
For the third year, the Rainbow Health Initiative, a Minneapolis-based advocacy group, has conducted its Voices of Health survey.
"The state isn't doing it for us, so we need to do it for ourselves," said Dylan Flunker, who is transgender and serves as the group's policy and community organizing coordinator.
The findings from the Voices of Health surveys appear to be consistent with similar surveys conducted elsewhere in the country that have revealed some potentially alarming health concerns for LGBT people.
John Salisbury, Rainbow Health Initiative's director of programs, said sexual and gender minorities experience several high risk behaviors and health problems at twice the rate of the general population.
"We find higher rates of smoking, we find higher rates of alcohol consumption, higher rates of anxiety, depression and PTSD in our survey," he said. "And we think that's due to lifetime experiences with discrimination, especially a lot of it in the health care settings."
Salisbury said discrimination in health care, or even the fear of it, can cause LGBT people to reduce or delay the care they need.
In the Voices of Health survey a quarter of the respondents reported receiving poor quality care because of their sexual orientation or gender identity. One in six survey participants said they had been discriminated against by their health care provider. Among transgender respondents in particular, nearly one in two said they had been discriminated against by a health care provider.
Alex Iantaffi, an assistant professor in the University of Minnesota's Program in Human Sexuality, is not surprised by the results.
"I've heard health professionals not just mis-pronoun, but kind of say things like 'he, she or whatever they are,'" said Iantaffi, a researcher and a marriage and family therapist.
When Iantaffi, who is transgender, was looking for a specialist to peform part of his gender-transition surgery, a few years ago, he met with an experienced surgeon. They had a great conversation, he said, until it was time to schedule his procedure.
"And then he turned around to me," Intaffi recalled, "and said, 'But I don't operate on transgender people, so you'll have to go to those other surgeons.'"
Iantaffi said he was stunned at how comfortable the doctor was with his decision to not treat a particular group of people. He suspects the physician didn't feel knowledgeable about transgender patients.
But Iantaffi said that's not a good enough reason to deny care.
"To me that really illustrates how people don't understand sometimes how simple it can be to experience a discrimination," he said.
While advocates and researchers alike agree that there's a great need for more data on the health challenges LGBT people face, Iantaffi said highlighting the results of new research could be a double-edged sword.
He said it's possible that some people won't want to associate themselves with a community that may have substantial health risks.
Still, Intaffi said, if increased public awareness of LGBT health disparities inspires more compassion for sexual and general minorities, it could make it easier for them to improve their health.
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