A new report on the health of transgender Californians provides further evidence of the challenges trans people face, including their extremely high risk of suicide.

Twenty-two percent of transgender adults in California have ever attempted suicide, compare with 4 percent of cisgender (nontrans) adult Californians, according to the policy brief from the Williams Institute, a think tank at the University of California, Los Angeles, and the UCLA Center for Health Policy Research. The report, released today, uses data from the 2015-2016 California Health Interview Survey.

The data indicates there are 92,000 transgender people between the ages of 18 and 70 in California, representing 0.35 percent of the state’s adult noninstitutionalized population. Their general health status, insurance, and health access, are similar to that of cisgender adults, but there are significant disparities.

In addition to having a rate of suicide attempts that is six times that of cisgender people, “transgender adults are about three times more likely to have had lifetime suicidal thoughts, 34 percent to 10 percent, and nearly four times more likely to have experienced serious psychological distress in the past year, 33 percent compared to 9 percent,” according to the brief. “They are significantly more likely to report having a disability due to a physical, mental or emotional condition, 60 percent to 27 percent. They are more likely to delay or not get needed doctor-prescribed medicine compared to cisgender adults, 32 percent compared to 11 percent.”

“In many ways, transgender adults in California are similar in characteristics and experiences to cisgender adults,” said Jody Herman, scholar of public policy at the Williams Institute and lead author of the brief, in a press release. “Yet this study points out that there’s still much that needs to be done in California to address health disparities for the transgender population.”

The researchers found no significant differences between transgender and cisgender Californians in rates of poverty and food insecurity, and most measures of health care access. They acknowledged that this was somewhat surprising, given that other studies have indicated trans people nationwide have higher rates of poverty than the cisgender population and often have difficulty accessing health care. The result could be due to sampling or due to the fact that California has protective public policies in place for trans people, they wrote in the brief.

“These findings call for future research to explain existing disparities and similarities, as well as for the creation of structural and clinical interventions to improve health care access and mental and physical health outcomes for the transgender population,” they concluded. “In particular, public policy research that focuses on the health of transgender adults should include a direct test of the relationship between delays in getting health care, experiences with discrimination, and health status.”