Health Care Use Among Transgender and Other Gender Diverse People in the United States: Influences of Stigma and Resilience

Abstract

Background: This dissertation explores the relationships between stigma, resilience, and health care among transgender and other gender diverse (TGGD) populations in the United States. The dissertation draws from multiple theoretical approaches and models (e.g., Fundamental Cause Theory, Bronfenbrenner’s Socio-Ecological Model, an intersectionality framework) and uses Minority Stress Theory as the primary theoretical foundation of the dissertation. Together, these theories and frameworks are used to explore how multiple aspects of stigma and resilience play a role in access to and use of health care among TGGD populations.

Methods: The dissertation is comprised of four papers including analyses of three separate datasets. Chapter II uses mixed methods to analyze data from the Affirming Voices for Action study and aims to understand experiences of stigma and gender affirmation across the health care experience among 33 trans-masculine and trans-feminine youth of color living in 14 U.S. cities. Chapter III uses principal components analysis and logistic regression to examine data from the Moxie study. This paper explores the relationships between minority stressors (e.g., enacted and anticipated stigma), resilience, and different types of health care use among a national online sample of TGGD youth. Chapters IV and V analyze data from the U.S. Trans Survey, conducted among more than 27,000 TGGD people across the United States. These papers use multilevel logistic regression to examine the role of state-level trans-specific policies on health care use, while also accounting for the clustering of data by U.S. state and exploring if the relationship between race/ethnicity and TGGD health care use vary across states. The health care use outcomes vary across these studies; Chapter IV examines non-use of health care due to fear of mistreatment and Chapter V examines the use of medical gender affirmation services.

Results: Across all four papers, stigma were generally related to less access to and use of health care. Resilience was found to improve access to and use of care. Stigma and resilience played a role in health care across different types of care, but the nuances in these relationships varied across types of care. Stigma and resilience also played a role in health care across the Socio-Ecological Model, occurring at intrapersonal, interpersonal, community, and structural levels. Experiences with health care varied across other identities (e.g., with TGGD youth and TGGD populations of color), highlighting the importance of applying an intersectionality framework when exploring the experiences of TGGD populations. When examining differences across gender identity (trans-masculine vs. trans-feminine vs. other gender diverse), differences were more salient in some papers than others; specifically, differences in experiences of stigma and resilience were greater when occurring outside of health care settings rather than inside of health care settings.

Conclusions: Findings from this dissertation suggest the importance of developing multi-level public health interventions occurring both within and outside of health care settings in order to improve access to health care among TGGD people. Policy and other structural interventions are also important, especially since they shape the social and political environment and play a role in access to resources. Future research exploring the role of stigma and resilience on health care among TGGD populations should consider applying an intersectionality framework, a resilience lens, and a focus on structural aspects of stigma and systematic vulnerability, in addition to the intrapersonal and interpersonal factors included in Minority Stress Theory.