Moral Panic, Backlash, and the Noxious Effects of Transphobia: Assessing the Structural Drivers of Trans Health

Abstract

This dissertation draws on Fundamental Cause Theory, the Socio-Ecological Model of Transgender Stigma and Health, and the Weathering Hypothesis, as well as methods from the fields of health services, epidemiology, and sociology to examine how stigma operates across levels of the social ecological model to shape the health of transgender and gender diverse (trans) people in the U.S. This dissertation follows a three-paper model to understand how structural stigma is associated with the health and wellbeing of trans populations in the U.S. and how trans people and their advocates are ensuring access to healthcare despite structural stigma and violence. In Chapter 2 (paper 1), I examined the risk of cardiovascular disease among a sample of trans people enrolled in private insurance from 2001-2019. I compared the risk of cardiovascular disease to a 10% sample of cisgender (cis) who shared their sex assigned at birth. After matching on social and enrollment characteristics, I found that trans people were at a greater risk for all cardiovascular diseases studied overall and at most ages compared to those who share their sex assigned at birth. In particular, trans people were at the greatest relative risk during early and middle adulthood, suggesting a “weathering” pattern. This study offers an alternative framing to understanding cardiovascular risk among trans populations, including identity threats and weathering. In Chapter 3 (paper 2), I explored how stigma operated across two levels of the Socio-Ecological Model of Transgender Stigma and Health and was associated with medical gender affirmation, specifically non-prescribed hormones (NPHs) use among one of the largest ever convenience sample of trans people in the U.S. Using structural equation modeling, I found that among trans adults using hormones, healthcare policy stigma was positively associated with NPHs use and operated through insurance coverage and anticipating stigma in healthcare settings. However, when assessing the model, I did not find a direct association between healthcare policy stigma and NPH use. Instead, I found chains of associations between healthcare policy stigma, insurance coverage, avoiding healthcare due to stigma, and using NPHs. This suggested that the model I tested was sufficient to explain the relationship between healthcare policy stigma and using NPHs. Chapter 4 (paper 3) aimed to understand how adolescent gender-affirming care providers navigate stigma across structural, interpersonal, and individual levels while continuing to provide gender-affirming care. To that end, I conducted 32 semi-structured interviews with adolescent gender-affirming care providers (AGAPs) from states that have either passed or introduced bans on gender-affirming care for adolescents. I found that providers were navigating stigma across all levels of the Socio-Ecological Model of Transgender Stigma and Health, such as structural or institutional policies restricting gender-affirming care for adolescents, interpersonal threats of violence and harassment from anti-trans activists, and identity management and concealment to avoid stigma or harassment at the individual level. In addition, stigma across all levels of the social ecological model influenced AGAPs' ability to advocate against efforts to restrict access to gender-affirming care for trans adolescents. This chapter showed how AGAPs could buffer the effects of stigma to facilitate access to gender-affirming care for adolescents. Still, these adaptations came at a cost to AGAPs, requiring them to make decisions about the ethical, legal, and personal tradeoffs to maintaining access to gender-affirming care for adolescents.