Abstract
Trans people tend to utilize health care at rates lower than cisgender people, which commonly results in short-term and long-term unfavorable health outcomes. Theoretically informed by Andersen's behavioral model of health services use and Lerner and Robles’ adapted behavioral model of health services use for transgender people, the current study examined how individual characteristics of trans people along with the external environment and health care service environment they must navigate impact their health care utilization. Binary logistic regression was used to analyze data from the 2015 United States Trans Survey (N = 27,715), the largest trans sample to date. Perception of health care provider (HCP) knowledge, health insurance status, and health care costs each produced the strongest effect on visiting a doctor or HCP in the past year. The results showed that having a provider that had some level of knowledge about trans people was potentially most critical to increase utilization. Discussion points include increasing trans-focused curriculum in health professional schools, utilizing trans standardized patients in health professional schools, and holding insurance companies accountable to provide trans affirming care.
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References
Abreu, R. L., Gonzalez, K. A., Mosley, D. V., Pulice-Farrow, L., Adam, A., & Duberli, F. (2022). “They feel empowered to discriminate against las chicas”: Latina transgender women’s experiences navigating the healthcare system. International Journal of Transgender Health, 23, 178–193. https://doi.org/10.1080/26895269.2020.1767752
Allport, G. W. (1954). The nature of prejudice. Addison-Wesley.
Alzahrani, T., Nguyen, T., Ryan, A., Dwairy, A., McCaffrey, J., Yunus, R., Forgione, J., Krepp, J., Nagy, C., Mazhari, R., & Reiner, J. (2019). Cardiovascular disease risk factors and myocardial infarction in the transgender population. Circulation: Cardiovascular Quality and Outcomes, 12(5597), 1–7. https://doi.org/10.1161/CIRCOUTCOMES.119.005597
American Psychological Association. (2015). Guidelines for psychologicalpractice with transgender and gender nonconforming people. American Psychologist, 70(9), 832–864.
Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 36(1), 1–10.
Baldwin, A., Dodge, B., Schick, V. R., Light, B., Scharrs, P. W., Herbenick, D., & Fortenberry, J. D. (2018). Transgender and genderqueer individuals’ experiences with health care providers: What’s working, what’s not, and where do we go from here? Journal of Health Care for the Poor and Underserved, 29(4), 1300–1318.
Bradford, J., Reisner, S. L., Honnold, J. A., & Xavier, J. (2013). Experiences of transgender-related discrimination and implications for health: Results from the Virginia transgender Health Initiative Study. American Journal of Public Health, 103(10), 1820–1829. https://doi.org/10.2105/AJPH.2012.300796
Byne, W., Bradley, S. J., Coleman, E., Eyler, A. E., Green, R., Menvielle, E. J., Meyer-Bahlburg, H. F. L., Pleak, R. R., & Tompkins, D. (2012). Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Archives of Sexual Behavior, 41(4), 759–796. https://doi.org/10.1007/s10508-012-9975-x
Clarke, T. C., Norris, T., & Schiller, J. S. (2017). National center for health statistics. Early release of selected estimates based on data from the 2016 National Health Interview survey. https://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201705.pdf.
Click, I. A., Mann, A. K., Buda, M., Rahimi-Saber, A., Schultz, A., Shelton, K. M., & Johnson, L. (2020). Transgender health education for medical students. The Clinical Teacher, 17(2), 190–194. https://doi.org/10.1111/tct.13074
Conron, K., Scott, G., Stowell, G., & Landers, S. (2012). Transgender health in Massachusetts: Results from a household probability sample of adults. American Journal of Public Health, 102(1), 118–122. https://doi.org/10.2105/AJPH.2011.300315
Cruz, T. M. (2014). Assessing access to care for transgender and gender nonconforming people: A consideration of diversity in combating discrimination. Social Science & Medicine, 110, 65–73. https://doi.org/10.1016/j.socscimed.2014.03.032
Deutsch, M. D. (Ed.). (2016). Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. Center of Excellence (COE) for Transgender Health. https://transcare.ucsf.edu/sites/transcare.ucsf.edu/files/Transgender-PGACG-6-17-16.pdf.
Deutsch, M. B., Green, J., Keatley, J., Mayer, G., Hastings, J., & Hall, A. M. (2013). Electronic medical records and the transgender patient: Recommendations from the World Professional Association for transgender Health EMR Working Group. Journal of the American Medical Informatics Association, 20(4), 700–703. https://doi.org/10.1136/amiajnl-2012-001472
Dichter, M. E., Ogden, S. N., & Scheffey, K. L. (2018). Provider perspectives on the application of patient sexual orientation and gender identity in clinical care: A qualitative study. Journal of General Internal Medicine, 33, 1359–1365. https://doi.org/10.1007/s11606-018-4489-4
Eckstrand, K., Ng, H., & Potter, J. (2016). Affirmative and responsible health care for people with nonconforming gender identities and expressions. AMA Journal of Ethics, 18(11), 1107–1118. https://doi.org/10.1001/journalofethics.2016.18.11.pfor1-1611
Fiani, C. N., & Han, H. J. (2019). Navigating identity: Experiences of binary and non-binary transgender and gender non-conforming (TGNC) adults. International Journal of Transgenderism, 20(2/3), 181–194. https://doi.org/10.1080/15532739.2018.1426074
Flores, A. R., Herman, J. L., Gates, G. J., & Brown, T. N. T. (2016). How many adults identify as transgender in the United States? The Williams Institute.
Giblon, R., & Bauer, G. R. (2017). Health care availability, quality, and unmet need: A comparison of transgender and cisgender residents of Ontario Canada. BMC Health Services Research, 17(283), 1–10. https://doi.org/10.1186/s12913-017-2226-z
Gonzales, G., & Henning-Smith, C. (2017). Barriers to care among transgender and gender nonconforming adults. The Millbank Quarterly, 95(4), 726–748. https://doi.org/10.1111/1468-0009.12297
Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at every turn: A report on the national transgender survey. National Center for transgender Equality (NCTE) and National Gay & Lesbian Task Force (NGLTF).
Herman, J. L., Wilson, B. D. M., & Becker, T. (2017). Demographic and health characteristics of transgender adults in California: Findings from the 2015–2016 California Health Interview Survey. NewYork: The Williams Institute.
James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report of the 2015 U.S. Transgender Survey. National Center for transgender Equality.
Kailas, M., Lu, H. M. S., Rothman, E. F., & Safer, J. (2017). Prevalence and types of gender-affirming surgery among a sample of transgender endocrinology patients prior to state expansion of insurance coverage. Endocrine Practice, 23(7), 780–786. https://doi.org/10.4158/EP161727.OR
Kattari, S. K., Atteberry-Ash, B., Kinney, M. K., Walls, N. E., & Kattari, L. (2019). One size does not fit all: Differential transgender health experiences. Social Work in Health Care, 58(9), 899–917. https://doi.org/10.1080/00981389.2019.1677279
Kattari, S. K., Bakko, M., Langenderfer-Magruder, L., & Holloway, B. T. (2021). Transgender and nonbinary experiences of victimization in health care. Journal of Interpersonal Violence, 36, 13054–13076. https://doi.org/10.1177/0886260520905091
Kattari, S. K., Walls, N. E., & Speer, S. R. (2017). Differences in experiences of discrimination in accessing social services among transgender/gender nonconforming individuals by (dis)ability. Journal of Social Work in Disability & Rehabilitation, 16(2), 116–140. https://doi.org/10.1080/1536710X.2017.1299661
Kattari, S. K., Walls, N. E., Whitfield, D. L., & Langenderfer-Magruder, L. (2015). Racial and ethnic differences in experiences of discrimination in accessing health services among transgender people in the United States. International Journal of Transgenderism, 16(2), 68–79. https://doi.org/10.1080/15532739.2015.1064336
Kcomt, L. (2019). Profound health care discrimination experienced by transgender people: Rapid systematic review. Social Work in Health Care, 58(2), 201–219. https://doi.org/10.1080/00981389.2018.1532941
Khan, L. (2011). Transgender health at the crossroads: Legal norms, insurance markets, and the threat of healthcare reform. Yale Journal of Health Policy, Law, and Ethics, 11(2), 375–418.
Lerner, J. E., & Robles, G. (2017). Perceived barriers and facilitators to health care utilization in the United States for transgender people: A review of recent literature. Journal of Health Care for the Poor and Underserved, 28(1), 127–152. https://doi.org/10.1353/hpu.2017.0014
Lurie, S. (2005). Identifying training needs of health-care providers related totreatment and care of transgendered patients: A qualitative needs assessment conducted in New England. International Journal of Transgenderism, 8(2/3), 93–112. https://doi.org/10.1300/J485v08n02_09
McCave, E. L., Aptaker, D., Hartmann, K. D., & Zucconi, R. (2019). Promoting affirmative transgender health care practice within hospitals: An IPE standardized patient simulation for graduate health care learners. MedEdPORTAL. https://doi.org/10.15766/mep_2374-8265.10861
American Medical Association (AMA). (2014). Mission provides a map to improve medicine: AMA CEO. https://www.ama-assn.org/about/leadership/mission-provides-map-improve-medicine-ama-ceo.
Moolchaem, P., Liamputtong, P., O’Halloran, P., & Muhamad, R. (2015). The lived experiences of transgender persons: A meta-synthesis. Journal of Gay & Lesbian Social Services, 27(2), 143–171. https://doi.org/10.1080/10538720.2015.1021983
National Center for Transgender Equality (NCTE) (2016). Frequently asked questions about transgender people. https://transequality.org/issues/resources/frequently-asked-questions-about-transgender-people.
National Center for Transgender Equality (NCTE) (2019). Health coverage guide. https://transequality.org/health-coverage-guide/.
National Center for Transgender Equality (2020). Getting your health care covered: A guide for transgender people. https://transequality.org/health-coverage-guide/.
National Association of Social Workers (NASW) (n.d.). About NASW. Washington, DC: NASW. http://www.socialworkers.org/nasw/default.asp.
Nolan, I. T., Kuhner, C. J., & Dy, G. W. (2019). Demographic and temporal trends in transgender identities and gender confirming surgery. Translational Andrology and Urology, 8(3), 184–190. https://doi.org/10.21037/tau.2019.04.09
Obedin-Maliver, J., Goldsmith, E. S., Stewart, L., White, W., Tran, E., Brenman, S., & Lunn, M. R. (2011). Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. Journal of the American Medical Association, 306(9), 971–977. https://doi.org/10.1001/jama.2011.1255
Operario, D., & Nemoto, T. (2017). On being transnational and transgender: Human rights and public health considerations. American Journal of Public Health, 107(10), 1537–1538. https://doi.org/10.2105/AJPH.2017.304030
Papanicolas, I. R., Woskie, L. R., & Jha, A. K. (2018). Health care spending in the United States and other high-income countries. Journal of the American Medical Association, 319(10), 1024–1039. https://doi.org/10.1001/jama.2018.1150
Pascoe, E. A., & Richman, L. S. (2009). Perceived discrimination and health: A meta-analytic review. Psychological Bulletin, 135(4), 531–554. https://doi.org/10.1037/a0016059
Peabody, J. W., Luck, J., Glassman, P., Dresselhaus, T., & Lee, M. (2000). Comparison of vignettes, standardized patients, and chart abstractions: A prospective validation study of 3 methods for measuring quality. Journal of the American Medical Association, 283(13), 1715–1722. https://doi.org/10.1001/jama.283.13.1715
Perez-Brumer, A., Hatzenbuehler, M. L., Oldenburg, C. E., & Bockting, W. (2015). Individual-and structural-level risk factors for suicide attempts among transgender adults. Behavioral Medicine, 41(3), 164–171. https://doi.org/10.1080/08964289.2015.1028322
Puckett, J. A., Cleary, P., Rossman, K., Mustanski, B., & Newcomb, M. E. (2018). Barriers to gender-affirming care for transgender and gender nonconforming individuals. Sexuality Research and Social Policy, 15(1), 48–59. https://doi.org/10.1007/s13178-017-0295-8
Rahman, M., Li, D. H., & Moskowitz, D. A. (2019). Comparing the healthcare utilization and engagement in a sample of transgender and cisgender bisexual+ person. Archives of Sexual Behavior, 48(1), 255–260. https://doi.org/10.1007/s10508-018-1164-0
Raphael, K. (1987). Recall bias: A proposal for assessment and control. International Journal of Epidemiology, 16(2), 167–170.
Reisner, S. L., Mimiaga, M. J., Bland, S., Mayer, K. H., Perkovich, B., & Safren, S. A. (2009). HIV risk and social networks among male-to-female transgender sex workers in Boston, Massachusetts. Journal of the Association of Nurses in AIDS Care, 20(5), 373–386. https://doi.org/10.1016/j.jana.2009.06.003
Rethans, J. J. (1998). Needs assessment in continuing medical education through standardized patients. Journal of Continuing Education in the Health Professions, 18(3), 172–178. https://doi.org/10.1002/chp.1340180307
Rider, G. N., McMorris, B. J., Gower, A. L., Coleman, E., & Eisenberg, M. E. (2018). Health and care utilization of transgender and gender nonconforming youth: A population-based study. Pediatrics. https://doi.org/10.1542/peds.2017-1683
Roberts, T. K., & Fantz, C. R. (2014). Barriers to quality health care for the transgender population. Clinical Biochemistry, 47, 983–987. https://doi.org/10.1016/j.clinbiochem.2014.02.009
Rodriguez, A., Agardh, A., & Asamoah, B. O. (2018). Self-reported discrimination in health-care settings based on recognizability as transgender: A cross-sectional study among transgender U.S. citizens. Archives of Sexual Behavior, 47(4), 973–985. https://doi.org/10.1007/s10508-017-1028-z
Safer, J. D., & Pearce, E. N. (2013). A simple curriculum content change increased medical student comfort with transgender medicine. Endocrine Practice, 19(4), 633–637. https://doi.org/10.4158/EP13014.OR
Scheppers, E., Van Dongen, E., Dekker, J., Geertzen, J., & Dekker, J. (2006). Potential barriers to the use of health services among ethnic minorities: A review. Family Practice, 23(3), 325–348. https://doi.org/10.1093/fampra/cmi113
Shipherd, J. C., Green, K. E., & Abramovitz, S. (2010). Transgender clients: Identifying and minimizing barriers to mental health treatment. Journal of Gay & Lesbian Mental Health, 14(2), 94–108. https://doi.org/10.1080/19359701003622875
Shires, D. A., Stroumsa, D., Jaffee, K. D., & Woodford, M. R. (2018). Primary careclinicians’ willingness to provide routine care for transgender patients and pap tests for transgender men. Annals of Family Medicine, 16(6), 555–558. https://doi.org/10.1370/afm.2298
Simpson, T. L., Balsam, K. F., Cochran, B. N., Lehavot, K., & Gold, S. D. (2013). Veterans’ administration health care utilization among sexual minority veterans. Psychological Services, 10(2), 223–232. https://doi.org/10.1037/a0031281
Stroumsa, D., Shires, D. A., Richardson, C. R., Jaffee, K. D., & Woodford, M. R. (2019). Transphobia rather than education predicts provider knowledge of transgender health care. Medical Education, 53, 398–407. https://doi.org/10.1111/medu.13796
Walch, S. E., Sinkannen, K. A., Swain, E. M., Francisco, J., Breaux, C. A., & Sjoberg, M. D. (2012). Using intergroup contact theory to reduce stigma against transgender individuals: Impact of a transgender speaker panel presentation. Journal of Applied Social Psychology, 42(10), 2583–2605. https://doi.org/10.1111/j.1559-1816.2012.00955.x
Xavier, J., Bobbin, M., Singer, B., & Budd, E. (2005). A needs assessment of transgender people of color living in Washington DC. International Journal of Transgenderism, 8(2–3), 31–47. https://doi.org/10.1300/J485v08n02_04
Yamanis, T., Malik, M., Río-González, D., María, A., Wirtz, A. L., Cooney, E., Lujan, M., Corado, R., & Poteat, T. (2018). Legal immigration status is associated with depressive symptoms among Latina transgender women in Washington, DC. International Journal of Environmental Research and Public Health, 15. https://doi.org/10.3390/ijerph15061246
Zunner, B. P., & Grace, P. J. (2012). The ethical nursing care of transgender patients: An exploration of bias in health care and how it affects this population. American Journal of Nursing, 112(12), 61–64. https://doi.org/10.1097/01.NAJ.0000423514.58585.a3
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Lerner, J.E., Martin, J.I. & Gorsky, G.S. To Go or Not to Go: Factors That Influence Health Care Use Among Trans Adults in a Non-Representative U.S. Sample. Arch Sex Behav 51, 1913–1925 (2022). https://doi.org/10.1007/s10508-022-02302-x
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DOI: https://doi.org/10.1007/s10508-022-02302-x