Transgender, gender non-conforming, and non-binary (TGNCNB) people commonly experience disrespect or discrimination from health care providers when attempting to utilize health care services and tend to avoid or postpone obtaining necessary care. Informed by Andersen’s Behavioral Model of Health Services Use and Lerner and Robles’ Adapted Behavioral Model of Health Care Utilization among Transgender People, we examine avoidance of health care utilization among TGNCNB adults based on anticipated disrespect or mistreatment from doctors.
Hierarchical logistic regression was used to analyze data from the 2015 United States Trans Survey (N = 27,715), the largest TGNCNB sample, to date, collected in 2015. A total of 21,930 participants were selected for the current study.
Nearly one fourth (22%) of the sample reported not utilizing health care when necessary because they anticipated being disrespected or mistreated when visiting a doctor. Cost (OR = 2.51, CI = 2.32–2.72), invasive questions (OR = 2.38, CI = 2.16–2.63), refusal of care (OR = 2.20, CI = 1.78–2.71), being verbally harassed (OR = 2.18, CI = 1.86–2.56), and needing to educate a provider (OR = 1.89, CI = 1.73–2.07) were the strongest predictors of avoidance of health care utilization.
Perceived doctor discriminatory behaviors, cost, need to educate a provider, verbal harassment, and perception of gender conformance are major barriers to TGNCNB people utilizing health care.
Social Policy Implications
Reducing transphobia among health professionals utilizing cultural safety by developing providers that are comfortable and affirming of TGNCNB people is critical. Federal policy, such as the Equality Act, is also vital so that transphobia is considered an illegal form of discrimination across the USA that will continue to discourage health insurance companies from denying claims for medically necessary, transition-related health care.
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Aboriginal Nurses Association of Canada. (2009). Cultural competence and cultural safety in nursing education: A framework for first nations. Ottawa: Métis and Inuit Nursing.
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.
Bauer, G. R., Hammond, R., Travers, R., Kaay, M., Hohenadel, K. M., & Boyce, M. (2009). “I don’t think this is theoretical; this is our lives”: How erasure impacts health care for transgender people. Journal of the Association of Nurses in AIDS Care, 20(5), 348–361.
Benson, K. E. (2013). Seeking support: Transgender client experiences with mental health services. Journal of Feminist Family Therapy, 25(1), 17–40.
Bockting, W., Robinson, B., Benner, A., & Scheltema, K. (2004). Patient satisfaction with transgender health services. Journal of Sex & Marital Therapy, 30(4), 277–294.
Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Hamilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103(5), 943–951.
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.
Centers for Disease Control and Prevention (CDC). (2018). National Health Interview Survey. Retrieved from https://www.cdc.gov/nchs/nhis/index.htm.
Congress.gov. (2019). H.R.5-Equality Act. https://www.congress.gov/bill/116th-congress/house-bill/5/text.
Corliss, H. L., Belzer, M., Forbes, C., & Wilson, E. C. (2008). An evaluation of service utilization among male to female transgender youth: Qualitative study of a clinic-based sample. Journal of LGBT Health Research, 3(2), 49–61.
Cruz, T. M. (2014). Assessing access to care for TGNCNB and gender nonconforming people: A consideration of diversity in combating discrimination. Social Science & Medicine, 110, 65–73.
Dickey, L. M., Budge, S. L., Katz-Wise, S. L., & Garza, M. V. (2016). Health disparities in the transgender community: Exploring differences in insurance coverage. Psychology of Sexual Orientation and Gender Diversity, 3, 275–282.
Dowshen, N., Nguyen, G. T., Gilbert, K., Feiler, A., Margo, K. L., & Stroumsa, D. (2014). Improving transgender health education for future doctors/Stroumsa responds. American Journal of Public Health, 104(7), E5–E6.
Fassaert, T., De Wit, M. A., Tuinebreijer, W. C., Wouters, H., Verhoeff, A. P., Beekman, A. T., et al. (2009). Psychometric properties of an interviewer administered version of the Kessler psychological distress scale (K10) among Dutch, Moroccan and Turkish respondents. International Journal of Methods in Psychiatric Research, 18(3), 159–168.
Gay & Lesbian Alliance against Defamation (GLAAD) (n.d.). Tips for allies of transgender people. Retrieved from https://www.glaad.org/transgender/allies.
Geronimus, A. T., Hicken, M. T., Pearson, J. A., Seashols, S. J., Brown, K. L., & Cruz, T. D. (2010). Do US black women experience stress-related accelerated biological aging? Human Nature, 21(1), 19–38.
Gonzales, G., & Henning-Smith, C. (2017). Barriers to care among transgender and gender nonconforming adults. The Milbank Quarterly, 95(4), 726–748.
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 Discrimination Survey, National Center for Transgender Equality (NCTE) and National Gay & Lesbian Task Force (NGLTF). Washington, DC: Retrieved from http://www.thetaskforce.org/downloads/reports/reports/ntds_full.pdf.
Green, J. (2016). Transgender: Why should we care? The Lancet, 388, 334–335.
Grollman, E. A. (2014). Multiple disadvantaged statuses and health the role of multiple forms of discrimination. Journal of Health and Social Behavior, 55(1), 3–19.
Hardacker, C. T., Rubinstein, B., Hotton, A., & Houlberg, M. (2014). Adding silver to the rainbow: The development of the nurses’ health education about LGBT elders (HEALE) cultural competency curriculum. Journal of Nursing Management, 22(2), 257–266.
Hendricks, M. L., & Testa, R. J. (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the minority stress model. Professional Psychology: Research and Practice, 43(5), 460–467.
Hughto, J. M. W., Reisner, S. L., & Pachankis, J. E. (2015). Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. Social Science & Medicine, 147, 222–231.
Human Rights Campaign. (2020). Transgender FAQ. Retrieved fromhttps://www.hrc.org/resources/transgender-faq#9.
Hussey, W. (2006). Slivers of the journey: The use of photovoice and storytelling to examine female to male transsexuals’ experience of health care access. Journal of Homosexuality, 51(1), 129–158.
Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding, The National Academies. Washington, DC: Retrieved from http://www.nap.edu/catalog.php?record_id=13128.
Jaffee, K. D., Shires, D. A., & Stroumsa, D. (2016). Discrimination and delayed health care among transgender women and men: Implications for improving medical education and health care delivery. Medical Care, 54(11), 1010–1016.
James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report of the 2015 U.S. Trans Survey. Washington, DC: National Center for Transgender Equality.
Kellett, P., & Fitton, C. (2017). Supporting transvisiblity and gender diversity in nursing practice and education: Embracing cultural safety. Nursing Inquiry, 24, e12146. https://doi.org/10.1111/nin.12146.
Kenagy, G. P. (2005). Transgender health: Findings from two needs assessment studies in Philadelphia. Health & Social Work, 30(1), 19–26.
Kenagy, G. P., & Bostwick, W. B. (2008). Health and social service needs of transgender people in Chicago. International Journal of Trangenderism, 8(2–3), 57–66.
Kessler, R., & Mroczek, D. (1992). An update of the development of mental health screening scales for the US national health interview study. Ann Arbor: Survey Research Center of the Institute for Social Research. University of Michigan.
Kessler, R. C., Andrews, G., Colpe, L. J., Hiripi, E., Mroczek, D. K., Normand, S. L., Walters, E. E., & Zaslavsky, A. M. (2002). Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine, 32(6), 959–976.
Khan, L. (2011). Transgender health at the crossroads: Legal norms, insurance markets, and the threat of healthcare reform. Yale Journal of Health Policy, Law, & Ethics, 11, 375–418.
Kirby, T. (2016). Sari Reisner-making transgender health visible. The Lancet, 388, 332.
Kirmayer, L. (2012). Rethinking cultural competence. Transcultural Psychiatry, 49(2), 149–164.
Kosenko, K., Rintamaki, L., Raney, S., & Maness, K. (2013). Transgender patient perceptions of stigma in health care contexts. Medical Care, 51(9), 819–822.
Lambda Legal (2010). When health care isn’t caring: Lambda Legal’s survey of discrimination against LGBT people and people with HIV. Retrieved fromhttp://www.lambdalegal.org/sites/default/files/publications/downloads/whcic-report_when-health-care-isnt-caring.pdf.
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.
Lim, F., Johnson, M., & Eliason, M. (2015). A national survey of faculty knowledge, experience, and readiness for teaching lesbian, gay, bisexual, and transgender health in baccalaureate nursing programs. Nursing Education Perspectives, 36(3), 144–152.
Lim, F. A., Brown, J. D. V., & Jones, B. A. H. (2013). Lesbian, gay, bisexual, and transgender health: Fundamentals for nursing education. Journal of Nursing Education, 52(4), 198–203.
Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27(1), 363–385.
Lo, S., & Horton, R. (2016). Transgender health: An opportunity for global health equity. The Lancet, 388, 316–318.
Mirza, S. & Rooney, C. (2018). Discrimination prevents LGBTQ people from accessing health care. Center for American Progress. Retrieved from https://www.americanprogress.org/issues/lgbt/news/2018/01/18/445130/discrimination-prevents-lgbtq-people-accessing-health-care/.
Moll, J.M., Krieger, P., Moreno-Walton, L., Lee, B., Slaven, E., James, T., … Heron, S.L. (2014). The prevalence of lesbian, gay, bisexual, and transgender health education and training in emergency medicine residency programs: What do we know? Academic Emergency Medicine, 21(5), 608–611.
Mona, L. R., Cameron, R. P., & Clemency Cordes, C. (2017). Disability culturally competent sexual healthcare. American Psychologist, 72(9), 1000–1010.
National Center for Transgender Equality. (2020). Getting your health care covered: A guide for transgender people. Retrieved from https://transequality.org/health-coverage-guide/.
O’Hara, C., Dispenza, F., Brack, G., & Blood, R. A. C. (2013). The preparedness of counselors in training to work with transgender clients: A mixed methods investigation. Journal of Issues in LGBT Counseling, 7, 236–256.
Phelan, J. C., Link, B. G., & Dovidio, J. F. (2008). Stigma and prejudice: One animal or two? Social Science & Medicine, 67(3), 358–367.
Poteat, T., German, D., & Kerrigan, D. (2013). Managing uncertainty: A grounded theory of stigma in transgender health care encounters. Social Science & Medicine, 84, 22–29.
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.
Reisner, S. L., Hughto, J. M. W., Dunham, E. E., Heflin, K. J., Begenyi, J. B. G., Coffey-Esquivel, J., & Cahill, S. (2015). Legal protections in public accommodations settings: A critical public health issue for transgender and gender-nonconforming people. The Milbank Quarterly, 93(3), 484–515.
Roller, C. G., Sedlak, C., & Draucker, C. B. (2015). Navigating the system: How transgender individuals engage in health care services. Journal of Nursing Scholarship, 47(5), 417–424.
Rutherford, K., McIntyre, J., Daley, A., & Ross, L. E. (2012). Development of expertise in mental health service provision for lesbian, gay, bisexual and transgender communities. Medical Education, 46, 903–913.
Safer, J. D., Coleman, E., Feldman, J., Garofalo, R., Hembree, W., Radix, A., & Sevelius, J. (2016). Barriers to health care for transgender individuals. Current Opinion in Endocrinology, Diabetes, and Obesity, 23(2), 168–171.
Sanchez, N. F., Sanchez, J. P., & Danoff, A. (2009). Health care utilization, barriers to care, and hormone usage among male-to-female transgender persons in New York City. American Journal of Public Health, 99, 713–719.
Seelman, K. L., Colón-Diaz, M. J., LeCroix, R. H., Xavier-Brier, M., & Kattari, L. (2017). Transgender noninclusive healthcare and delaying care because of fear:Connections to general health and mental health among transgender adults. Transgender Health, 2(1), 17–28.
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.
Simmons-Duffin, S. (12 June, 2020). Transgender health protections reversed by trump administration. NPR. Retrieved from https://www.npr.org/sections/healthshots/2020/06/12/868073068/transgender-health-protections-reversed-by-trump-administration.
Snelgrove, J. W., Jasudavisius, A. M., Rowe, B. W., Head, E. M., & Bauer, G. R. (2012). “Completely out-at-sea” with “two-gender medicine”: A qualitative analysis of physician-side barriers to providing healthcare for transgender patients. BMC Health Services Research, 12(1), 110–123.
Sperber, J., Landers, S., & Lawrence, S. (2005). Access to health care for transgendered persons: Results of a needs assessment in Boston. International Journal of Transgenderism, 8(2–3), 75–91.
Stotzer, R. L. (2009). Violence against transgender people: A review of United States data. Aggression and Violent Behavior, 14(3), 170–179.
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.
Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125.
Thornhill, L., & Klein, P. (2010). Creating environments of care with transgender communities. Journal of the Association of Nurses in AIDS Care, 21(3), 230–239.
Totenberg, N. (2020, June 15). Supreme Court delivers major victory to LGBTQ employees. NPR. Retrieved from https://www.npr.org/2020/06/15/863498848/supreme-court-delivers-major-victory-to-lgbtq-employees.
UCLA Institute for Digital Research and Education. (2019). Multinomial logistic regression: Stata annotated ouput. Retrieved from https://stats.idre.ucla.edu/stata/output/multinomial-logistic-regression-2/.
United States Trans Survey (USTS). (2017). 2015 US Transgender Survey- methodology report. Retrieved from ustranssurvey.org.
Varcoe, C., & Browne, A. J. (2015). Culture and cultural safety. In D. Gregory, C. Raymond-Seniuk, L. Patrick, & T. Stephen (Eds.), Fundamentals: Perspectives on the art and science of Canadian nursing. Philadelphia: Wolters Kluwer-Lippincott Williams & Wilkins.
Walch, S. E., Sinkkanen, 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.
White Hughto, J. M., Rose, A. J., Pachankis, J. E., & Reisner, S. L. (2017). Barriers to gender transition-related healthcare: Identifying underserved transgender adults in Massachusetts. Transgender Health, 2(1), 107–118.
Wilson, E. C., Arayasirikul, S., & Johnson, K. (2013). Access to HIV care and support services for African American transwomen living with HIV. International Journal of Transgenderism, 14(4), 182–195.
Winter, S., Settle, E., Wylie, K., Reisner, S., Cabral, M., Knudson, G., & Baral, S. (2016). Synergies in health and human rights: A call to action to improve transgender health. The Lancet, 388, 327–330.
Wylie, K., Knudson, G., Khan, S. I., Bonierbale, M., Watanyusakul, S., & Baral, S. (2016). Serving transgender people: Clinical care considerations and service delivery models in transgender health. The Lancet, 388, 401–411.
Xavier, J. M., Bobbin, M., Singer, B., & Budd, E. (2005). A needs assessment of transgendered people of color living in Washington, DC. International Journal of Transgenderism, 8(2–3), 31–47.
Xavier, J., Honnold, J., & Bradford, J. (2007). The health, health-related needs, and lifecourse experiences of transgender Virginians. Richmond: Virginia Department of Health Division of Disease Prevention through the Centers for Disease Control and Prevention.
Yiengprugsawan, V., Kelly, M., & Tawatsupa, B. (2014). Kessler psychological distress scale. In Encyclopedia of quality of life and well-being research (pp. 3469–3470). Springer: Netherlands.
We would like to express deep gratitude to the National Center for Transgender Equality for providing the 2015 United States Transgender Survey data for our analysis. Our research would not have been possible without their generosity.
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Lerner, J.E., Martin, J.I. & Gorsky, G.S. More than an Apple a Day: Factors Associated with Avoidance of Doctor Visits Among Transgender, Gender Nonconforming, and Nonbinary People in the USA. Sex Res Soc Policy 18, 409–426 (2021). https://doi.org/10.1007/s13178-020-00469-3