State-Level Transgender-Specific Policies, Race/Ethnicity, and Use of Medical Gender Affirmation Services among Transgender and Other Gender-Diverse People in the United States

Population health Original Scholarship

Policy Points:

  • Protective transgender-specific policies (including those related to experiences of discrimination, health insurance coverage, and changing legal documents) are associated with increased access to medical gender affirmation services (hormone treatment, therapy/counseling) for transgender and other gender-diverse people. Restrictive transgender-specific policies are associated with less access to these services.
  • The relationship between race/ethnicity and use of medical gender affirmation services varies across states and is context specific, indicating that race/ethnicity also plays a role in access to these types of care across states.
  • Advocacy is needed to prevent or overturn restrictive policies and promote protective policies for transgender and other gender-diverse people, especially for people of color.

Context: In the 2010s, the number of federal, state, and local transgender-specific policies increased. Some of these policies advanced protections for transgender and other gender-diverse (TGGD) people, and others were restrictive. Little is known about the relationships between these policies and use of medical gender affirmation services (eg, hormone treatment, therapy/counseling), or about how these associations may vary among different racial and ethnic groups.

Methods: Multilevel modeling was used to examine the associations between state-level transgender-specific policies and the use of medical gender affirmation services among TGGD people in the United States. Data are from the 2015 U.S. Trans Survey of nearly 28,000 TGGD people. The medical gender affirmation services examined in this study were hormone treatment and therapy/counseling. The state policies we analyzed addressed discrimination, health insurance coverage, and changing legal documents; these policies were measured individually and as a composite index. Race/ethnicity was included in the multilevel regression models as a random slope to determine whether the relationship between race/ethnicity and the use of medical gender affirmation services varied by state.

Findings: Individual policies and the policy index were associated with both outcomes (use of therapy/counseling and hormone treatment services), indicating that protective policies were associated with increased care. Broad religious exemption laws and Medicaid policies that excluded transgender-specific care were both associated with less use of therapy/counseling, whereas transgender-care-inclusive Medicaid policies were associated with more use of therapy/counseling. Nondiscrimination protections that include gender identity were associated with increased use of hormone treatment services. The relationship between race/ethnicity and medical gender affirmation services varied across states.

Conclusions: State-level transgender-specific policies influence medical gender affirmation service use and seem to affect use by non-Hispanic white TGGD people and TGGD people of color differently. Advocacy is needed to repeal restrictive policies and promote protective policies in order to reduce health inequities among TGGD people, especially people of color.

Keywords: Transgender, medical gender affirmation, hormone treatment, intersectionality, therapy, stigma, policies, health care.

 

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Citation:
Goldenberg T, Reisner SL, Harper GW, Gamarel KE, Stephenson R. State-Level Transgender-Specific Policies, Race/Ethnicity, and Use of Medical Gender Affirmation Services among Transgender and Other Gender-Diverse People in the United States. Milbank Q. 2020;98(3):802-846. https://doi.org/10.1111/1468-0009.12467