Considerations for Transgender Population Health Research Based on US National Surveys

Aging in isolation: Sexual orientation differences in navigating cognitive decline

Introduction

Subjective cognitive decline is a self-reported measure of worsening memory and day-to-day decision making. Cognitive decline may impair an individual's ability to complete instrumental activities of daily living (IADL) such as preparing meals or taking medication, ultimately limiting one's ability to live independently. People with IADL impairments typically rely on informal care from spouses or children. Interpersonal and structural discrimination towards sexual minority (SM, including lesbian, gay, bisexual, and other queer identified) populations may contribute to disparities in cognitive decline and informal care outcomes.

Objective

Estimate differences in prevalence, severity, and receipt of social support for subjective cognitive decline stratified by sex and SM status.

Methods

Cross-sectional study design using a probability sample (n = 172,047) from the Behavioral Risk Factor Surveillance System 2015-2019. Prevalence estimates and multivariable Poisson regression models were used to compare outcomes by sex and sexual identity.

Results

Compared to heterosexual peers, SM men and women were more likely to experience cognitive decline (15% of SM men, 11% of heterosexual men, 17% of SM women, 11% of heterosexual women). In adjusted models, SM women were 22% more likely (95%CI:3%-44%, p < .05) to report IADL impairments due to cognitive decline but were 17% less likely (95%CI:1%-31%, p < .05) to receive any social support with IADL impairments compared to heterosexual women. In adjusted models, SM men were 25% more likely (95%CI: 0%-56%, p < .05) to report IADL impairments due to cognitive decline but reported no significant difference in receiving social support with IADL impairments compared to heterosexual men.

Discussion

We identified significant unmet need for social supports for IADL impairments, with highest unmet need among SM women. Comprehensive strategies such as LGBTQ + affirming assisted living and home and community-based services are needed to ensure equity in receipt of long-term supports and services for SM populations.

Disparities in behaviors and experiences among transgender and cisgender high school students - 18 U.S. states, 2021

PURPOSE

Transgender youth (those whose gender identity differs from their sex assigned at birth) experience stigma and discrimination that can place them at increased risk for poor health outcomes compared with cisgender youth (those whose gender identity aligns with their sex assigned at birth). Limited population-based data exist on disparities among transgender and cisgender youth.

METHODS

We examined differences in experiences of violence, substance use, mental health, suicide, sexual behavior, unstable housing, parental monitoring, and school connectedness among 98,174 transgender and cisgender high school students using data from 18 states that included an item to assess transgender identity on their 2021 Youth Risk Behavior Survey.

RESULTS

Overall, 2.9% of students identified as transgender and 2.6% questioned whether they were transgender. Among transgender students, 71.5% reported that their mental health was not good, 32.3% had attempted suicide, and 29.0% experienced sexual violence. Transgender students were more likely than cisgender students to report experiences of violence, substance use, poor mental health, suicide risk, some sexual risk behaviors, and unstable housing, and were less likely to report feeling connected to others at school.

CONCLUSIONS

Interventions that can address the causes of these adverse outcomes and promote the health and wellbeing of transgender youths are warranted.

Methods for structural sexism and population health research: Introducing a novel analytic framework to capture life-course and intersectional effects

Accumulating evidence links structural sexism to gendered health inequities, yet methodological challenges have precluded comprehensive examinations into life-course and/or intersectional effects. To help address this gap, we introduce an analytic framework that uses sequential conditional mean models (SCMMs) to jointly account for longitudinal exposure trajectories and moderation by multiple dimensions of social identity/position, which we then apply to study how early life-course exposure to U.S. state-level structural sexism shapes mental health outcomes within and between gender groups. Data came from the Growing Up Today Study, a cohort of 16,875 children aged 9-14 years in 1996 who we followed through 2016. Using a composite index of relevant public policies and societal conditions (e.g., abortion bans, wage gaps), we assigned each U.S. state a year-specific structural sexism score and calculated participants' cumulative exposure by averaging the scores associated with states they had lived in during the study period, weighted according to duration of time spent in each. We then fit a series of SCMMs to estimate overall and group-specific associations between cumulative exposure from baseline through a given study wave and subsequent depressive symptomology; we also fit models using simplified (i.e., non-cumulative) exposure variables for comparison purposes. Analyses revealed that cumulative exposure to structural sexism: (1) was associated with significantly increased odds of experiencing depressive symptoms by the subsequent wave; (2) disproportionately impacted multiply marginalized groups (e.g., sexual minority girls/women); and (3) was more strongly associated with depressive symptomology compared to static or point-in-time exposure operationalizations (e.g., exposure in a single year). Substantively, these findings suggest that long-term exposure to structural sexism may contribute to the inequitable social patterning of mental distress among young people living in the U.S. More broadly, the proposed analytic framework represents a promising approach to examining the complex links between structural sexism and health across the life course and for diverse social groups.

Delays in Accessing Healthcare Across the Gender Spectrum in the All of Us Research Program

BACKGROUND

Gender minorities and cisgender women face barriers to healthcare access. Prior work suggests cost may represent a particular barrier to accessing care for transgender and gender diverse (TGD) individuals.

OBJECTIVE

To examine odds of delaying care for any reason and, secondarily, for 7 specific reasons among TGD individuals and cisgender women compared with cisgender men in the All of Us Research Program.

DESIGN

We calculated the odds of delayed care by gender identity relative to cisgender men using multivariable-adjusted logistic regression, with adjustment for age, race, income, education, and Charlson comorbidity index.

PARTICIPANTS

We examined 117,806 All of Us participants who completed the healthcare access and utilization survey.

MAIN MEASURES

The primary outcome was self-reported delayed care in the past 12 months for any of 7 potential reasons: cost (out-of-pocket cost, co-payment costs, and/or high deductible), lack of childcare, lack of eldercare, nervousness associated with visiting the healthcare provider, rurality, inability to take time off work, and lack of transportation.

KEY RESULTS

Compared with cisgender men, the multivariable-adjusted odds ratio (OR) for delaying care for any reason was 1.48 (95% CI, 1.44-1.53; P < 0.001) among cisgender women, 1.65 (95% CI, 1.24-2.21; P < 0.001) among TGD individuals assigned male at birth, and 2.76 (95% CI, 2.26-3.39; P < 0.001) among TGD individuals assigned female at birth. Results were consistent across multiple sensitivity analyses. TGD individuals were substantially more likely to cite nervousness with visiting a healthcare provider as a barrier, whereas cisgender women were more likely to delay care due to lack of childcare coverage.

CONCLUSIONS

Cisgender women and TGD individuals were more likely to delay seeking heath care compared with cisgender men, and for partially different reasons. These findings highlight the need to address common and distinct barriers to care access among marginalized groups.

Racial/ethnic differences in the association between transgender-related U.S. state policies and self-rated health of transgender women

BACKGROUND

Policy protections for transgender adults in the United States are consistently associated with positive health outcomes. However, studies over-represent non-Latinx White transgender people and obscure variation in policies' intended goals. This study examined racial differences in the relationship between transgender-related policies and transgender women's self-rated health. Guided by Critical Race Theory, we hypothesized that policies conferring access to resources (e.g., healthcare) would be associated with better self-rated health among all participants while policies signifying equality (e.g., nondiscrimination laws) would be associated with better self-rated health only for White participants.

METHODS

Using cross-sectional data collected between March 2018-December 2020 from 1566 transgender women, we analyzed 7 state-level 'access policies,' 5 'equality policies,' and sum indices of each. Participants represented 29 states, and 54.7% were categorized as people of color. We fit a series of multilevel ordinal regression models predicting self-rated health by each policy. Multivariate models were adjusted for relevant covariates at the individual- and state-level. We then tested moderation by race/ethnicity using interaction terms and generated stratified predicted probability plots.

RESULTS

In bivariate models, 4 access policies, 2 equality policies, and both indices were associated with better self-rated health, but associations did not persist in adjusted models. Results from the multivariable models including interaction terms indicated that policies concerning private insurance coverage of gender-affirming care, private insurance nondiscrimination, credit nondiscrimination, and both indices were statistically significantly associated with better self-rated health for White participants and worse self-rated health for participants of color.

CONCLUSIONS

The policies included in this analysis do not mitigate racism's effects on access to resources, indicating they may be less impactful for transgender women of color than White transgender women. Future research and policy advocacy efforts promoting transgender women's health must center racial equity as well as transgender people of color's priorities.

Pain mechanisms in the transgender individual: a review

Specific Aim

Provide an overview of the literature addressing major areas pertinent to pain in transgender persons and to identify areas of primary relevance for future research.

Methods

A team of scholars that have previously published on different areas of related research met periodically though zoom conferencing between April 2021 and February 2023 to discuss relevant literature with the goal of providing an overview on the incidence, phenotype, and mechanisms of pain in transgender patients. Review sections were written after gathering information from systematic literature searches of published or publicly available electronic literature to be compiled for publication as part of a topical series on gender and pain in the Frontiers in Pain Research.

Results

While transgender individuals represent a significant and increasingly visible component of the population, many researchers and clinicians are not well informed about the diversity in gender identity, physiology, hormonal status, and gender-affirming medical procedures utilized by transgender and other gender diverse patients. Transgender and cisgender people present with many of the same medical concerns, but research and treatment of these medical needs must reflect an appreciation of how differences in sex, gender, gender-affirming medical procedures, and minoritized status impact pain.

Conclusions

While significant advances have occurred in our appreciation of pain, the review indicates the need to support more targeted research on treatment and prevention of pain in transgender individuals. This is particularly relevant both for gender-affirming medical interventions and related medical care. Of particular importance is the need for large long-term follow-up studies to ascertain best practices for such procedures. A multi-disciplinary approach with personalized interventions is of particular importance to move forward.

Inequities in the distribution of adverse childhood experiences and their association with health among transgender people of color

BACKGROUND

Racism and cisgenderism expose transgender people of color to adversity across the life course. However, little is known about the prevalence of adverse childhood experiences (ACEs) in this population or their association with health in comparison to other groups.

OBJECTIVE

Guided by the structural trauma framework, we examined race/ethnicity/gender group differences in the prevalence of ACEs and their association with adult mental and physical health.

PARTICIPANTS AND SETTING

2019-2021 Behavioral Risk Factor Surveillance Survey.

METHODS

Transgender participants (n = 551) were matched with two cisgender men (n = 1102) and two cisgender women (n = 1102) on key covariates. We compared age-adjusted predicted probabilities of nine ACEs by race/ethnicity/gender group. We then fit adjusted logistic regression models predicting poor mental and physical health by each ACE and compared marginal effects between groups.

RESULTS

Transgender people of color had higher age-adjusted probabilities of six ACEs than at least one other group; for example, household incarceration was 0.16 (95 % CI: 0.11-0.22) compared to 0.09 (95 % CI: 0.06-0.13) for cisgender men of color (p = 0.032). The relationship between five ACEs and poor mental health was greater for transgender people of color than at least one other group. For instance, the marginal effect of household alcoholism on poor mental health was 0.28 (95 % CI: 0.11-0.45) compared to 0.07 (0.01-0.14) for White cisgender men (p = 0.031). There were no statistically significant differences regarding effects on poor physical health.

CONCLUSIONS

ACEs inequitably impact transgender people of color, reflecting the need to restructure the interlocking systems that drive adversity among transgender children of color and exacerbate ACEs' health effects among adults.

Access to Health Care for Transgender and Gender-Diverse Adults in Urban and Rural Areas in the United States

The objective of this study is to examine access to care based on gender identity in urban and rural areas, focusing on transgender and gender diverse (TGD) populations. Data on TGD (n = 1,678) and cisgender adults (n = 403,414) from the 2019 to 2020 Behavioral Risk Factor Surveillance System were used. Outcome measures were four barriers to care. We conducted bivariate and multivariable logistic regressions to assess associations between access, rurality, and gender identity. Bivariate results show that TGD adults were significantly more likely to experience three barriers to care. In multivariable models, TGD adults were more likely to delay care due to cost in the full sample (adjusted odds ratio [AOR]: 2.00, p < .001), rural subsample (AOR: 2.14, p < .01), and urban subsample (AOR: 1.97, p < .01). This study revealed greater barriers to care for TGD adults, with the most frequent barriers found among rural TGD adults. Increased provider awareness and structural policy changes are needed to achieve health equity for rural TGD populations.

Ethical Imperatives for Working With Diverse Populations in Digital Research

Digital research methodologies are driving a revolution in health technology but do not yet fully engage diverse and historically underrepresented populations. In this paper, we explore the ethical imperative for such engagement alongside accompanying challenges related to recruitment, appreciation of risk, and confidentiality, among others. We critically analyze existing research ethics frameworks and find that their reliance on individualistic and autonomy-focused models of research ethics does not offer adequate protection in the context of the diversity imperative. To meet the requirements of justice and inclusivity in digital research, methods will benefit from a reorientation toward more participatory practices.

Improving access for and experience of transgender and non-binary patients in clinical research: Insights from a transgender patient focus group and targeted literature reviews

INTRODUCTION

The transgender and non-binary communities make up a significant, growing proportion of the population, but, to date, few clinical trials report including transgender and non-binary individuals.

METHODS

As part of a mixed-method approach, multiple literature searches for articles published from January 2018 to July 2022 and a Patient Advisory Council (a semi-structured patient focus group) meeting were conducted to identify challenges faced by the transgender and non-binary communities when accessing healthcare and participating in clinical research. A set of guidelines to promote inclusivity in clinical research was developed using these findings.

RESULTS

During this time period, only 107 (0.08%) of 141,661 published articles of clinical trials reported participation of transgender or non-binary patients. A targeted search identified only 48 articles reporting specific barriers to inclusion in clinical research, while an expanded search identified 290 articles reporting barriers to healthcare access for transgender and non-binary patients. Several key considerations to promote study inclusivity emerged from the literature searches and Patient Advisory Council: adjust clinical protocols, informed consent documents, and data collection forms to distinguish sex assigned at birth from gender identity; involve members of the transgender and non-binary communities in research whenever possible; provide communication training to personnel involved in clinical research; and maximize accessibility for potential participants.

CONCLUSION

Future research on investigational drug dosing and drug interactions in transgender and non-binary patients, along with regulatory guidance, are recommended to ensure clinical trials' processes, designs, systems, and technologies are transgender and non-binary patient-friendly, inclusive, and welcoming.

Prevalence of 12 Common Health Conditions in Sexual and Gender Minority Participants in the All of Us Research Program

Importance

Limited data describe the health status of sexual or gender minority (SGM) people due to inaccurate and inconsistent ascertainment of gender identity, sex assigned at birth, and sexual orientation.

Objective

To evaluate whether the prevalence of 12 health conditions is higher among SGM adults in the All of Us Research Program data compared with cisgender heterosexual (non-SGM) people.

Design, Setting, and Participants

This cross-sectional study used data from a multidisciplinary research consortium, the All of Us Research Program, that links participant-reported survey information to electronic health records (EHR) and physical measurements. In total, 372 082 US adults recruited and enrolled at an All of Us health care provider organization or by directly visiting the enrollment website from May 31, 2017, to January 1, 2022, and were assessed for study eligibility.

Exposures

Self-identified gender identity and sexual orientation group.

Main Outcomes and Measures

Twelve health conditions were evaluated: 11 using EHR data and 1, body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), using participants' physical measurements. Logistic regression (adjusting for age, income, and employment, enrollment year, and US Census division) was used to obtain adjusted odds ratios (AORs) for the associations between each SGM group and health condition compared with a non-SGM reference group.

Results

The analytic sample included 346 868 participants (median [IQR] age, 55 [39-68] years; 30 763 [8.9%] self-identified as SGM). Among participants with available BMI (80.2%) and EHR data (69.4%), SGM groups had higher odds of anxiety, depression, HIV diagnosis, and tobacco use disorder but lower odds of cardiovascular disease, kidney disease, diabetes, and hypertension. Estimated associations for asthma (AOR, 0.39 [95% CI, 0.24-0.63] for gender diverse people assigned male at birth; AOR, 0.51 [95% CI, 0.38-0.69] for transgender women), a BMI of 25 or higher (AOR, 1.65 [95% CI, 1.38-1.96] for transgender men), cancer (AOR, 1.15 [95% CI, 1.07-1.23] for cisgender sexual minority men; AOR, 0.88 [95% CI, 0.81-0.95] for cisgender sexual minority women), and substance use disorder (AOR, 0.35 [95% CI, 0.24-0.52] for gender diverse people assigned female at birth; AOR, 0.65 [95% CI, 0.49-0.87] for transgender men) varied substantially across SGM groups compared with non-SGM groups.

Conclusions and Relevance

In this cross-sectional analysis of data from the All of Us Research Program, SGM participants experienced health inequities that varied by group and condition. The All of Us Research Program can be a valuable resource for conducting health research focused on SGM people.

A 64-year-Old patient assigned male at birth with COPD and worsening dyspnea while on estrogen and antiandrogen agents

Among patients with COPD, ventilatory inefficiency in response to exercise can be due to respiratory muscle dysfunction or expiratory flow limitation causing air-trapping and dynamic hyperinflation. We discuss a case of severe ventilatory limitation in response to exercise due to reduced respiratory muscle mass in the setting of gender-affirming hormone therapy (GAHT), and how the interpretation of pulmonary function testing (PFT) and respiratory symptoms among transgender and gender diverse (TGD) patients can be influenced by GAHT.

Transgender Adults From Minoritized Ethnoracial Groups in the U.S. Report Greater Subjective Cognitive Decline

OBJECTIVES

Investigate subjective cognitive decline (SCD) among 4 study groups consisting of cisgender and transgender adults who are from minoritized ethnoracial groups (i.e., minoritized ethnoracial transgender, minoritized ethnoracial cisgender) and White cisgender and transgender adults aged 45+ (i.e., White transgender, White cisgender) to determine the odds of SCD by group and to test for group differences.

METHODS

Data from the 2015-2020 Behavioral Risk Factor Surveillance System were used in a modified case-control approach to perform an intercategorical intersectional study. Each transgender participant was matched to 2 cisgender men and 2 cisgender women, on state, ethnoracial identity, and age. Multivariable logistic regressions modeled SCD odds by group and post hoc contrasts estimated pairwise odds ratios comparing the SCD odds for each combination of groups.

RESULTS

SCD prevalence was highest among minoritized ethnoracial transgender (21.6%), followed by White transgender (15.0%), minoritized ethnoracial cisgender (12.0%), and White cisgender (9.0%). After accounting for age, education, and survey year, the odds of SCD were higher in minoritized ethnoracial transgender when compared to White cisgender (adjusted odds ratio [aOR] = 2.51, 95% confidence interval [CI]: 1.59-3.96) and minoritized ethnoracial cisgender (aOR = 1.89, 95% CI: 1.16-3.09). The odds of SCD were higher in White transgender compared to White cisgender (aOR = 1.66, 95% CI: 1.20-2.30).

DISCUSSION

When considering the intersection of transgender and ethnoracial identities, we found that transgender adults from minoritized ethnoracial groups reported higher odds of SCD when compared to cisgender adults from minoritized ethnoracial groups. Additional studies are needed to understand the relationship between racialized and gendered inequities in cognitive impairment and how specific mechanisms of systemic transphobia and racism may contribute to this inequity.

Sleep disturbance and suicide risk among sexual and gender minority people

Sleep disturbance has emerged as an independent, mechanistic, and modifiable risk factor for suicide. Sexual and gender minority (SGM) people disproportionately experience sleep disturbance and are at higher risk of death by suicide relative to cisgender and/or heterosexual individuals. The present narrative review evaluates nascent research related to sleep disturbance and suicide-related thoughts and behaviors (STBs) among SGM populations, and discusses how experiences of minority stress may explain heightened risk among SGM people. Although there is a growing understanding of the link between sleep disturbance and STBs, most research has not been conducted in SGM populations or has not examined suicide as an outcome. Research is needed to examine whether and how aspects of sleep disturbances relate to STBs among SGM people in order to better tailor sleep treatments for SGM populations.

Syndemic relationship of depressive symptoms, substance use, and suicidality in transgender youth: a cross-sectional study using the U.S. youth risk behavior surveillance system

PURPOSE

Syndemics are co-occurring epidemics that cluster within populations due to shared socio-structural factors and are often in populations with intersecting forms of vulnerability. Suicide, depression, and substance use all disproportionately affect transgender and gender diverse (TGD) youth. In this study, we test a syndemic model of the relationship between these three mental health conditions in the context of economic deprivation and interpersonal discrimination.

METHODS

We used data on substance use, depressive symptoms, suicidality, and social-structural factors from 2680 TGD youth captured in the 2017 and 2019 survey waves of the Youth Risk Behavior Surveillance System. We used a latent class analysis (LCA) to identify groups with distinct patterns of self-reported substance use and depressive symptoms, and regression models to characterize the relationship between substance-use, depressive symptoms, class membership, social-structural factors, and suicidality.

RESULTS

A three-class LCA solution identified a subset of student respondents in a "high use" latent class characterized by high self-reported substance use frequency and depressive symptoms compared with other classes. Online bullying (aOR: 1.58; 95% CI: 1.28-1.95) and housing insecurity (aOR: 8.78; 95% CI: 4.35-17.71) were associated with increased odds of "high use" class membership relative to the "no use" class membership. "High use" class membership was associated with increased odds of suicidal ideation (aOR: 2.26; 95% CI: 1.75-2.94), plans (aOR: 2.59; 95% CI: 2.01-3.36), and attempts (aOR: 6.85; 95% CI: 3.17-15.68).

CONCLUSION

The co-occurrence of substance use and depressive symptoms is associated with socio-structural factors and may drive risk for suicidality among TGD youth. Meaningful suicide prevention efforts that address disproportionate risk in this population must be attentive to and mitigate the shared determinants of mood symptoms and substance use behavior.

State Policies and Health Disparities between Transgender and Cisgender Adults: Considerations and Challenges Using Population-Based Survey Data

CONTEXT

The authors examined the association between state-level policy protections and self-rated health disparities between transgender and cisgender adults.

METHODS

They used data on transgender (n = 4,982) and cisgender (n = 1,168,859) adults from the 2014-2019 Behavioral Risk Factor Surveillance System. The authors estimated state-specific health disparities between transgender and cisgender adults, and they used multivariable logistic regression models to compare adjusted odds ratios between transgender and cisgender adults by state-level policy environments.

FINDINGS

Transgender adults were significantly more likely to report poor/fair health, frequent mental distress, and frequent poor physical health days compared to cisgender adults. Disparities between transgender and cisgender adults were found in states with strengthened protections and in states with limited protections. Compared to transgender adults in states with limited protections, transgender adults in states with strengthened protections were marginally less likely to report frequent mental distress.

CONCLUSIONS

Transgender adults in most states reported worse self-rated health than their cisgender peers. Much more research and robust data collection on gender identity are needed to study the associations between state policies and transgender health and to identify best practices for achieving health equity for transgender Americans.

State-level heterogeneity in associations between structural stigma and individual healthcare access: A multilevel analysis of transgender adults in the United States

OBJECTIVE

State-level variation in how restrictive policies affect health care access for transgender populations has not been widely studied. Therefore, we assessed the association between structural stigma and four measures of individual health care access among transgender people in the United States, and the extent to which structural stigma explains state-level variability.

METHODS

Data were drawn from the 2015-2019 Behavioral Risk Factor Surveillance System and the Human Rights Campaign's State Equality Index. We calculated weighted proportions and conducted multilevel logistic regression of individual heterogeneity and discriminatory accuracy.

RESULTS

An increase in the structural stigma score by one standard deviation was associated with lower odds of health care coverage (OR = 0.80; 95% CI: 0.66, 0.96) after adjusting for individual-level confounders. Approximately 11% of the total variance for insurance coverage was attributable to the state level; however, only 18% of state-level variability was explained by structural stigma. Adding Medicaid expansion attenuated the structural stigma-insurance association and explained 22% of state-level variation in health insurance. For the remaining outcomes (usual source of care, routine medical check-up, and cost-related barriers), we found neither meaningful associations nor considerable between-state variability.

CONCLUSIONS

Our findings support the importance of Medicaid expansion and transgender-inclusive antidiscrimination protections to enhance health care insurance coverage. From a measurement perspective, however, additional research is needed to develop and validate measures of transgender-specific structural stigma to guide future policy interventions.

Sexual Orientation and Gender Identity Data Reporting Among U.S. Health Centers

INTRODUCTION

Sexual orientation and gender identity data collection is necessary to address health inequities. This study examines sexual orientation and gender identity data reporting among community health centers.

METHODS

Using the 2016-2019 Uniform Data System for 1,381 community health centers, trends in reporting of sexual orientation and gender identity data were examined. Multivariable logistic regression was used to assess associations between community health center characteristics and whether sexual orientation and gender identity data were available for ≥75% of a community health center's patients in 2019. Data were analyzed in 2021.

RESULTS

In 2016-2019, the percentage of community health centers with sexual orientation and gender identity data for ≥75% of patients increased from 14.9% to 53.0%. In 2019, community health centers were more likely to have this data for ≥75% of patients if they were in nonmetro counties (OR=1.48, 95% CI=1.04, 2.10 versus metro), were in the South (OR=2.27, 95% CI=1.57, 3.31) or West (OR=1.91, 95% CI=1.27, 2.88 versus the Northeast), and had more patients aged between 18 and 39 years (OR=1.04, 95% CI=1.02, 1.07), between 40 and 64 years (OR=1.04, 95% CI=1.02, 1.06 vs <18 years), or veterans (OR=1.10, 95% CI=1.01, 1.20). This was less likely among community health centers serving 10,000-20,000 patients (OR=0.70, 95% CI=0.52, 0.95) and >20,000 patients (OR=0.44, 95% CI=0.32, 0.61 vs <10,000) and community health centers with more patients of American Indian/Alaskan Native (OR=0.98, 95% CI=0.97, 0.99) or unknown race (OR=0.92, 95% CI=0.86, 0.97 versus White).

CONCLUSIONS

Collection of sexual orientation and gender identity data by community health centers has increased substantially since 2016, although gaps remain.

Cumulative exposure to state-level structural sexism and risk of disordered eating: Results from a 20-year prospective cohort study

BACKGROUND

Gendered inequities in disordered eating are well-documented, yet few studies have examined their structural drivers. To help fill this gap, we investigated whether cumulative exposure to state-level structural sexism from childhood through young adulthood potentiates differences in disordered eating risk between cisgender girls/women and boys/men.

METHODS

Participants came from the Growing Up Today Study (N = 16,875), a cohort of children aged 9-14 years in 1996 who we followed through 2016. Using a composite index of relevant state policies and social inequalities from the Institute for Women's Policy Research, we categorized states as having high or low levels of structural sexism and summed the number of years participants had lived in a high structural sexism state during the study period to quantify their cumulative exposure. We fit sequential conditional mean models to estimate the effect of cumulative exposure on risk of four outcomes (chronic dieting, purging, binge eating, and overeating), controlling for individual- and state-level confounders via propensity scores. We then tested whether effects differed between girls/women and boys/men by including cumulative-exposure-by-gender-identity interaction terms and calculating the relative excess risk due to interaction (RERI).

RESULTS

In the full sample, each additional year of living in a high structural sexism state was associated with a 5% increased risk of purging (95% confidence interval (CI): 3%, 7%), an 8% increased risk of binge eating (95% CI: 6%, 10%), and a 9% increased risk of overeating (95% CI: 8%, 11%). Risk increases were larger on average for girls/women than for boys/men, and girls/women who had lived in a high structural sexism state for four or more years had excess risk of chronic dieting (RERI: 0.64, 95% CI: 0.18, 1.10), purging (RERI: 2.64, 95% CI: 1.24, 4.30), and binge eating (RERI: 2.21, 95% CI: 0.93, 3.50).

CONCLUSIONS

Structural sexism may contribute to inequities in disordered eating between cisgender girls/women and boys/men. Future research should include transgender and gender diverse participants, explore intersectional effects, and identify underlying mechanisms to inform policy-oriented interventions.

Ethnoracial inequities in access to gender-affirming mental health care and psychological distress among transgender adults

PURPOSE

Transgender people face known barriers to accessing mental health care generally, and gender-affirming care in particular. However, little research has been done to evaluate the impact of systemic racism on access to gender-affirming mental health care (GAMHC) among transgender people of color (TPOC).

METHODS

We conducted a cross-sectional, secondary analysis of data on 20,967 respondents to the 2015 United States Transgender Survey who reported a desire for GAMHC services related to their gender transition. We estimated inequities across ethnoracial groups in access to GAMHC, and measured the association between severe psychological distress and access to GAMHC among TPOC.

RESULTS

We found decreased access to GAMHC across all TPOC groups. Inequities in access to GAMHC were most severe among assigned male at birth respondents in the Black/African-American group (aOR 0.51, 95% CI 0.37-0.71), Latino/a/e/Hispanic group (aOR 0.52, 95% CI 0.42-0.65), and Native American group (aOR 0.59, 95% CI 0.38-0.94). Among all respondents, severe psychological distress was highest among Native American respondents (47.4%), Latino/a/e/Hispanic (47.1%) respondents, and other/multiracial respondents (46.7%) and lowest among whites (39.9%). Further, among all TPOC, access to GAMHC was associated with decreased odds of severe psychological distress (aOR 0.74, 95% CI 0.62-0.87).

CONCLUSION

These results illustrate the need for research that explicitly addresses the intersectional experiences of transgender communities, and the structural drivers of inequities in access to gender-affirming care.

Prevalence of Private and Public Health Insurance Among Transgender and Gender Diverse Adults

BACKGROUND

Little is known about how health insurance payer types differ between transgender and gender diverse (TGD) people and cisgender people. Much of what is known about insurance coverage among TGD adults has been based on research from claims and electronic health record data, which excludes individuals who have not accessed gender-affirming care. Research designed to understand how TGD populations pay for health care to best inform care interventions and public insurance policies is lacking.

OBJECTIVE

The objective of this study was to examine differences in the prevalence of public and private health insurance between transgender and cisgender adults.

METHODS

Using data from the Behavioral Risk Factor Surveillance System, this study estimated prevalence of health insurance coverage among TGD and cisgender adults residing in 22 states that administered the Sexual Orientation and Gender Identity module and the Healthcare Access module from 2014 to 2019. This study estimated the odds of health insurance coverage (no insurance, private insurance, public insurance) among cisgender adults compared with TGD adults.

RESULTS

TGD people had greater odds of being uninsured compared with cisgender women. Among nondisabled, nonelderly respondents, TGD adults had lower odds of having private insurance and higher odds of public insurance compared with cisgender men. Among respondents who were likely Medicaid-eligible, TGD respondents had lower odds of having public insurance and higher odds of being uninsured compared with cisgender women.

CONCLUSION

These findings provide foundational information about the payer mix among TGD people and provide insight into barriers to health insurance that TGD adults may face.

Cancer Risk Behaviors, Cancer Beliefs, and Health Information Seeking Among Under-Represented Populations in San Francisco: Differences by Sexual Orientation and Gender Identity

Purpose

Sexual and gender minority (SGM) individuals in the United States are at increased risk of cancer compared to the non-SGM population. Understanding how SGM persons perceive cancer risk and their practices and preferences for accessing health information is key for improving the preventive and health care services they receive.

Methods

In this cross-sectional study, we analyzed data from the San Francisco Health Information National Trends Survey. SGM individuals were identified by self-report. Differences in cancer risk factors, cancer beliefs, and health information seeking were evaluated by SGM status using multivariable logistic regression models.

Results

Out of 1027 participants, 130 (13%) reported being SGM individuals. Current smoking (odds ratio [OR]=1.93, 95% confidence interval [CI]=1.24-3.01) and alcohol use (OR=1.69, 95% CI=1.10-2.59) were more common among SGM persons than among non-SGM persons. No differences by SGM status were observed in health information seeking behaviors, preferences, and cancer beliefs, but SGM participants reported significantly higher odds of feeling frustrated (OR=1.78, 95% CI=1.20-2.64) and having concerns about the quality of the information (OR=1.54, 95% CI=1.03-2.31) during their most recent health information search.

Conclusions

Intervention efforts aimed at SGM individuals with current use of tobacco and/or alcohol should be expanded. SGM communities also need improved access to consistent, reliable, and accurate sources of health information. Their increased frustration when seeking health information and concerns about the quality of the information they find have important implications for SGM health and care, and the drivers of these differences merit further evaluation.