Correlations between healthcare provider interactions and mental health among transgender and nonbinary adults

Abstract

Highlights

Introduction

Transgender and nonbinary (TNB) individuals are those whose gender identity does not align with the social expectations associated with their sex assigned at birth (Devor & Thomas, 2019). This can include trans women, trans men, nonbinary people, a gender individuals, genderfluid or genderqueer people, two-spirit members of indigenous communities, and other evolving identities. The United States Census and more representative government surveillance systems do not reliably collect data on gender identity. However, surveys have suggested that this population makes up 0.4% of the general adult population (Meerwijk & Sevelius, 2017), and 0.7%–3.2% of young adults age 24 years or younger (Eisenberg et al., 2017; Herman, Flores, Brown, Wilson, & Conron, 2017; Wilson, Choi, Herman, Becker, & Conron, 2017), with more young people identifying as a gender other than cisgender (non-transgender) men and women. It should be noted that trans and nonbinary themselves are fluid categories; some trans people identify as nonbinary (including, for example, as a nonbinary trans woman), and some nonbinary people identify as trans. However, not all nonbinary people are trans. These categories are neither completely overlapping nor completely separate, as may be common with identity based labels.

The TNB population has high rates of mental health concerns, especially depression, anxiety, and suicidal thoughts (James et al., 2016). Much of the literature documents the alarming rates of health disparities and discrimination faced by this population (Cruz, 2014; Kcomt, 2019; Reisner, White, Bradford, & Mimiaga, 2014). Yet little is known about how mental health is related to interactions with healthcare providers, including experiences of being treated with respect by a provider, or having to educate a provider about one's own identity group.

Methods

Results

Descriptive results (Table 1) of the analytical sample are presented for both the unweighted and weighted samples, but all analyses were conducted using the latter. Approximately two-thirds of the weighted sample identified as transgender, 31.56% being trans men and 35.19% being trans women. While 63.44% of the weighted sample identified as White, 16.40% identified as Latino/a/Hispanic and 12.64% identified as Black. The vast majority of weighted sample respondents had at least some college education (88.41%); however, 36.83% earned an income of $25,000 or less. The mean age was 31.24 years old and 28.48% of the respondents were disabled. Nearly half of all respondents in the weighted sample (48.36%) had suicidal thoughts and 37.68% scored 13 or higher on the K6 scale, indicating serious psychological distress.

Bivariate results (Table 2) demonstrated a significant relationship between gender identity and both being treated with respect (F = 812.81, p < 0.001) and teaching about trans people (F = 57.79, p < 0.001). While the overall majority of respondents were treated with respect (62.99%), the majority of AFAB genderqueer/nonbinary individuals (72.55%) and AMAB genderqueer/nonbinary individuals (65.58%) did not have a doctor that knew they were trans and treated them with respect. Conversely, a greater proportion of transgender respondents than genderqueer/nonbinary respondents had to teach a doctor or healthcare professional about trans people, including 25.69% of trans women and 31.20% of trans men. In total, 24.31% (n = 4891) of the weighted sample had to teach their healthcare providers about trans people .

Overall, both multivariate logistic regression models were statistically significant (p < 0.001), see Table 3. All results assume we were controlling for other variables in the model. Those individuals assessed as having serious psychological distress on the K6 scale had lower odds (OR: 0.67; p < 0.001) of being treated with respect, and greater odds (OR: 1.17; p < 0.01) of needing to teach about trans people, in comparison with those without serious psychological distress. Similarly, those individuals with suicidal thoughts had lower odds (OR: 0.88; p < 0.05) of being treated with respect and greater odds (OR: 1.33; p < 0.001) of needing to teach about trans people, in comparison with those who did not have suicidal thoughts.

In comparison with transgender respondents, those who were genderqueer or nonbinary had lower odds (OR: 0.11; p < 0.001) of having a doctor who knew they were trans and being treated with respect. However, this group also had lower odds (OR: 0.46; p < 0.001) of having to teach their providers about trans people in comparison with those who identified as transgender. In terms of income, those who were low income (OR = 1.47, p < 0.001), low-mid income (OR = 1.16, p < 0.05), and mid-income (OR = 1.26, p < 0.01) had greater odds of needing to teach doctors and other healthcare professionals about trans people in comparison with those who were high income. However, no income categories were significantly associated with being treated with respect. Similarly, no racial categories were associated with either dependent variable. Those whose highest level of educational attainment was an associate's degree or lower had decreased odds of being treated with respect in comparison with those with a bachelor's degree as their highest level of attainment. However, those with a graduate or professional degree were more likely to have to teach providers about trans people (OR = 1.18, p < 0.05). Additionally, those who were disabled had 1.55 greater odds of needing to teach about trans people (p < 0.001) but also 1.19 greater odds (p < 0.01) of being treated with respect. Increased age was associated with greater odds of both being treated with respect (OR = 1.15, p < 0.001) and needing to teach providers about trans people (OR = 1.08, p < 0.001).

Discussion

Our results clearly indicate that there are major differences in who is able to access respectful healthcare providers. Over one-third of the total sample (37.01%) had experienced a provider not treating them respectfully when knowing about their TNB identity. Those experiencing depression and suicidal thoughts were significantly less likely to have had a provider treat them with respect. This finding leads to the question of whether mental health status impacts TNB people's access to affirming providers or if having a disrespectful provider increases depression and suicidal thoughts in this population.

Minority Stress Theory posits that people who experience high levels of stigma around their marginalized identity (ies) are more likely to have elevated levels of depression, anxiety, substance use, and other mental health concerns (Meyer, 1995). While Meyer's model of minority stress focuses on the experience of lesbian, gay, and bisexual individuals, many researchers have used this model to explain some of the high rates of mental health concerns among the TNB population (Rood et al., 2016; Scandurra, Amodeo, Valerio, Bochicchio, & Frost, 2017; Seelman, Colón-Diaz, LeCroix, Xavier-Brier, & Kattari, 2017) and other researchers have found that many of these assumptions and domains can be similarly applied to this population (Testa, Habarth, Peta, Balsam, & Bockting, 2015). Therefore, it is likely that some of the negative mental health outcomes are due to experiencing providers who are disrespectful when knowing of one's TNB identity, or the process of having to educate one's provider. However, it is also possible that those TNB individuals experiencing high rates of depression or anxiety may be less likely to access a respectful provider due to the elevated stress that mental health concerns can place on an individual. This additional stress may further reduce an individual's capacity to search for and/or access a more respectful provider. More research is needed to understand the directionality of this association.

Similarly, those experiencing depression and suicidal thoughts were significantly more likely to have had to educate their providers about trans people than their counterparts without these mental health experiences. As with the findings regarding disrespectful providers, it is possible they were less likely to have the capacity to seek out providers who had more experience with TNB care. However, in line with minority stress theory, is likely that the process of having to their educate providers increased their experiences of depression and/or anxiety. It is important for longitudinal research to explore this relationship more deeply.

Regarding the control variables, nonbinary individuals (including both AMAB and AFAB) were significantly less likely to have had a provider who knew they were trans and treated them with respect than either trans men or trans women, which is interesting, given that a recent study found that nonbinary individuals were less likely to delay care due to fear of discrimination than their transfeminine counterparts (Kattari, Atteberry-Ash, Kinney, Walls, & Kattari, 2019). Nonbinary individuals were less likely to have had to educate providers; it is possible that they were also less likely to share (i.e., to be out about) their gender identity with their providers.

Those with lower levels of education were less likely to have a respectful provider than those with a bachelor's degree, though there was no significant difference for those with graduate degrees. Lower education attainment has been associated with lower rates of access to transgender-affirming care (White Hughto, Rose, Pachankis, & Reisner, 2017). Those with a high school diploma or some college were less likely to have had to educate a provider than those with a bachelor's degree. Income was not significant regarding respectful provider interactions, indicating that fiscal access may not be directly related to having a respectful provider, although those with low to mid-levels of income were significantly more likely to have had to educate providers about TNB people than those with higher income, which may indicate that those with a higher income were able to select providers they already knew to be knowledgeable about the trans population. Increase in age and disability status also increased the likelihood of having a provider who treated them with respect when knowing their TNB status, as well as the likelihood of having to educate a provider about trans people.

Conclusion

TNB patients have a wide array of experiences with providers when attempting to access healthcare. Findings from the study indicate that patients have a variety of experiences with providers, both positive, in being respected by their providers, and challenging, in having to educate their providers. These experiences are associated with mental health factors. Providers need ongoing training and education to improve their care of TNB patients, specifically in acknowledging the multiple backgrounds and experiences of such patients including gender, race, age, class, educational level, and disability. Incorporating proactive approaches to the inclusive treatment and care of TNB patients will ensure these patients are treated not just with respect but also that they do not have to take on the role of educator for their provider.

Ethics

This study was found to be exempt from full review by the University of Michigan Institutional Review Board in 2018.

Author statement

Shanna K. Kattari – Conceptualization, methodology, writing (original draft), writing (review and editing), supervision.

Matthew Bakko - Conceptualization, methodology, formal analysis, writing (original draft), writing (review and editing).

Hillary K. Hecht – Writing (original draft), writing (review and editing).

Leonardo Kattari - Writing (original draft), writing (review and editing).

Acknowledgements

References