Mai-Han Trinh

Background: Transgender and gender diverse (TGD) populations have high mental and behavioral health morbidity, yet few studies have explored inequities in TGD people at the intersection of multiple identities. Purpose: This study sought to describe inequities in severe psychological distress and substance use by gender/sex, race, and socioeconomic status (SES) in TGD adults. Methods: We conducted an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) with 25 443 TGD people in the 2015 US Transgender Survey, nested within 48 intersectional social strata defined by gender/sex, race/ethnicity, and SES. For each outcome, a multilevel intersectional logistic model was fit with the additive effects of gender/sex, race/ethnicity, and SES and adjusting for age, gender expression, and US region. Results: Mean age was 31 years (SD = 13); 35% were transgender women, 30% transgender men, 7% nonbinary assigned-male-at-birth, 29% nonbinary assigned-female-at-birth; 18% BIPOC; and 34% SES below poverty. Stratum-specific predicted outcome probabilities ranged from: 26%-64% severe psychological distress, 21%-36% binge drinking, 19%-37% cannabis use, 7%-12% illicit drug use, and 16%-34% cigarette smoking. Highest probabilities of cannabis and illicit drug use were among transgender women below the poverty line identifying as Biracial/Multiracial (37% and 12%) and Black/African American (34% and 12%), respectively. Conclusion: Findings highlight the nuance of privilege and oppression, heterogeneity in groups that may share one identity, and need for public health and equity efforts.

Purpose: Transgender and gender diverse (TGD) patients experience challenges in health care settings, including stigma, lack of culturally competent providers, and suboptimal gender-affirming care. However, differences in patient satisfaction between TGD patients compared with cisgender patients have been inadequately studied. This study aimed to assess such differences in patient satisfaction with care received in a large academic medical care system in Boston, Massachusetts. Methods: Routine patient satisfaction surveys were fielded from January to December 2021 and were summarized. Logistic regression models compared low net promoter scores (NPS; ≤6) between gender identity groups (cisgender women, transmasculine and nonbinary/genderqueer people assigned female at birth [AFAB], transfeminine and nonbinary/genderqueer people assigned male at birth) relative to cisgender men, adjusting for age, race, ethnicity, education, inpatient/outpatient service delivery, and distance from medical center. Results: Of 94,810 patients, 246 (0.3%) were TGD and 94,549 (99.7%) were cisgender. The mean age was 58.3 years (standard deviation = 16.6). Of the total sample, 17.0% of patients were people of color, 6.6% were Hispanic/Latinx, 48.6% were college graduates, and 2.6% had received inpatient care. In general, patient satisfaction with health care received was lower for TGD patients than for cisgender patients (7.3% vs. 4.5% reporting low NPS; adjusted odds ratio [aOR] = 1.14; 95% confidence interval [CI] = 0.70–1.85). Transmasculine and nonbinary/genderqueer patients AFAB had elevated odds of low NPS compared with cisgender men (8.8% vs. 3.6%; aOR = 1.71; 95% CI = 1.02–2.89). Conclusion: Future research is warranted to better understand factors driving lower ratings among TGD patients. Health care quality improvement efforts are needed to address gender identity inequities in care.

Background: Few population-based studies have compared the mental health of gender minority and cisgender adolescents. Aims: To compare reports of psychological distress, behavioural and emotional difficulties, self-harm and suicide attempts between gender minority and cisgender adolescents. Method: Data came from the Millennium Cohort Study (n = 10 247), a large nationally representative birth cohort in the UK. At a 17-year follow-up, we assessed gender identity, psychological distress (Kessler K6 scale), behavioural and emotional difficulties (parent and child reports on the Strengths and Difficulties Questionnaire), self-harm in the previous year, suicide attempts, substance use, and victimisation including harassment and physical and sexual assaults. Multivariable modified Poisson and linear regression models were used. Attenuation after the inclusion of victimisation and substance use was used to explore mediation. Results: Of the 10 247 participants, 113 (1.1%) reported that they were a gender minority. Gender minority participants reported more psychological distress (coefficient 5.81, 95% CI 4.87–6.74), behavioural and emotional difficulties (child report: coefficient 5.60; 95% CI 4.54–6.67; parent/carer report: coefficient 2.60; 95% CI 1.47–3.73), self-harm including cutting or stabbing (relative risk (RR) 4.38; 95% CI 3.55–5.40), burning (RR 3.81; 95% CI 2.49–5.82), taking an overdose (RR 5.25; 95% CI 3.35–8.23) and suicide attempts (RR 3.42; 95% CI 2.45–4.78) than cisgender youth. These associations were partially explained by differences in exposure to victimisation. Conclusions: Gender minority adolescents experience a disproportionate burden of mental health problems. Policies are needed to reduce victimisation and services should be adapted to better support the mental health of gender minority adolescents.

Purpose Victimization contributes to mental and behavioral health inequities among transgender and gender diverse (TGD) people, but few studies have simultaneously examined health-promoting resiliencies. We sought to identify classes of risk and resilience among TGD adults, assess characteristics associated with these classes, and examine their relationship with mental health and substance use outcomes. Methods Cross-sectional data were from the 2015 US Transgender Survey, a non-probability study including 26,957 TGD adults. Using latent class analysis, we classified patterns of vulnerability and resilience based on risk (past-year denial of equal treatment, verbal harassment, physical attack, bathroom-related discrimination; lifetime sexual assault, intimate partner violence) and protective (activism; family, work, classmate support) factors. Regression models were fit to (1) determine the association between sociodemographic and gender affirmation characteristics and latent classes; (2) model associations between latent classes and mental health (current serious psychological distress, past-year and lifetime suicidal thoughts and attempts, and lifetime gender identity/transition-related counseling) and substance use (current binge alcohol use, smoking, illicit drug use; past-year drug/alcohol treatment) outcomes. Results Three latent classes were identified: high risks, with activism involvement (“risk-activism,” 35%); low risks, with not being out about one’s TGD identity (“not-out,” 25%); and low risks, with high family support (“family-support,” 40%). Gender affirmation and sociodemographic characteristics, such as race/ethnicity and sexual orientation, were associated with latent classes. Risk-activism class membership was associated with higher odds of negative mental health and substance use outcomes, while the family-support class had lower odds of these outcomes. Conclusions Interventions leveraging family support, and policy protections from discrimination and victimization, may promote TGD mental and behavioral health.