Predictors of Mental Health Service Utilization Among Transgender and Gender Nonconforming Adults

Abstract

Purpose:

The purposes of this study were to determine which transgender and gender nonconforming (TGNC) adults used mental health services in the past 12 months, to compare TGNC who did and did not access mental health care, to query reasons for not accessing mental health services, and to determine what indicators influenced mental health service utilization.

Methods:

The research team gathered data from 274 TGNC adults from September to November 2019 via an electronic survey. This exploratory study assessed mixed methods data on mental health services utilization. The convergent, parallel mixed methods design was used to compare and interpret the quantitative and qualitative data for convergence or divergence.

Results:

Approximately 24% of TGNC adults did not use mental health services, with 44% of that group indicating it was because they did not need them, which means that 56% needed services but did not use them. The top reasons for not accessing needed mental health services included: inability to pay, not believing that care would be effective, not expecting to find providers who understood specific TGNC experiences or needs, and not trusting mental health professionals. Income, location, and mental health status were significant indicators.

Conclusion:

This study provides evidence that some TGNC adults who do not utilize mental health services still need them while outlining the specific barriers that inhibit TGNC adults from accessing needed mental health care. Comparing TGNC adults who did and did not access mental health services reveals that mental health status, location, and income are predictive of mental health service utilization. Recommendations are discussed.

Introduction

Access to mental health services can be evaluated using Andersen's behavioral model of health services use, which identifies three categories of factors associated with health care utilization: predisposing factors, enabling factors, and need.¹ The predisposing and enabling factors provide the means for use or potential to access health care services. Realized access occurs when an individual needs health care services and can navigate predisposing and enabling factors to utilize health care services. However, it is important to note that realized access does not mean equitable access. Inequitable access can occur based on demographic and predisposing disparities (i.e., race, gender, sexual orientation, gender identity), health and cultural beliefs, and other enabling resources (i.e., insurance, income, transportation).¹

Barriers in both categories are prevalent across gender minority and majority populations, but these barriers tend to be more overwhelmingly present and compound and interact in ways that result in long-lasting health repercussions among vulnerable marginalized populations, such as transgender and gender nonconforming (TGNC) adults.² All patients seeking mental health care must first overcome a constellation of predisposing and enabling inhibitors from a variety of sources, such as stigma, insurance, cost, transportation, provider shortages, and cultural competency and training of providers.

Stigma illustrates how these barriers can interact and compound differently for gender minority groups, who are subjected to the generalized stigma associated with mental illness, as well as limited knowledge about how to access mental health services, such as knowing when and how to seek help.³ However, this stigma is heightened among minority populations⁴ who must also contend with the stigma associated with their gender identities⁵ and the fear that seeking specialized appropriate care providers will “out” them to their communities. These compounding stigmas act as increased barriers to needed mental health services.⁶

If these layers of stigma are overcome, TGNC patients are still faced with significant predisposing and enabling access to care barriers, which are often limiting across patient populations. These include financial and insurance-based issues,⁷ educational attainment,⁸ transportation,⁹ health literacy, distrust of providers,¹⁰ lack of knowledge of and ignorance about how to access mental health illnesses and treatment options, and prejudice and discrimination against adults diagnosed with mental health illnesses.¹¹ Systemic barriers to needed mental health care services and inhibitors of future service utilization indicated as problematic by both sexual and gender minorities include: lack of specifically trained providers, lack of trust in mental health provision systems, encounters with gatekeeping, discrimination, and intolerance in care settings, and a general inability to navigate complicated bureaucratic provision systems.²

Finally, assuming that the patient has the capacity to overcome multiple forms of stigma, systemic barriers to access mental health services, the general limited availability of providers may restrict their ability to use those services. According to Kaiser Family Foundation,¹² the United States has almost 6000 Mental Health Professional Shortage Areas (MHPSAs) and only 28.1% of the country's mental health needs are met. In addition, 20% of rural communities lack mental health services altogether.¹³

These shortages are exponentially amplified if a member of a gender minority group is seeking a mental health care provider who is trained and qualified to meet their specific needs,^2,14 which research has shown is imperative for effective service provision.¹⁵ Qualified and queer-affirming providers are in short supply,^16,17 with shortages being especially pronounced in rural areas,^18,19 or for gender minority populations who do not speak English as their first language.²⁰

In addition, the stakes are relatively high for care providers to offer a high-quality encounter to TGNC clients since a bad prior experience with mental health services decreases the likelihood of seeking current or future care that is needed.²¹ As Romanelli and Hudson⁵ pointed out, “care-seekers who value identity affirmation, but with past experiences of receiving stigmatizing or pathologizing care, might delay or forgo services” (p. 719). Thus, the general shortage of trained and culturally competent mental health providers is much more of a barrier for TGNC adults than it is for majority populations.

Unfortunately, amplified and compounded barriers to mental health services are an inappropriate response to gender minorities' increased need for them. Because of societal discrimination and minority stress,^22,23 TGNC adults report higher mental health needs than majority populations,²⁴ especially among unaffirmed gender identities. TGNC adults who have access to gender-affirming care report mental health status similar to the cisgender population.¹⁶ Similarly, one study found that mood and anxiety disorder, use of antidepressant and anxiolytic prescriptions, and hospitalizations after suicide attempt decreased significantly as length of time after gender-affirming surgery increased.²⁵ These results showcase the importance of access to gender-affirming care.

This baseline mental health need is compounded by the fact that insurance providers require TGNC patients to document extended experiences of gender dysphoria before seeking gender-confirming care such as hormone treatment therapy or top or bottom surgery. The capacity to access a mental health provider who has the qualifications and willingness to act in this capacity thus can have a strong impact on holistic health, including both overall mental wellness and accessing potentially lifesaving physical treatments.^21,26 Unfortunately, this has complicated the relationship between TGNC clients and their mental health providers who can be perceived as gatekeepers to services that aid in transitioning, with some clients reporting feeling exploited by the power differentials in these relationships.²

Insufficient or inequitable access to mental health services impacts mental health status and can lead to greater unmet health needs, especially among TGNC. For example, transgender adults are 2.4 times more likely than cisgender adults to report unmet mental health needs with untreated depression being significantly more likely among transgender adults.²⁷ Among adults who identify as transgender, 23% delayed seeking care due to fear of discrimination.²⁸ This prevailing strain can cause long-term physical and mental health problems, including an increased risk of suicide.²⁹ Higher rates of suicidal ideation have been found among adults who have faced discrimination based on their race/ethnicity, gender identity, and sexual orientation.³⁰

Purpose

The purposes of this study were to determine which TGNC adults used mental health services in the past 12 months, to compare TGNC individuals who did and did not access mental health care, to query reasons for not accessing mental health services, and to determine what demographic indictors influenced mental health service utilization. This study fills a gap in the current knowledge by providing mixed methods results of and valuable insights into the predisposing, enabling, and need-based barriers and the resulting health system utilization associated with disparities in access to mental health services despite mental health status among gender minority adults.

Methods

Design

A 39-question mixed methods survey used a convergent parallel design where quantitative and qualitative data were gathered at the same time, using multiple choice, Likert scale, and open-ended style questions. The Survey on Disparities in Quality of Health Care: Spring 2001 by Princeton Survey Research Associates for the Commonwealth Fund was used as a guide in developing an access to care mental health survey.³¹ The publicly available survey questions were modified in scope of services from primary care to mental health, behavioral health, or substance misuse services. The dependent variable was use of mental health services over the past 12 months, measured using the following question:

In the last 12 months, have you used health care services for mental health, behavioral health and/or substance misuse concerns? For example, have you spoken to a counselor or therapist, asked a doctor about depression or anxiety, asked a pastor for counseling, or been involved in any addiction recovery groups?

The predisposing independent variables included demographic variables: age (18–24, 25–34, 35–44, 45–64, 65+ years), marital status (married or domestic partnership, never married, divorced, living as married), and participant location (urban, suburban, rural). Enabling factors include health insurance (employer-based, parent's coverage, Medicare, Medicaid, uninsured, other), education (no high school, high school graduate, some college, technical or vocational school, college graduate, postgraduate degree), income (measured in increments of $25,000), and employment status (full-time, part-time, student, not employed for pay, disabled, other or retired). Other independent variables pertained to the need for care, including usual source of care (yes/no), primary care doctors visit in the past 12 months (yes/no), physical health status (poor, fair, good, very good, excellent), mental health status (poor, fair, good, very good, excellent), and confidence in ability to receive future mental health care (strongly disagree, disagree, neutral, agree, strongly agree).

It is important to note that throughout the article “mental health providers” was used to reference mental health, behavioral health, and/or substance misuse care providers.

Data collection

Inclusionary criteria included identification as lesbian, gay, bisexual, transgender, and queer (LGBTQ) and at least 18 years of age. Adults were recruited via social media outlets (i.e., Facebook), LGBT-friendly blogs, and word of mouth from September to November 2019. As an incentive for participating in the study, adults could enter a drawing to win a $25 gift card. To ensure anonymity of responses, participants were directed to a separate survey to enter their contact information for the incentive drawing. To ensure quality and integrity of the data collected, the research team used several strategies, including exclusion of incomplete records, assessment of the thoroughness of open-ended qualitative responses, and uniqueness of responses to eliminate duplication of data from participants.

Sample

This study was a subset of a larger project focused on the entire LGBTQ community. With a sample of more than 80% TGNC participants, the research team chose to focus only on this subgroup of the LGBTQ community to increase the generalizability of the findings for the variables of interest.

This exploratory study analyzed data from 477 adults who consented to participate. Of those adults, 71 did not complete the survey, 116 participants did not identify as TGNC or state that they identified as a gender different from their gender assigned at birth, and 16 were located outside the United States and were removed from further analysis. The final sample size was 274 TGNC participants. Demographic data indicate that our sample tended to be younger, more educated, never married, and had access to private health insurance either through their job or through their parent's job (Table 1).

Table 1.

Descriptive Statistics of the Sample

Participant demographic characteristic	n	%
Age, years
18–24	124	45.42
25–34	115	42.12
35–44	19	6.96
45–64	13	4.76
65+	2	0.73
Marital status
Married or domestic partnership	40	14.81
Never married	202	74.81
Divorced	8	2.96
Living as married	20	7.41
Insurance
Employer-based coverage through my job/spouse job	111	40.81
Employer-based coverage through my parent's job	62	22.79
Medicare	21	7.72
Medicaid or CHIP	25	9.19
No insurance	37	13.60
Other	16	5.88
Education
High school, did not graduate	8	2.96
High school graduate	41	15.19
Some college, no 4-year degree	98	36.30
Business, technical, or vocational school after high school	7	2.59
College graduate (4-year degree)	77	28.52
Postgraduate training or professional schooling after college (Masters, PhD, law school, medical school)	39	14.44
Income
0–$25,000	97	36.06
$25,001–$50,000	63	23.42
$50,001–$75,000	37	13.75
$75,001–$100,000	25	9.29
$100,001–$125,000	20	7.43
$125,001+	27	10.04
Employment status
Employed full-time	116	44.27
Student	33	12.60
Not employed for pay	79	30.15
Disabled	22	8.40
Other/retired	12	4.58
Location
Urban	144	52.75
Suburban	93	34.07
Rural	36	13.19
Usual source of care
Yes/more than 1	212	79.10
No	56	20.90
Doctor visit in the past 12 months
Yes	252	92.99
No	19	7.01

CHIP, Children's Health Insurance Program.

Analysis

Descriptive statistics assessed the use of mental health services based on participant's demographics. Logistic regression determined the log odds of not using mental health services given the independent variables. The independent variables selected for this analysis align with significant findings of access to care barriers in the literature. If participants did not use mental health services in the past 12 months, the survey jumped to an open-ended question to allow for a contextual response, “Why haven't you used mental health services in the past 12 months?” Participants were prompted to select all that apply from the list of 10 prepopulated access to care barriers supported in the literature. If participants selected “other,” they were asked to provide further details regarding their access to care barriers. Researchers assessed the open-ended qualitative responses using a constant comparative method in NVivo software.

Results were organized into two categories of barriers that align with Andersen's model.¹ The predisposing barriers included location, lack of trust in the health care system, and the providers themselves. The enabling barriers included money and time. Using the convergent, parallel mixed methods design, the results of the quantitative and qualitative data were compared and interpreted for convergence or divergence.

Ethics

This study was approved by Ohio University's Institutional Review Board (IRB) No. 18-X-327. The research team followed appropriate processes as outlined in the IRB, and appropriate ethical approval was received. The study participants consented to their participation and to their data being used for research purposes. The data were gathered anonymously. If participants choose to enter the drawing, they were directed to a separate survey to input their contact information to ensure anonymity of the responses.

Results

Descriptive data were gathered from 274 TGNC participants (Table 1). Findings indicate a younger sample with 87% younger than 34 years. Approximately 75% of the sample identified as trans women, 23% were trans men, and 2% were gender nonconforming. Three quarters were never married, 63% had employer-based insurance coverage either through their job or through their parent's job, and 64% completed at least a 4-year college degree. However, ∼60% of the sample made less than $50,000 a year, and only 44% were employed full-time. Only 13% lived in a rural community.

The sample's need and care-seeking behavior was high: 79% reported at least one usual source of care and 93% had a primary care doctor visit in the past 12 months. Table 2 compares the details of the 209 participants who used mental health services and the 65 who did not. Among the participants who did not use mental health services, 53% were between the ages of 25–34 years with at least some college or a college degree, and the majority were never married with private insurance through their job, making less than $50,000 per year. More than 30% of this sample was not employed for pay and 19% lived in a rural community. Seventy-four percent reported having at least one usual source of care. The only significant difference between the two utilization groups was that 16% of adults who did not use mental health services reported no primary care doctor visit in the past year compared with 4% of adults who used mental health services (p=0.002).

Table 2.

Descriptive Statistics of the Sample Based on the Use of Mental Health Services in the Past 12 Months

	Used mental health		Did not use mental health		p
	n	%	n	%
Age, years					0.240
18–24	102	48.80	22	34.38
25–34	81	38.76	34	53.13
35–44	15	7.18	4	6.25
45–64	10	4.78	3	4.69
65+	1	0.48	1	1.56
Marital status					0.668
Married or domestic partnership	28	13.59	12	18.75
Never married	155	75.24	47	73.44
Divorced	6	2.91	2	3.13
Living as married	17	8.25	3	4.69
Insurance					0.272
Employer-based coverage through my job/spouse job	87	41.63	24	38.10
Employer-based coverage through my parent's job	49	23.44	13	20.63
Medicare	12	5.74	9	14.29
Medicaid or CHIP	20	9.57	5	7.94
No insurance	27	12.92	10	15.87
Other	14	6.70	2	3.17
Education					0.719
High school, did not graduate	7	3.38	1	1.59
High school graduate	30	14.49	11	17.46
Some college, no 4-year degree	74	35.75	24	38.10
Business, technical or vocational school after high school	6	2.90	1	1.59
College graduate (4-year degree)	57	27.54	20	31.75
Postgraduate training or professional schooling after college (Masters, PhD, law school, medical school)	33	15.94	6	9.52
Income					0.227
0–$25,000	73	35.44	24	38.10
$25,001–$50,000	43	20.87	20	31.75
$50,001–$75,000	32	15.53	5	7.94
$75,001–$100,000	21	10.19	4	6.35
$100,001–$125,000	14	6.80	6	9.52
$125,001+	23	11.17	4	6.35
Employment status					0.481
Employed full-time	94	46.77	22	36.07
Student	21	10.45	12	19.67
Not employed for pay	60	29.85	19	31.15
Disabled	17	8.46	5	8.20
Other/retired	9	4.48	3	4.92
Location					0.317
Urban	113	54.07	31	48.44
Suburban	72	34.45	21	32.81
Rural	24	11.48	12	18.75
Usual source of care					0.278
Yes/more than 1	166	80.58	46	74.19
No	40	19.42	16	25.81
Doctor visit in the past 12 months					0.002
Yes	199	95.67	53	84.13
No	9	4.33	10	15.87
Confident in future treatments					0.283
Strongly disagree	12	9.23	5	10.64
Disagree	30	23.08	14	29.79
Neutral	34	26.15	17	36.17
Agree	37	28.46	8	17.02
Strongly agree	17	13.08	3	6.38
Physical health status					0.245
Poor	21	16.15	4	8.51
Fair	16	12.31	10	21.28
Good	50	38.46	16	34.04
Very good	31	23.85	15	31.91
Excellent	12	9.23	2	4.26
Mental health status					0.250
Poor	36	27.69	14	29.79
Fair	47	36.15	10	21.28
Good	30	23.08	12	25.53
Very good	12	9.23	9	19.15
Excellent	5	3.85	2	4.26

Although not statistically significant, a greater percentage of participants who did not access mental health services reported being in very good or excellent physical or mental health compared with participants who used services. Conversely, confidence in their ability to receive future mental health treatments was higher among those who accessed services compared with those who did not.

There were numerous reasons why participants did not use mental health services in the past 12 months, including not needing mental health services (43.75%), unable to pay (29.69%), belief that the services will be ineffective (26.56%), lack of providers who understand their needs (26.56%), and lack of trust (23.44%) (Table 3).

Table 3.

Reasons for Not Using Mental Health Services

Reasons for not using mental health services a	n	%
I do not need mental health services	28	43.75
I can't pay for mental health services	19	29.69
I don't believe mental health services will be effective	17	26.56
There are no mental health providers who understand my experiences or needs	17	26.56
I do not trust mental health professionals	15	23.44
I don't know how to access mental health services	11	17.19
Mental health providers are too far away and/or I don't have transportation	9	14.06
My insurance doesn't cover mental health services	6	9.38
I don't have medical insurance	3	4.69
Other	13	20.31

^a Participants were instructed to select all that apply, so the percentage will not equal 100%

Qualitative analysis of the open-ended responses to “other” indicated several predisposing barriers: lack of providers with knowledge and specialty in LGBTQ care, a lack of trust in mental health providers and energy to engage with the system, and fear of discrimination. In reference to the number of mental health providers, one participant commented, “lack of in-network providers that specialize in LGBTQ issues.” A few participants mentioned the gatekeeping function of mental health providers; for example, “I don't want to engage with gatekeepers in the medical profession. I don't need them to validate my gender for me.” Several participants referenced communicative concerns while accessing mental health services, including fear of discrimination and lack of trust in mental health providers. “Unless they are LGBT (and even then it can be a toss-up if they're not specifically trans). A lot of mental health professionals in my experience look down on their trans clients.”

Other participants discussed the lack of trust associated with the enabling barrier of cost of services: “there are only a very small, limited number of professionals who can be trusted, but they [practice] privately and I can't afford the costs.” And, “[I] have been repeatedly ripped off by ‘mental health professionals' preying upon trans people in need of letters.” Lack of trust can impact future care-seeking behaviors, especially when “mental health providers have not been helpful in the past.” To describe their personal reasons, several participants referred to a lack of time and/or energy to seek mental health services, especially on a recurring basis. Another participant stated, “I feel like others have worse problems than I do.” While others commented that they resort to self-counseling to meet their needs.

Table 4 displays the results of the multinomial logistic regression of adults who did not access mental health services in the past 12 months with the referent group being those who did access care. There was a statistically significant relationship between income, location, and mental health status with the use of mental health services. Participants in rural communities were 2.19 times more likely to not use mental health services compared with those in urban and suburban areas (confidence interval [CI]: 1.20–3.98; p=0.011). Adults with lower incomes ($25,000–$50,000) were significantly more likely to use metal health services compared with those with the highest incomes (odds ratio [OR]=0.004; CI: 0.48–0.87; p=0.004). Finally, participants with fair physical health status were significantly more likely to use mental health services compared with adults with excellent physical health (OR=0.04, CI: 0.00–0.71; p=0.029).

Table 4.

Logistic Regression Modeling Transgender Individuals Who Did Not Use Mental Health Services in the Past 12 Months

Mental health visit in the past 12 monthsa	B	Standard error	Exp(B)	95% Confidence interval for Exp(B)
				Lower bound	Upper bound
Intercept	−0.36	1.82
Age	0.09	0.28	1.10	0.63	1.90
Marital status	−0.28	0.28	0.76	0.44	1.31
Insurance	0.04	0.16	1.04	0.76	1.41
Education	−0.01	0.16	0.99	0.72	1.36
Incomeb	−0.44	0.15	0.64	0.48	0.87
Employment status	−0.17	0.21	0.84	0.56	1.28
Locationb	0.78	0.31	2.19	1.20	3.98
Usual source of care (yes)	−0.24	0.54	0.78	0.27	2.25
Usual source of care (no)	0c
Doctor visit in the past 12 months (yes)	−0.97	0.80	0.38	0.08	1.82
Doctor visit in the past 12 months (no)	0c
Confident in future treatments (strongly disagree)	1.98	1.15	7.22	0.76	68.63
Confident in future treatments (disagree)	1.67	0.87	5.31	0.97	29.00
Confident in future treatments (neutral)	1.58	0.82	4.87	0.97	24.48
Confident in future treatments (agree)	0.79	0.86	2.20	0.41	11.91
Confident in future treatments (strongly agree)	0c
Physical health status (poor)	1.17	1.56	3.21	0.15	68.74
Physical health status (fair)	2.63	1.42	13.83	0.86	223.20
Physical health status (good)	2.19	1.35	8.91	0.63	125.14
Physical health status (very good)	2.28	1.30	9.82	0.77	125.26
Physical health status (excellent)	0c
Mental health status (poor)	−2.81	1.50	0.06	0.00	1.14
Mental health status (fair)b	−3.29	1.50	0.04	0.00	0.71
Mental health status (good)	−2.18	1.43	0.11	0.01	1.87
Mental health status (very good)	−1.12	1.42	0.33	0.02	5.22
Mental health status (excellent)	0c

Exp(B) is the odds ratio.

^a The reference category: use of mental health services.

^b Significant at p<0.05.

^c This parameter is set to zero because it is redundant.

Discussion

Less than half of the TGNC participants who did not access mental health services (44%) indicated it was because they did not need them, which was the most indicated reason for not using mental health services (Table 3). This finding is consistent with the significance of mental health status (i.e., choosing good, very good, or excellent) as a predictor of service utilization. However, the majority (56%) of the TGNC participants who did not access mental health services indicated that they still needed them, with more than half of the participants who had not visited a mental health professional in the past 12 months indicating that they had only “poor” or “fair” mental health status.

Transgender adults who needed but did not use mental health services may have been met with predisposing and enabling barriers that inhibit their access such as the inability to pay, lack of insurance coverage for their chosen provider, and the distance or transportation needed to access appropriate care, which were the second, seventh, eighth, and ninth most indicated reasons. In addition, the use of primary care was significantly greater among TGNC adults who sought mental health services, perhaps highlighting the important role of primary care providers in mental health utilization. However, the participants reflected on their inability to trust providers, except for a select few who are too expensive to see, which highlights the enabling barriers that impact utilization.

Aside from these predisposing and enabling barriers, TGNC clients indicated additional communicative barriers that prevented them from accessing needed mental health care. These reasons included questioning the effectiveness of treatment, mental health providers do not understand them, lack of trust in mental health providers and systems, and not knowing how to access mental health services. Importantly, these communicative barriers that are operationalized at the organizational or individual level ranked (after not needing or being able to pay for mental health services) as the third, fourth, fifth, and sixth most chosen reasons for not using mental health services. Furthermore, participants commented on the disparaging interactions they had with mental health providers from lack of trust, to “gatekeepers,” to gender validators.

These results, which heavily emphasize a lack of belief in effective treatment and trust in providers, suggest that participants may have accessed mental health services in the past and have resisted accessing the system more recently due to previous negative experiences.^21,26 Another explanation is that these patients have heard of others' experiences and delayed seeking care for fear of discrimination, judgment, and lack of trust in providers, which shows the impacts of negative care experiences rippling through the LGBTQ community to discourage care-seeking behaviors among those who have not yet experienced a discriminatory or ineffective care situation.^2,32

These concerns are corroborated by participants' qualitative responses, which overwhelmingly indicated the inaccessibility of specialty care, participants' lack of trust based on bad past experiences, the prevalence and power of the word of mouth inside LGBTQ communities, and the ineffectiveness of seeking care from inadequately trained professionals. These findings are also consistent with past research that indicated how LGBTQ patients who did not trust, reported inadequate time with, or felt judged by their providers reported significantly lower satisfaction with mental health services and were less confident in their ability to receive future mental health services.³²

Like other patient populations, LGBTQ patients encounter significant systemic and interactional barriers in accessing mental health care; however, not only are TGNC adults found to have lower rates of insurance coverage, but they are also affected more broadly by barriers influenced by social and structural determinants of health.³³ These patients are not simply limited by the undersaturation of mental health providers, cost, access to a specialist, the availability of services,³⁴ and lack of mental and primary care integration³⁵ but are further constrained by providers unequipped to employ inclusive care practices. At the systems level, TGNC patients might struggle to find a professional in their area who is knowledgeable about working with gender minorities.^34,35 These findings are consistent with physical health disparities as well. For instance, there is a reported lack of continuity of care across providers for LGBTQ patients seeking cancer treatment.³⁶

At the provider level and linked to participant satisfaction with service use, providers and organizations may be inadvertently practicing anti-LGBT bias and discrimination and lack LGBT-friendly policies.³⁷ For example, LGBTQ patients can be exposed to provider discrimination, lack of cultural competency, trans-specific training and literacy, discriminatory intake forms and policies,⁹ and possibly even hostility, violence, and insensitivity in the care setting.³⁸ Research indicates that only 34% of TGNC adults' doctors knew that they were trans and treated them with respect.⁸ In addition to the cost of treatment, the fear of discriminatory treatment, previous bad experiences, and concerns around stigma are interpersonal barriers that have been reported by transgender patients.²⁶

Furthermore, a lack of provider knowledge on LGBTQ issues and specific health care needs is a major barrier to having access to high-quality care. One study found that 64% of respondents identifying as LGBTQ felt that their mental health care providers lacked this knowledge.³⁹ These barriers at the client–provider level can be a deterrent to seeking care in a patient population that reports a greater burden of mental health needs.²⁸ They can also dramatically decrease clients' satisfaction with the quality of mental health care received, impacting confidence in their ability to receive future mental health services.³² In terms of improving mental health status, 20% of LGBTQ clients reported that mental health providers did a “poor” or “very poor” job.³⁹

If patients feel supported by their providers, they are less likely to delay care and more likely to perceive higher quality care. Loeb et al.⁴⁰ found that provider discrimination may cause LGBTQ adults to delay seeking care. Delays in care may be more prevalent based on gender identity, with transgender adults being more likely to delay seeking care than cisgender participants.⁴¹ TGNC adults who delay seeking care experienced greater risk for depression, suicide attempts, and suicidal ideations.³⁹ Furthermore, provider support encourages patients to have a positive perception of their ability to seek future mental health services. Having a choice of providers whom the patient trusts can limit the fear of discrimination, give patients an internal locus of control in their care, and improve access to care.⁴²

It is encouraging that some TGNC participants did not seek care in the past 12 months because they did not need it. However, a majority of those who did not seek care indicated a mental health status that could be benefited from accessing appropriate services. Significant demographic differences between the group who did and did not seek care point to location and income as significant predictors of care utilization in addition to mental health status. In addition, participants' indication that payment, belief in care effectiveness, trust in providers, knowledge about how to access care, and adequate access to insurance and transportation are all barriers that need to be addressed if all TGNC adults who need mental health services are to access them. Specific initiatives to address these beliefs, behaviors, and logistical inhibitors have the potential to significantly decrease barriers to service access while simultaneously improving the quality of care within individual service encounters.

Limitations

Convenience sampling limited the scope of our study. Since the study was posted on LGBTQ-friendly blogs and Reddit posts, adults had to subscribe to these social media sources to learn about the study or hear via word of mouth. The sample was also self-selected to participate. Because of these recruitment limitations, responses may not be representative of the perspectives of the entire TGNC community. Possibly as a result of the self-selection process and social media postings, the participants tended to be a younger population of students, highly educated, privately insured, and of higher economic status.

The participants' experiences were likely influenced by social and/or economic privilege and did not reflect the experiences of lower socioeconomic standing, people of color, or those with differing physical abilities. Data on race and ethnicity were not accurately captured on the survey, so due to a significant sample of missing data regarding race and ethnicity, the variable was excluded from this analysis. Future research should assess mental health utilization using an intersectionality perspective with race, ethnicity, and ability status. Similarly, the data were skewed with nearly 75% of trans women, making gender-based analyses more difficult. To ensure a more diverse sample, researchers should adapt strategic recruitment efforts among minority groups, organizations, and social media outlets.

The lack of data from the majority populations for comparison purposes serves as another limitation. Without a comparison group, we can only extrapolate findings from the literature to make claims about how this study's results generalize to the population. Future research will expand the recruitment efforts to ensure a more equitable and diverse sample of participants representative of the entire LGBTQ community and the majority population for comparison purposes. Another limitation is participant recall bias. If a patient had not accessed services in over a year, their ability to recall their experiences may diminish over time and be less accurate.

Physical and mental health status were gathered using a single question that employed self-reporting. Using self-report instead of a validated health status scale is a limitation of this study. Although a patient's perception of their physical and mental health status is important to capture as an access to care measure, it is also equally important to capture actual need or clinical health status. Future research will incorporate both perceived and actual health status.

Conclusions

Regardless of access to mental health services, TGNC adults who need mental health services have significant unmet needs. Income, location, and mental health status all influence an individual's ability to access mental health services. However, communication, prejudiced providers, and discriminatory practices may prevent further utilization of needed mental health services. Cultural humility trainings can educate providers on the unique needs of this minority population and enhance accessibility and equity of mental health services for TGNC adults.

Data Availability

The data cannot be made available due to the sensitive and identifiable nature of the data collected.

Abbreviations Used

CHIP

Children's Health Insurance Program

CI

confidence interval

OR

odds ratio

TGNC

transgender and gender nonconforming

Authors' Contributions

K.A.S.: Conceptualization, data curation, formal analysis, investigation, methodology, project administration, supervision, validation, visualization, original draft. R.P.C.: Conceptualization, data curation, formal analysis, methodology, project administration, supervision, writing original draft, review and editing. M.W.: Conceptualization, investigation, methodology, writing original draft, review and editing.

Author Disclosure Statement

The authors have no conflicts of interest to disclose.

Funding Information

No funding was received for this article.

Cite this article as: Schuller KA, Crawford RP, Wolf M (2025) Predictors of mental health service utilization among transgender and gender nonconforming adults, Transgender Health 10:1, 73–83, DOI: 10.1089/trgh.2023.0107.