Abstract
Purpose
Trans*female youth are an underserved population at risk for a variety of poor health outcomes, in part related to barriers to accessing health and mental health care.
Methods
We conducted a secondary analysis of data collected with 250 TFY aged 16 to 24 years in the San Francisco Bay Area from 2012–2014. Logistic regression was used to test associations between socio-demographic variables and barriers to gender identity-based medical and mental health care.
Results
Having a history of unstable housing was associated with significantly higher odds of problems accessing both medical care (OR 2.16, 95% CI 1.12, 4.13) and mental health care due to gender identity (OR 2.65, 95% CI 1.08, 6.45). Conversely, identifying as genderqueer/genderfluid, Latina, or living in dependent housing was associated with access to either medical or mental health care.
Conclusions
Interventions are needed to address housing and discrimination barring access to health care among TFY.
Keywords: Gender Identity, Person, Transgender, Adolescent, Homeless Youth, Homelessness, Access to Health Care, Mental Health, San Francisco Bay Area
Trans*female youth (TFY) are an understudied and underserved population at risk for a variety of poor health outcomes. In addition to navigating the growth and development typical of adolescence, TFY must also navigate the incorporation of multiple stigmatized identities such as a gender-nonconforming identity1 and identifying within the feminine gender spectrum. A 2002 survey of 51 ethnic minority male-to-female transgender youth in Chicago found that these youth were at risk for experiencing economic hardships, legal problems, barriers to accessing gender-affirming health care, limited family support, and risky sexual behavior2. Not surprisingly, trans adults are known to experience health inequities including higher rates of HIV and other STIs, hypertension, dyslipidemia, substance use, abuse and addiction, depression, and suicide than their adult cisgender counterparts3,4. A study of 55 transgender youth ages 15–21 in the early 2000's in New York City found that TFY are at high risk for suicidal ideation and attempts5. Further, an online, nationally based study of youth ages 13–18 in 2010 found that substance use, bullying and harassment was disproportionately experienced by gender minority youth compared to cisgender youth6.
Lack of health insurance for youth has been associated with poorer access to health care services and poorer health outcomes than insured youth7. Youth overall are the least likely age group to access medical care, and are the most uninsured and underinsured of all age groups7. An online survey of 6,456 transgender adults in 2011 found that a higher percentage of transwomen than transmen reported issues with unequal treatment in health care settings, denial of service altogether, and postponement of accessing general medical care4. The same study found that transgender women experience more health care discrimination than transgender men4. However, little information exists about factors associated with lack of access to medical care for TFY.
Methods
We conducted a secondary analysis data from a large study of TFY aged 16–24 years in the San Francisco Bay Area to identify associations between socio-demographic factors and lack of access to medical and mental health care because of one’s gender identity or presentation. Procedures for recruitment, consent/assent, and enrollment are described in detail elsewhere8. Socio-demographic variables assessed were age, race/ethnicity, monthly income, gender identity, housing (current living situation and history of unstable housing), county of residence, health insurance status, and education (education completed and currently in school). Logistic regression was utilized to assess for associations between the socio-demographic variables and barriers to medical and mental health care due to gender identity and presentation. Unadjusted odds ratios are presented.
Results
Of the 314 youth enrolled in the study, participants were excluded if there were missing data for any of the 10 independent variables (n=14), or if they responded, “Refuse to answer,” “Don’t know,” or “Not applicable” to at least one of the dependent variables (n=50), leaving data from 250 participants (Table1). Youth who identified as Latina had lower odds of reporting problems accessing mental health care (OR 0.22, 95% CI 0.06, 0.79) relative to white youth (Table 2). Youth who identified as genderqueer/genderfluid had lower odds of having problems accessing medical care compared to those who identified as female (OR 0.18, 95% CI 0.04, 0.77). Participants who reported a history of unstable housing had higher odds of problems accessing medical care compared to youth who had always been stably housed (OR 2.16, 95% CI 1.12, 4.13). Participants who reported a history of unstable housing had higher odds of having problems accessing mental health care than those who had always been stably housed (OR 2.65, 95% CI 1.08, 6.45).
Table 1.
Frequencies of Socio-demographic factors of trans*female youth ages 16–24 (n=250): Shine Study, San Francisco Bay Area, 2012–2014
| Category | Total N (%) | Category | Total N (%) | ||
|---|---|---|---|---|---|
| Age (years) | Current living situation | ||||
| 16–18 | 35 (14.0) | Independent housing | 115 (46.0) | ||
| 19–20 | 51 (20.4) | Dependent housing | 69 (27.6) | ||
| 21–23 | 129 (51.6) | Transitional housing/shelter | 51 (20.4) | ||
| 24 | 35 (14.0) | Other | 15 (6.0) | ||
| Race | Ever had unstable housing | ||||
| Latina | 71 (28.4) | No | 111 (44.4) | ||
| White | 96 (38.4) | Yes | 139 (55.6) | ||
| Black | 30 (12.0) | County of residence | |||
| Asian | 17 (6.8) | San Francisco | 102 (40.8) | ||
| Mixed | 30 (12.0) | Surrounding Bay Area | 125 (50.0) | ||
| Additional | 6 (2.4) | Health insurance status | |||
| Income (monthly) | Uninsured | 46 (18.4) | |||
| 0–500 | 131 (52.4) | Insured | 204 (81.6) | ||
| 501–1000 | 54 (21.6) | Education completed | |||
| 1001–1500 | 20 (8.0) | Some high school or less | 51 (20.4) | ||
| 1501–2000 | 17 (6.8) | High school | 84 (33.6) | ||
| 2000+ | 26 (10.4) | Some college, AA, technical school | 88 (35.2) | ||
| Gender identity | College, some or all of graduate school | 27 (10.8) | |||
| Female | 121 (48.4) | Currently in school | |||
| Transgender female | 82 (32.8) | No | 152 (60.8) | ||
| Genderqueer/genderfluid | 35 (14.0) | Yes | 98 (39.2) | ||
| Additional Gender | 12 (4.8) | ||||
Table 2.
Associations Between socio-demographic factors and health and mental health care barriers due to gender identity or presentation: Shine Study, San Francisco Bay Area, 2012–2014
| Problems accessing medical care |
Problems accessing mental health care |
||
|---|---|---|---|
| Age(years) | |||
| 16–18 | 0.63 (0.22, 1.78) | 1.38 (0.41, 4.65) | |
| 19–20 | 1.16 (0.54, 2.52) | 1.43 (0.50, 4.10) | |
| 21–23 | - | - | |
| 24 | 1.31 (0.55, 3.12) | 2.68 (0.95, 7.54) | |
| Race | |||
| Latina | 0.55 (0.25, 1.18) | 0.22 (0.06, 0.79)* | |
| White | - | - | |
| Black | 0.30 (0.08, 1.07) | 0.17 (0.02, 1.36) | |
| Asian | 0.17 (0.02, 1.33) | <0.001 (<0.01, >100.0) | |
| Mixed | 0.82 (0.31, 2.14) | 1.00 (0.33, 3.00) | |
| Additional Identity(ies) | 5.39 (0.93, 31.174) | 5.00 (0.93, 27.04) | |
| Income (monthly) | |||
| 0–500 | - | - | |
| 501–1000 | 0.67 (0.30, 1.53) | 1.07 (0.41, 2.77) | |
| 101–1500 | 0.84 (0.26, 2.71) | 0.80 (0.17, 3.77) | |
| 1501–2000 | 1.84 (0.63, 5.38) | 0.45 (0.06, 3.62) | |
| 2000+ | 0.61 (0.30, 1.92) | 0.60 (0.13, 2.78) | |
| Gender Identity | |||
| Female | - | - | |
| Transgender female | 0.82 (0.42, 1.59) | 1.38 (0.41, 4.65) | |
| Genderqueer/gender fluid | 0.18 (0.04, 0.78)* | 1.43 (0.50, 4.10) | |
| Additional Identity(ies) | 0.58 (0.12, 2.80) | 2.68 (0.95, 7.54) | |
| Current living situation | |||
| Independent housing | - | - | |
| Dependent housing | 0.45 (0.20, 1.01) | 0.09 (0.01, 0.65)* | |
| Transitional housing/shelter | 0.72 (0.32, 1.63) | 0.63 (0.22, 1.80) | |
| Other | 1.48 (0.47, 4.70) | 2.88 (0.88, 9.48) | |
| Ever had unstable housing? | |||
| No | - | - | |
| Yes | 2.16 (1.12, 4.13)* | 2.65 (1.08, 6.45)* | |
| County of residence | |||
| San Francisco | 1.04 (0.54, 1.99) | 0.66 (0.28, 1.56) | |
| Surrounding Bay Area | - | - | |
| Health Insurance Status | |||
| Uninsured | 0.97 (0.45, 2.11) | 0.47 (0.14, 1.63) | |
| Insured | - | - | |
| Education completed | |||
| Some high school or less | 0.64 (0.27, 1.53) | 0.29 (0.06, 1.34) | |
| High school | 0.60 (0.28, 1.27) | 0.84 (0.33, 2.14) | |
| Some college, AA, technical school | - | - | |
| College, some or all of graduate school | 1.26 (0.49, 3.29) | 2.00 (0.66, 6.04) | |
| Currently in school | |||
| No | - | - | |
| Yes | 0.93 (0.50, 1.73) | 1.00 (0.45, 2.25) | |
Discussion
Unstable housing was the most consistent and significant variable associated with barriers to medical and mental health care due to gender identity. Research to explain the relationship between unstable housing and problems accessing medical and mental health care for TFY is limited. Stigma and perceived stigma from providers towards gender nonconforming youth on top of homelessness are likely the biggest barriers to accessing medical and mental health care9. Homeless youth’s lack of support structures, including supportive people to advocate for their rights to health care as a trans person may also explain lack of access. Efforts to secure housing may lessen resources youth have to devote to accessing health care.
We also found that youth who identified as genderqueer/genderfluid were less likely than those who identified as female to report problems accessing medical care because of their gender identity or presentation. Previous qualitative research with LGBTQ youth has shown that some youth prefer having flexibility with their gender identity because it offers them more control over how they present themselves to others10. In health care situations where a gender non-conforming identity may not feel safe to disclose, flexibility in presenting one’s gender identity to clinicians and clinic staff to avert stigma could result in increased access to medical care for genderqueer/genderfluid youth. More research is needed to assess the possible meanings behind differences in access to health care among people with various trans*female identities.
These data support the need for interventions to address both discrimination and housing to increase access to medical and mental health care among TFY. With over a quarter (26%) of the youth in our sample currently living in unstable housing and over half (56%) with a history of unstable housing, the potential benefit of an intervention to alleviate the burden of homelessness on this at risk population is clear. Safe, affordable housing and multi-service programs that incorporate both health and housing services for TFY are just two of many possible structural responses to these findings. Such interventions have the opportunity facilitate the transition of TFY to a healthier adulthood.
Implications and Contributions.
Little data exist about the overall health of young trans*females. This study suggests that discrimination is multi-layered for trans*female youth and providers wanting to serve this community will need to address the co-occurring factors this population faces, especially housing.
Acknowledgments
This work was supported by the National Institute on Minority Health and Health Disparities, National Institutes of Health (grant number R25MD006832); the National Institute of Mental Health (grant number R01MH095598); and the Helen Schoeneman Scholarship. We thank Karen Sokal-Gutierrez MD, MPH for critical review of the study design, inspiration, and editing. We also thank Julianna Deardorff PhD and Lela Bachrach MD, MS for their content review and editorial assistance.
Abbreviations
- TFY
Trans*female youth
- LGBTQ
Lesbian, gay, bisexual, transgender, queer
- STI
Sexual transmitted infection
Footnotes
A version of this work was presented at the 2015 National Transgender Health Summit as well as the American Public Health Association’s 2016 Annual Meeting and Expo.
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