Stigma, Resilience, and Health Care Use Among Transgender and Other Gender Diverse Youth in the United States

Abstract

Purpose: To understand the relationships between stigma, resilience, and health care use among transgender and other gender diverse youth (TGDY).

Methods: Data include a national sample of 171 TGDY (ages 15–24). Previously developed Gender Minority Stress Theory scales were used to measure experiences of stigma and resilience. Health care use included two outcomes: difficulty accessing care and medical gender affirmation service use (e.g., hormones and surgery). Principal components analysis (PCA) was used to reduce data. Logistic regression was used to test relationships between components and the outcomes; interactions between components were also tested.

Results: The PCA determined three components representing (1) enacted stigma, (2) a positive sense of identity, and (3) social support. Two scales (mis-gendering and anticipated stigma) did not fit into any components and were included as separate variables. In the main effects model, none of the minority stress variables were associated with difficulty accessing care. However, an interaction between enacted stigma and a positive sense of identity indicated that having a more positive sense of identity was only associated with reduced difficulty accessing care for participants experiencing less stigma. For medical gender affirmation services, participants who experienced more anticipated stigma were less likely to use these services and participants with a more positive sense of identity were more likely to use them.

Conclusions: Findings suggest that stigma and resilience experienced both inside and outside of health care settings can play a role on access to care for TGDY. Interventions should consider how to reduce stigma and promote resilience across multiple contexts.

Introduction

In the United States, stigma targeted at transgender and other gender diverse youth (TGDY) contributes to health inequities and limited health care access.^1–4 As identity develops during adolescence and young adulthood and as TGDY transition from pediatric to adolescent or adult care, it is important to find providers and health care settings that are affirming of transgender and other gender diverse (TGD) identities (e.g., with inclusive medical forms and correct use of names/pronouns).^5–7 Some TGDY also seek medical gender affirmation (e.g., gender-affirming hormones and surgery). For those seeking medical gender affirmation, accessing these services may improve mental health and well-being.^8,9 For TGDY, adolescence/young adulthood can also be an essential time for seeking these services, since, for some, medical gender affirmation can play a role in gender identity development.⁷ Some research has explained that stigma occurring within health care is a barrier to accessing health care (including medical gender affirmation) among TGD populations (including both youth and adults),^4,10,11 but less is known about how stigma and resilience occurring across multiple settings may contribute to different types of health care use (e.g., primary care and medical gender affirmation) among TGDY.

Minority stress theory^12,13 is useful for understanding how stigma influences health care use among TGDY. The theory characterizes stigma as occurring through distal (e.g., discrimination, victimization, and rejection) and proximal minority stressors (e.g., internalized and anticipated stigma), and posits that experiencing these stressors results in poorer mental and physical health.^12–14 Research also demonstrates that minority stress occurring within health care settings can limit health care use.^11,15 For example, TGD populations often report avoiding health care due to fears of mistreatment.¹⁶ However, TGD populations experience minority stress across multiple settings. For example, results from the U.S. Trans Survey, conducted among a large national sample of TGD adults, demonstrate that TGD people experience stigma in education, employment, housing, health care, and so on.¹⁶ These experiences of stigma may be unique for TGDY and more research is needed to better understand how stigma experienced across settings may be associated with health care use for TGDY.

Minority stress theory also explains how resilience can influence health.^12,13,17 Resilience refers to a social process occurring when an individual is exposed to a stressor (e.g., minority stress) and accesses resources (e.g., social support) and/or employs coping mechanisms (e.g., self-affirmation) to overcome the negative health consequences associated with that stressor.^17,18 Some research has identified that resilience plays a role in health care use among TGDY.¹⁵ For example, one study found that having positive health care experiences was associated with less health care avoidance.¹⁵ However, more research is needed to understand how stigma and resilience processes occurring across a variety of settings influence health care use. This study examines the relationships between minority stress, resilience, and health care use among TGDY. We hypothesize that minority stress will be associated with reduced health care use and resilience will be associated with increased health care use.

Methods

This is a secondary analysis of baseline survey data from Project Moxie, a randomized controlled trial testing a telehealth home-based HIV testing intervention for TGDY. Additional study details are described in Stephenson et al.¹⁹

Participants

This study included 202 participants 15–24 years of age, residing in the United States, with a gender identity different from their sex assigned at birth. Eligibility criteria specific to the study's intervention included not living with HIV; being willing to have HIV test kits delivered to a provided address; and having access to a computer, smartphone, or tablet that supports the intervention software. Recruitment occurred through online advertisements on multiple social media platforms, in TGDY advocacy groups, through online dating sites, and through social media accounts of community stakeholders.

Procedures

This study was approved by the Institutional Review Board at the University of Michigan. Participants provided electronic informed consent/assent. The online survey included 205 possible questions and took an average of ∼80 min to complete. Survey questions included topics such as demographics, health care experiences, and HIV testing. All participants received $30 for completing the survey.

Measures

Measures included health care outcomes, minority stress theory variables, and other covariates.

Health care use was measured through two variables: (1) difficulty accessing health care in general and (2) medical gender affirmation service use. Difficulty accessing health care was based on whether participants reported having problems getting health care in the past 6 months because of their gender identity or gender presentation. Medical gender affirmation was based on the lifetime use of any health care used to medically affirm gender (e.g., hormones and surgery). For the analysis of this outcome, participants were excluded if they reported not wanting these services (n=45; 22.28% of the sample). Compared with participants identifying as transgender, those who did not identify as transgender (e.g., nonbinary and gender queer) were less likely to want to access medical gender affirmation (p<0.001).

Minority stress theory variables included distal and proximal minority stressors and resilience occurring across multiple settings. All constructs were measured using scales developed by Testa et al.,¹⁴ described in Table 1. Scales were developed for TGD adults, but all measures were tested among TGDY to ensure face validity.

Table 1.

Scale Descriptions for Minority Stress Theory Constructs

Scale	No. of items	Response options (score)	Scale range	Sample items	Alpha
Distal minority stressors
Gender-related discrimination14	5	Never (0); yes, before age 18 (1); yes, after age 18 (1); yes, in the past year (1)	0–5	“I have had difficulty finding housing or staying in housing because of my gender or gender expression”	0.72
				“I have experienced difficulty getting identity documents that match my gender”
Gender-related victimization14	5	Never (0); yes, before age 18 (1); yes, after age 18 (1); yes, in the past year (1)	0–5	“I have been verbally harassed or teased because of my gender or gender expression (For example, being called ‘it’)”	0.77
				I have been pushed, shoved, hit, or had something thrown at me because of my gender or gender expression”
Gender-related rejection14	6	Never (0); yes, before age 18 (1); yes, after age 18 (1); yes, in the past year (1)	0–6	“I have had difficulty finding a partner or have had a relationship end because of my gender or gender expression”	0.73
				“I have been rejected by or made to feel unwelcome by a religious community because of my gender or gender expression”
Gender nonaffirmation14	6	Strongly disagree (0) to strongly agree (4)	0–24	“I have difficulty being perceived as my gender”	0.87
				“I have to be ‘hypermasculine’ or ‘hyperfeminine’ in order for people to accept my gender”
Proximal minority stressors
Internalized trans-related stigma14	8	Strongly disagree (0) to strongly agree (4)	0–32	“I resent my gender identity or expression”	0.90
				“I feel that my gender identity or expression is embarrassing”
Anticipated trans-related stigma14	9	Strongly disagree (0) to strongly agree (4)	0–36	“If I express my gender identity, others wouldn't accept me”	0.95
				“If I express my gender identity, people would think I am mentally ill or ‘crazy’ ”
Resilience factors
Self-affirmation14	7	Strongly disagree (0) to strongly agree (4)	0–28	“My gender identity or expression makes me feel special and unique”	0.88
				“I am proud to be a person whose gender identity is different from my sex assigned at birth”
Social support22	4	None of the time (0) to all of the time (3)	0–12	“How often is someone available to help with daily chores if you are sick?”	0.80
				“How often is someone available to get together with you or relaxation?”
Community connectedness14	5	Strongly disagree (0) to strongly agree (4)	0–20	“I feel connected to other people who share my gender identity”	0.79
				“I feel isolated and separate from other people who share my gender identity” (reverse coded)

Distal minority stressors included gender-related discrimination, victimization, rejection, and nonaffirmation. Gender-related discrimination involves being treated poorly or being denied access to resources (e.g., housing and employment) because of gender identity/expression.^14,20 Gender-related victimization refers to experiences of sexual, physical, and verbal violence and harassment targeted at individuals because of their gender identity/expression.^14,21 Gender-related rejection involves the experience of being unwanted or unwelcome by individuals or groups (e.g., family, friends, and religious communities). Gender nonaffirmation refers to an interpersonal process in which an individual's gender is not affirmed or is mistaken by others.^14,21

Proximal minority stressors included internalized and anticipated stigma. Internalized transgender-related stigma refers to the shame about one's own gender identity that occurs when an individual internalizes societal stigma and believes the negative attributes that are assigned to their identity.^12,20 Anticipated transgender-related stigma refers to a continuous and repeated expectation that stressful and stigmatizing events will occur.^12,13

Resilience variables were comprised of internal and external resilience processes,¹⁸ including self-affirmation, community connectedness, and social support. Self-affirmation and community connectedness were measured using adapted Testa et al.¹⁴ scales and social support was measured using a brief version of the Social Support Survey used in the Medical Outcomes Study.²² Self-affirmation is an intrapersonal process and refers to an internalized feeling of pride related to one's identity. Community connectedness refers to having a sense of community and is linked with greater access to community-level support and sense of belonging.^17,23 Finally, although not included as a construct in Minority Stress Theory,^12–14 previous research has identified social support as a resilience resource that is linked with improved health outcomes.^24,25 Therefore, this variable was also included as an aspect of resilience.

Covariates included age, gender identity, race/ethnicity, U.S. region, and health insurance coverage. Gender identity included trans-feminine, trans-masculine, and other gender diverse identities (distinguishing between individuals assigned male at birth [AMAB] and assigned female at birth [AFAB]). Race/ethnicity was measured as a binary variable (non-Hispanic white vs. racial/ethnic minority). Region was defined based on the U.S. Census.²⁶ Finally, since the ability to pay for care contributes to health care accessibility,^16,27 health insurance was based on having any type of coverage.

Analysis

Data were analyzed using STATA 14 (College Station, TX). Principal components analysis (PCA) was used to reduce data and logistic regression was used to determine associations between minority stress theory variables and health care use outcomes.

Since fewer than 10% of responses were missing on each variable, all responses with missing data were excluded (n=31), resulting in a sample size of 171, including 131 who reported wanting medical gender affirmation. None of the independent variables (IVs) demonstrated multicollinearity. Descriptive statistics assessed the sample distribution and patterns of health care use. Bivariate analyses (chi-square and t-tests) tested the independent relationships between each IV and both outcomes. An alpha level of 0.05 determined significance for all analyses.

For all minority stress theory scales, a PCA was conducted to reduce data. Reducing the number of variables in the models helps to increase the power to detect significant relationships, despite small samples.²⁸ PCA aims to explore underlying clusters in the data through the development of latent constructs comprising parceled survey items.²⁹ For the PCA, each minority stress theory scale was kept intact and was inserted into the analysis as a separate variable. Each component had an Eigenvalue >1 and comprised at least 10% of the explained variance.³⁰ All items with a factor loading <0.4 were not included in a component.³¹ Scoring coefficients were generated for each component, using the factor loadings to calculate standard regression coefficients; these were assigned to participants, so that components from the PCA could be examined as IVs using logistic regression.

Logistic regression was used to determine associations between the components and each health care use outcome, with a separate model being fit for each outcome. The components and the covariates were included as IVs in the regression models. Minority stress theory scales that did not fit into any component (i.e., factor loading <0.4) were included as separate IVs. Main effects models were fit in addition to models including interaction terms between theoretically relevant components, with each interaction term being tested in a separate regression model.

Results

The participants' average age is 19, with ∼40% identifying as trans-masculine (n=72), 18% as trans-feminine (n=26), and about 40% as another gender diverse identity (n=68) (Table 2). Approximately 26% (n=44) of participants reported difficulty accessing health care and 38% (n=50) of participants wanting medical gender affirmation had accessed these services in their lifetime. Older participants and those identifying as trans-masculine or trans-feminine were more likely to report accessing medical gender affirmation.

Table 2.

Descriptive Statistics and Binary Analyses Examining Minority Stress Theory Variables, Covariates, and Health Care Use Outcomes

		Difficulty accessing care (n=171)			Use of medical gender affirmation services (n=131)
	Range	Sample distribution	Had difficulty accessing care	p	Distribution who want medical gender affirmation services	Used medical gender affirmation services	p
Age, mean (SD)	15–24	19.12 (2.61)	19.70 (2.60)	0.110	19.06 (2.57)	20.18 (2.43)	<0.001
Gender identity, % (n)				0.701			0.003
Trans-feminine		17.54 (30)	20.00 (6)		19.08 (25)	52.00 (13)
Trans-masculine		42.69 (73)	28.77 (21)		55.73 (73)	45.21 (33)
Other gender diverse (AMAB)		12.87 (22)	18.18 (4)		9.16 (12)	8.33 (1)
Other gender diverse (AFAB)		26.90 (46)	28.26 (13)		16.03 (21)	14.29 (3)
Race/ethnicity, % (n)				0.256			0.522
Non-Hispanic white		66.08 (113)	23.01 (26)		68.70 (90)	40.00 (36)
Racial minority		33.92 (58)	31.03 (18)		31.30 (41)	34.15 (14)
Region, % (n)				0.907			0.120
Northeast		14.04 (24)	25.00 (6)		16.03 (21)	57.14 (12)
Midwest		28.07 (48)	29.17 (14)		25.95 (34)	35.29 (12)
South		38.01 (65)	23.08 (15)		39.69 (52)	28.85 (15)
West		19.88 (34)	26.47 (9)		18.32 (24)	45.83 (11)
Health insurance, % (n)				0.240			0.406
Does not have insurance coverage		11.11 (19)	36.84 (7)		11.45 (15)	26.67 (4)
Has insurance coverage		88.89 (152)	24.34 (37)		88.55 (116)	39.66 (46)
Gender-related discrimination, mean (SD)	0–5	2.58 (1.56)	2.70 (1.66)	0.536	2.60 (1.51)	2.56 (1.66)	0.798
Gender-related victimization, mean (SD)	0–5	2.22 (1.64)	2.23 (1.61)	0.981	2.24 (1.72)	2.28 (1.71)	0.822
Gender-related rejection, mean (SD)	0–6	3.68 (1.81)	3.93 (1.77)	0.282	3.66 (1.83)	3.60 (1.94)	0.755
Mis-gendering, mean (SD)	0–21	15.31 (5.37)	15.77 (5.47)	0.509	15.44 (8.38)	14.92 (5.95)	0.375
Internalized trans-related stigma, mean (SD)	1–32	17.23 (8.48)	16.93 (8.17)	0.784	17.71 (8.38)	18.68 (7.60)	0.300
Anticipated trans-related stigma, mean (SD)	0–36	20.04 (10.16)	19.95 (8.76)	0.952	20.15 (9.91)	18.08 (10.56)	0.060
Self-affirmation, mean (SD)	0–28	14.79 (6.86)	15.77 (6.47)	0.271	14.77 (6.69)	14.26 (6.46)	0.583
Social support, mean (SD)	0–12	6.29 (2.78)	6.11 (2.97)	0.633	6.27 (2.69)	6.30 (2.64)	0.933
Community connectedness, mean (SD)	0–20	12.56 (4.60)	12.45 (4.02)	0.866	12.82 (4.56)	12.60 (4.31)	0.670
Total, % (n)		171	25.73 (44)		131	38.17 (50)

Boldface indicates statistical significance (p < 0.05).

AFAB, assigned female at birth; AMAB, assigned male at birth; SD, standard deviation.

PCA results

The PCA resulted in three components, comprising a total of 58.81% of the variance (Table 3). Component 1 (Eigenvalue=2.81 and Variance explained=28.25%) is characterized as enacted stigma, and comprised discrimination (Factor loading=0.53), victimization (Factor loading=0.49), and rejection (Factor loading=0.44), with a Cronbach's alpha=0.76. Component 2 (Eigenvalue=1.44 and Variance explained=18.80%) represents a positive sense of identity, and includes internalized stigma (Factor loading=−0.60), self-affirmation (Factor loading=0.63), and community connectedness (Factor loading=0.42), with an alpha=0.52. The third component was comprised of only one variable (social support; factor loading=0.85), accounting for 11.76% of the variance (Eigenvalue=1.04).

Table 3.

Principal Component Analysis Results

	Component 1	Component 2	Component 3
Gender-related discrimination	0.53
Gender-related victimization	0.49
Gender-related rejection	0.44
Mis-gendering
Internalized trans-related stigma		−0.60
Anticipated trans-related stigma
Self-affirmation		0.63
Social support			0.85
Community connectedness		0.42
Eigen value	2.81	1.44	1.04
Variance explained, %	28.25	18.80	11.76
Cronbach's alpha	0.76	0.52

Logistic regression results

Regression models examining health care outcomes included computed scores from each component, the additional minority stress variables not included in components (gender nonaffirmation and anticipated stigma), and the additional covariates.

Difficulty accessing care

In the main effects model for difficulty accessing health care, age was the only significantly associated variable (Table 4). For each additional year of a participant's age, they were 16% more likely to report having difficulty accessing health care (p=0.049). In separate models, two interaction terms (grounded in Minority Stress Theory^12,13,21) were also examined, including the interaction between positive sense of identity (component 2) and enacted stigma (component 1), as well as positive sense of identity (component 2) and anticipated stigma (included as its own variable). The interaction between enacted stigma and a positive sense of identity was the only interaction term significantly associated with difficulty accessing care.

Table 4.

Logistic Regression Results Examining the Relationships Between Minority Stress Theory Components and Health Care Use Among Transgender and Other Gender Diverse Youth

	Difficulty accessing care (n=171)			Used medical gender affirmation services (n=131)
	Odds ratio	95% CI	p	Odds ratio	95% CI	p
Main effects model results
Enacted stigma (Component 1)a	1.03	0.70–1.52	0.884	1.04	0.64–1.68	0.867
Positive sense of identity (Component 2)b	1.12	0.82–1.53	0.475	1.73	1.15–2.59	0.008
Social support (Component 3)c	0.86	0.57–1.30	0.474	1.35	0.80–2.27	0.267
Mis-gendering	1.03	0.94–1.14	0.523	0.93	0.83–1.05	0.220
Anticipated trans-related stigma	0.99	0.95–1.05	0.904	0.92	0.86–0.98	0.012
Age	1.16	1.00–1.34	0.049	1.63	1.29–2.07	<0.001
Gender identity
Trans-feminine	Reference group			Reference group
Trans-masculine	1.96	0.63–6.13	0.247	1.02	0.31–3.41	0.967
Other gender diverse (AMAB)	0.82	0.18–3.60	0.788	0.07	0.005–0.99	0.049
Other gender diverse (AFAB)	1.81	0.54–6.02	0.334	0.08	0.01–0.47	0.005
Race/ethnicity
Non-Hispanic white	Reference group			Reference group
Racial minority	1.85	0.86–3.99	0.115	0.78	0.27–2.21	0.635
Region
Northeast	Reference group			Reference group
Midwest	1.45	0.44–4.77	0.540	0.24	0.05–1.03	0.055
South	1.15	0.36–3.73	0.810	0.21	0.05–0.84	0.028
West	1.23	0.35–4.40	0.745	1.06	0.26–4.35	0.940
Health insurance
Does not have insurance coverage	Reference group			Reference group
Has insurance coverage	0.52	0.18–1.52	0.230	1.39	0.27–7.19	0.698
Significant interaction term results
Enacted stigma (Component 1)×positive sense of identity (Component 2)
Enacted stigma quartile 1	Reference group
Enacted stigma quartile 2	1.79	0.70–4.58	0.222
Enacted stigma quartile 3	1.53	0.60–3.90	0.378
Enacted stigma quartile 4	4.35	1.53–12.38	0.006

Boldface indicates statistical significance (p < 0.05).

^aComponent 1 comprised gender-related discrimination, gender-related victimization, and gender-related rejection.

^bComponent 2 comprised internalized trans-related stigma (reversed), self-affirmation, and community connectedness.

^cComponent 3 comprised social support.

CI, confidence interval.

To better understand the interaction, the enacted stigma component was examined as a categorical variable, based on a quartile split, ranging from the lowest (first quartile) to the highest (fourth quartile) reports of enacted stigma. Figure 1 demonstrates that for participants experiencing the most enacted stigma, as their positive sense of identity increased, the predicted probability of having difficulty accessing health care also increased. However, for participants reporting the least enacted stigma, as their positive sense of identity increased, the predicted probability of having difficulty accessing care decreased.

FIG. 1.

Predicted probability of having difficulty accessing care across the positive sense of identity component for TDGY youth with the lowest and highest enacted stigma scores. TGDY, transgender and other gender diverse youth.

Use of medical gender affirmation services

The main effects model examining the use of medical gender affirmation services (Table 4) found that participants experiencing a greater positive sense of identity were more likely to access medical gender affirmation (adjusted odds ratio [aOR]=1.73, p=0.008) and participants experiencing more anticipated stigma were less likely to access medical gender affirmation (aOR=0.092, p=0.012). Older participants were more likely to report using medical gender affirmation services (aOR=1.63, p<0.001). Compared with trans-feminine participants, those identifying as another gender diverse identity were less likely to report accessing medical gender affirmation (AMAB aOR=0.07, p=0.049; AFAB aOR=0.08, p=0.005). Finally, participants living in the South were less likely to use medical gender affirmation services (aOR=0.21, p=0.028), compared to those in the Northeast. Interaction terms between stigma and a positive sense of identity were tested, but were not statistically significant.

Discussion

Findings suggest that stigma and resilience experienced across multiple settings matter for access to different types of health care for TGDY. Even though PCA results were not identical to Minority Stress Theory,^12,13 results were still grouped according to positive (i.e., a positive sense of identity) and negative (i.e., transgender-related stigma) components. When examining associations between these positive and negative experiences across multiple health care outcomes, findings varied by health care type.

For difficulty accessing care, although none of the Minority Stress Theory variables was associated with the health care outcome, the interaction between enacted stigma and a positive sense of identity was significant. For individuals experiencing more stigma, as their positive sense of identity increased, the predicted probability of experiencing difficulty accessing care also increased. However, for individuals experiencing less stigma, as their positive sense of identity increased, the predicted probability of having difficulty accessing care decreased. It is possible that TGDY experiencing more enacted stigma may try to access more care when they have a more positive sense of identity. These increased attempts to access care may lead to more difficulty accessing care. On the other hand, TGDY who experience less enacted stigma may benefit more from a positive sense of identity as a way to improve access to care.

Results differed for the medical gender affirmation outcome. Aligned with Minority Stress Theory,^12,13 anticipating more stigma was associated with less use of medical gender affirmation services. Individuals who generally expect that more stigma will occur may also be more likely to anticipate stigma within health care settings, which could prevent them from accessing medical gender affirmation services. In addition, anticipated stigma in other environments (e.g., home and school) may prevent TGDY from accessing medical gender affirmation, especially if there are concerns about anticipated stigma related to outness and changes to gender presentation.

Having a positive sense of identity was associated with increased medical gender affirmation service use. Particularly, with medical gender affirmation services, being connected to a community may help TGD individuals navigate health care systems and find providers who offer medical gender affirmation services. However, it is also possible that, for individuals who want to access medical gender affirmation, using this type of health care may promote a process of internalized self-affirmation and may reduce internalized stigma.⁵

Gender diverse participants not identifying as transgender were less likely to report using medical gender affirmation services. This suggests that norms around medical gender affirmation may create additional challenges for individuals who experience gender diversity, but do not identify as transgender. Health care settings should consider the unique needs of gender diverse individuals not identifying as transgender, who seek medical gender affirmation. Findings also demonstrate that TGDY living in the South were less likely to access medical gender affirmation. Many states in the U.S. South have less accepting social/political environments for TGD people³²; current findings are aligned with extant research demonstrating that living in states with less accepting social/political environments is detrimental to both health and health care access.^32–34

Current findings are consistent with previous research highlighting that stigma and resilience play a role in TGDY's access to health care.^10,35 This study builds on extant literature by highlighting how minority stress and resilience occurring across multiple settings may play a role in health care use, and that these relationships vary across different types of health care. More research is still needed to better understand these relationships across different types of care, including mental health care and emergency care.

To improve TGDY's health care access, experiences of stigma both inside and outside of health care settings should be addressed. Stigma and resilience occur across multiple settings^7,11 and experiences are distinct for TGDY. For example, TGDY may rely on parents or guardians for access to health care (e.g., transportation to care, paying for care, and consent for accessing services); when TGDY do not have family support, but instead experience stigma, health care (and especially medical gender affirmation services) may not be an available and affordable option.^36,37 Therefore, while addressing stigma within health care settings is important, public health programs that work to address stigma and foster resilience across multiple environments may be more successful at improving TGDY's access to health care.

Limitations

This study is cross-sectional, so causal inferences cannot be made. The study was comprised of a convenience sample of TGDY. Convenience samples are common for recruiting hard-to-reach populations such as TGDY³⁸; however, caution should be taken when generalizing results. Furthermore, since data were from an HIV testing intervention study, eligibility criteria required for the intervention limit the sample. The small sample size may also limit the study's power to detect significant associations; however, PCA was used to reduce data and ensure maximum ability to detect associations.²⁸ The small sample limited the variables included in the models,²⁸ excluding possible additional covariates (e.g., education, homelessness, poverty, and mental and physical health status). Furthermore, we were unable to determine if participants accessed health insurance through parents or guardians, since this was not asked in the survey. Finally, even though the scales were tested among TGDY, they were developed for adults. Future research should consider developing youth-specific scales examining transgender-related stigma. Future studies should also consider examining the relationships between stigma, resilience, and health care use with larger samples that allow for an examination of multiple covariates. Still, this sample demonstrates diversity across gender (with 40% identifying as another gender diverse identity) and the scales included in this study are useful for exploring relationships between minority stress, resilience, and health care.

Conclusions

This study demonstrates that stigma and resilience experienced across multiple settings are associated with different types of health care use. Understanding the nuanced role that stigma and resilience play in health care use is important, especially when considering these relationships across multiple types of health care. Stigma and resilience occur across multiple settings and it is important to reduce stigma and foster resilience both inside and outside of health care to increase health care access among TGDY.

Abbreviations Used

AFAB

assigned female at birth

AMAB

assigned male at birth

aOR

adjusted odds ratio

IVs

independent variables

PCA

principal components analysis

TGD

transgender and other gender diverse

TGDY

transgender and other gender diverse youth

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This work received support from the Population Research Training grant (T32 HD007168) and the Population Research Infrastructure Program (P2C HD050924) awarded to the University of North Carolina at Chapel Hill by the Eunice Kennedy Shriver National Institute of Child Health and Human Development R01HD078131.

Cite this article as: Goldenberg T, Kahle EM, Stephenson R (2020) Stigma, resilience, and health care use among transgender and other gender diverse youth in the United States, Transgender Health 5:3, 173–181, DOI: 10.1089/trgh.2019.0074.