Abstract
A geospatial analysis of services that support transgender and gender diverse (“trans”) people in New York City (NYC) was conducted to investigate associations with neighborhood-level sociodemographic characteristics. In June 2019, there were 5.3 services for every 100,000 of the general NYC population; controlling for other covariates, they were more commonly located in neighborhoods with larger populations of non-Hispanic Black (rate ratio [RR]=1.02, 95% confidence interval [CI]: 1.00–1.04), Hispanic/Latino (RR=1.03, 95% CI: 1.00–1.06), and gay/lesbian people (RR=1.53, 95% CI: 1.03–2.34). These findings suggest that the distribution of trans-focused services in NYC is proximal to communities that are most in need, but research should examine proximity to trans people specifically and distribution in nonurban areas.
Keywords: geospatial, health equity, nonbinary, spatial epidemiology, transgender
Introduction
Transgender (“trans”), gender nonbinary, and other gender diverse people face numerous disparities in the context of their health and well-being, many of which are particularly prominent at the intersections of race and socioeconomic status.1,2 Especially notable health disparities among trans and gender diverse people in the United States include mental health and sexual and reproductive health,1 and these populations often face barriers to culturally competent health care.2 Fortunately, in some parts of the United States, services exist that provide population-specific care and support in terms of physical and mental health, gender affirmation, legal and housing needs, and social issues. Generally, research with diverse populations, conditions, and contexts has shown that proximity to health services is a key factor in their utilization,3 but this reality remains largely unexamined among trans and gender diverse populations.
Existing geographically situated research among trans and gender diverse people in the United States has predominantly focused on differences along state lines. This research has found that the state in which trans and gender diverse people live is associated with mental health outcomes and refusals of care,4,5 whereas state-level gender-affirming insurance coverage and public policy are associated with access to and uptake of health care.6,7 Although understanding state-level factors in the health and health care of trans and gender diverse people is important, access among trans and gender diverse people to health and support services must also be examined within individual states and cities.
Although there has been little geospatial-focused research with trans and gender diverse conducted to date, one study of lesbian, gay, bisexual and transgender (LGBT) services distribution in Chicago found that they were disproportionately situated within white, upper-income neighborhoods.8 This study illuminated important disparities in service placement in one large U.S. city but by collapsing LGBT services into a single category did not attend to the unique needs of trans and gender diverse populations. Further, the geographic and social specificity of Chicago makes it difficult to apply the findings to guide service planning and delivery in other cities, including New York City (NYC).
NYC is the largest and most densely populated U.S. city, with an overall population that is among the most diverse nationally in terms of race and socioeconomic status.9 NYC also has a long and storied history as a center for communities of trans and gender diverse people both globally and in the United States.10 To better understand the geospatial distribution of health and support services for trans and gender diverse people in NYC and guide future efforts to improve access and uptake, this study presents an analysis of neighborhood-level sociodemographic characteristics that define the placement of these services.
Methods
In June 2019, data were extracted from a publicly available resource known as “TransAtlas” (https://callen-lorde.org/transmap/), which collates geocoded information on a diverse host of NYC-based health and support services for trans and gender diverse people. TransAtlas is managed by the Callen-Lorde Community Health Center, which is one of the largest providers of care for trans and gender diverse people in the United States, employs trans and gender diverse staff, and is supported by a Community Advisory Board comprising numerous leaders from NYC's trans and gender diverse communities. TransAtlas is a “living” database, which means that the expertise and community connections of Callen-Lorde are used by staff on an ongoing basis to identify services, confirm offerings and details, update lists, and remove any identified as inactive.11 The tool provides an interactive map with which users can identify the location, contact details, and general description of services that specifically support trans and gender diverse people, organized into broad categories including mental health, housing, legal aid, gender affirmation, primary health care, and HIV prevention and management.
For each service listed by TransAtlas, as of June 4, 2019, line-listed data were extracted, comprising its name, location (longitude and latitude), description of services, and service category. Using the defined service categories and service descriptions, each service was recoded into three broad and nonexclusive categories: (1) general health care (i.e., primary care, mental health, reproductive services, HIV management, sexual health care), (2) gender affirmation (i.e., surgeons, speech therapy, endocrinology), and (3) social and other support (i.e., legal aid, housing support, substance use and addiction support, religious groups, general social support, advocacy, and activism). To assess potential omissions, service listings were reviewed by an individual familiar with NYC's trans and gender diverse communities with any uncertainty resolved by examining service websites if available or contacting the service directly; through this process we identified four additional potentially relevant organizations, but these were determined to not offer direct services and were, therefore, not included. This review also identified and excluded 25 services listed in TransAtlas that either did not provide direct services (n=11) or may have been relevant to gender affirmation (e.g., electrolysis and hair removal) but were not necessarily specific to trans and gender diverse people (n=14).
The number of trans and gender diverse services were counted by ZIP code tabulated areas (ZCTAs) within ArcGIS (ESRI, Redlands, CA, USA). The ZCTA was selected for this analysis to minimize the risk of sparse data bias from using a smaller boundary like census tract,12 and because of its utility in the planning of services and policy.3 The number of trans and gender diverse services by ZCTA was counted by types and used as our outcome measure; these were also calculated as a rate standardized per 100,000 of the overall population. Descriptive analyses were conducted. To investigate associations between service distribution and sociodemographics, data from the U.S. Census Bureau were used to assign median household income as well as proportions of the total population of each ZCTA-defined neighborhood that were non-Hispanic Black, non-Hispanic Asian and/or Pacific Islander, non-Hispanic of other racial backgrounds, Hispanic, without health insurance, and living in a same gender partnered household.13 These were selected based on the nature of this study's aims and their past significance in geospatial research investigating LGBT service placement in Chicago.8
To assess associations between ZCTA-defined neighborhood sociodemographics and the geospatial distribution of trans and gender diverse services in NYC, we employed conditional autoregressive models using a row-standardized binary contiguity spatial weight matrix with first-order queen's criteria. We used Besag-York-Mollié (BYM), a Bayesian hierarchical spatial model (lognormal Poisson) that includes spatial auto-correlation and an ordinary random-effects components for nonspatial heterogeneity.14 For this model, we used a Poisson link function for the distribution of trans and gender diverse services based on 10,000 Markov chain Monte Carlo samples, which were obtained by running the chain for 50,000 samples, with 10,000 being discarded as the burn-in period and the remaining 40,000 being thinned by four to reduce autocorrelation.
Posterior estimates with 95% confidence intervals (CIs) were obtained to measure the associations between services and neighborhood sociodemographics as well as to determine significance. This analysis was conducted overall and among the three service types defined by this analysis (i.e., general health care, gender affirmation, and social and other support) using the R software package “CARBayes.” To assess goodness-of-fit, Deviance Information Criterion (DIC) was estimated for our BYM models and for the same analyses carried out using nonspatial Poisson regression and Leroux's mixed model for spatial dependence.
Results
In June 2019, the TransAtlas database included 356 unique service listings that supported trans and gender diverse people in NYC; 30 organizations operated branches or programs at multiple locations, representing 207 individual organizations. Among the total unique listings, in the nonexclusive service categories a total of 232 (65.2%) services were identified as providing general health care, 20 (5.6%) gender-affirming care, and 275 (77.3%) social and other forms of support. Seven services provided support across all three domains (2.0%). The dataset used for this analysis has been published and can be accessed via the service figshare (10.6084/m9.figshare.14207351).
Services were identified within each of the five boroughs of NYC, including 166 in Manhattan (46.6%), 80 in the Bronx (22.5%), 70 in Brooklyn (19.7%), 27 in Queens (7.6%), and 13 in Staten Island (3.7%); see Figure 1 for a map. Of the total population, there were 5.3 services total per 100,000 people (standard deviation [SD]=9.92), 2.9 per 100,000 dedicated to general health (SD=4.6), 0.5 per 100,000 to gender-affirming services (1.8), and 2.1 per 100,000 to social and other support services (SD=6.2).
FIG. 1.
Spatial distribution of health and support services for transgender, gender nonbinary, and other gender diverse people in NYC. Data extracted in June 2019 from the digital resource, TransAtlas.11 GAP, Gender-Affirming Care; NYC, New York City; ZCTA, ZIP code tabulated areas.
Results of the multivariable analyses are presented in Table 1. In the BYM multivariable model, trans and gender diverse services of all types in NYC were more commonly located in ZCTA-defined neighborhoods with a greater proportion of Black, Latino, and Hispanic racial/ethnic groups and a greater proportion of people living in same gender partnered households. For example, while controlling for other covariates, a one percentage point increase in a ZCTA's non-Hispanic Black population was associated with a 2% increase in the expected count of trans and gender diverse services, whereas a one-point increase in the proportion of same gender partnered households was associated with a 53% increase in expected services (rate ratio [RR]=1.53, 95% CI: 1.03–2.34).
Table 1.
Multivariable Model Estimations (Besag-York-Mollié) for the Relationships Between Neighborhood-Level Population Sociodemographics and Density of Trans and Gender Diverse Services in New York City
| Neighborhood characteristica | Trans and gender diverse service typeb RR (95% CI) |
|||
|---|---|---|---|---|
| All | General health | Gender affirming care | Social/other support | |
| Total population (in 1000) | 1.02 (1.01–1.03) | 1.02 (1.01–1.03) | 1.04 (1.02–1.06) | 1.02 (1.01–1.03) |
| Black, non-Hispanic | 1.02 (1.00–1.04) | 1.02 (1.00–1.05) | 0.99 (0.94–1.02) | 1.03 (1.01–1.06) |
| Asian, non-Hispanic | 1.03 (0.99–1.06) | 1.02 (0.99–1.07) | 1.01 (0.95–1.06) | 1.03 (1.00–1.09) |
| “Other” race, non-Hispanicc | 1.06 (0.97–1.15) | 1.05 (0.94–1.15) | 1.07 (0.87–1.21) | 1.07 (0.92–1.19) |
| Latino/Hispanicd | 1.03 (1.00–1.06) | 1.02 (0.99–1.07) | 1.00 (0.94–1.06) | 1.05 (1.02–1.09) |
| Median income (in $1000) | 1.00 (0.98–1.01) | 0.99 (0.98–1.01) | 1.01 (0.98–1.03) | 1.01 (0.99–1.03) |
| Uninsured | 0.98 (0.89–1.08) | 0.95 (0.85–1.05) | 0.98 (0.79–1.20) | 0.98 (0.86–1.10) |
| Same gender household | 1.53 (1.03–2.34) | 1.33 (0.87–2.01) | 1.06 (0.61–1.84) | 2.49 (1.57–4.23) |
| DIC | ||||
| BYM (results shown here) | 513 | 442 | 165 | 301 |
| Nonspatial Poisson (results not shown) | 771 | 561 | 206 | 360 |
| Leroux's model (results not shown) | 513 | 442 | 166 | 302 |
Bold=p<0.05.
Neighborhoods defined using ZIP code tabulated areas, with sociodemographic characteristics assigned using the American Community Survey.13
Service listings extracted from the TransAtlas tool in June 2019.11
Includes all racial groups other than Black and White among those of non-Hispanic ethnicity.
Includes all racial groups with Hispanic ethnicity.
BYM, Besag-York-Mollié; CI, confidence interval; DIC, Deviance Information Criterion; RR, rate ratio.
Similar relationships were observed among general health organizations and those that provided social and other forms of support, but no relationships between the location of gender-affirming services and neighborhood sociodemographic characteristics were observed (although we note the small number of such services [n=20] included in our analysis). Across the models, we observed no relationship between the geospatial distribution of trans and gender services and household income or insurance coverage. As described, these analyses were repeated using nonspatial Poisson and Leroux's regression models; results were generally similar between these different approaches and BYM consistently demonstrated lower DIC values, suggesting superior goodness-of-fit (Table 1).
Discussion
This study provides the first geospatial analysis of services that support the health and well-being of trans, gender nonbinary, and other gender diverse people in NYC. Trans and gender diverse services were most commonly situated within neighborhoods, with higher proportions of racial and ethnic minority groups and same gender partnered households. Given the unique health barriers and disparities that face trans and gender diverse people of color,15–18 it is promising that services for this population in NYC are located in neighborhoods that are racially and ethnically diverse. That we observed no relationship between service placement and either income or insurance coverage in NYC neighborhoods, however, suggests that greater efforts could be paid to ensuring these services are geographically proximal to trans and gender diverse people of lower socioeconomic status.
Households comprising same gender partners can serve as a useful proximal marker for a neighborhood's overall population of gay and lesbian people,19 suggesting that services for trans and gender diverse people tend to be situated in the “gayborhoods” of NYC. Although gayborhoods are often conceptualized as broadly inclusive of all LGBT people,20 research from NYC has found that among some trans and gender diverse people—particularly those of color—they are viewed with suspicion as spaces of whiteness, gentrification, and sites of potential stigma and discrimination.21 This finding echoes results of earlier Chicago-based geospatial research, which concluded that the disproportionate placement of LGBT services in urban gayborhoods could diminish access to people of color and lower socioeconomic status.8 Enhanced data are needed to define the settlement patterns of trans and gender diverse people as distinct from cisgender gay and lesbian populations, which will help guide more appropriate and accessible placement of health and support services. Further, given what many have noted as the gentrification of traditional gayborhoods in many urban centers,22 future research should seek to contend specifically with the displacement of trans and gender diverse people and its role in distancing them from the services for which they have need.
Our analysis identified only a small number of clinical options for gender-affirming care available to trans and gender diverse people in NYC, especially relative to other population-focused services. Access to gender-affirming surgeries and procedures is incredibly important for the health and well-being of many trans and gender diverse people23 and it is troubling that even in a city as large NYC, so few options were available. The sparsity of gender-affirming care may explain why numerous other studies have highlighted a lack of access and long wait times as prominent barriers.2 To address these barriers, greater investment is needed in training and situating a greater number of gender-affirming care providers in diverse locations around NYC. Location, however, is only one aspect of service access, and although this study did not attend to issues such as affordability and patient capacity, it is clear that a multifaceted and multilevel approach is needed to truly ensure that the service needs of trans and gender diverse people are met.
There are several limitations inherent in this study, including our definition of what constitutes a neighborhood. Although the use of ZCTAs was done so for practical purposes pertaining to analysis and future planning, the mobile areal unit problem must, nevertheless, be considered when interpreting our findings.3 It should also be noted that relevant services may have been missing from our dataset, although this potential was likely minimized by the review processes described earlier and the “living” nature of TransAtlas, which means it is regularly reviewed and updated. A further note is that our analysis could not account for mobile health services, although at the time of data collection only one mobile service that explicitly targeted trans and gender diverse communities was known to be operating in NYC by the same center responsible for TransAtlas.
Findings from this study suggest that in many ways services for trans and gender diverse people are well placed to support access among subpopulations that are most in need. These insights are important given that the growing attention to neighborhoods is a defining feature in the health and well-being of trans and gender diverse populations.24 Given that each city is unique, and NYC has many features that make it entirely unique in the U.S. context, it is not realistic to generalize our findings to other places; similar analyses should be undertaken to guide service planning in other parts of the United States. Further, research has found that trans and gender diverse people in rural areas experience unique needs for and barriers to service access,25 suggesting that geospatial analyses could benefit efforts to reduce disparities in nonurban parts of the country.
Abbreviations Used
- BYM
Besag-York-Mollié
- CI
confidence interval
- DIC
Deviance Information Criterion
- LGBT
lesbian, gay, bisexual and transgender
- MCMC
Markov chain Monte Carlo
- NYC
New York City
- RR
rate ratio
- ZCTA
ZIP code tabulated areas
Author Disclosure Statement
The authors have no competing interests to report. TransAtlas tool is funded through and managed by the Callen-Lorde Community Health Center; there are no financial benefits arising from this product.
Funding Information
This study was conducted as the Trying to Understand Relationships, Networks and Neighborhoods (TURNNT) Study (www.turnnt.com), which received funding from the National Institute on Minority Health and Health Disparities (R01MD013554; 3R01MD013554-02S1).
Cite this article as: Callander D, Kim B, Domingo M, Tabb LP, Radix A, Timmins L, Baradaran A, Clark MB, Duncan DT (2022) Examining the geospatial distribution of health and support services for transgender, gender nonbinary, and other gender diverse people in New York City, Transgender Health 7:4, 369–374, DOI: 10.1089/trgh.2020.0144.
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