Mental Health and Mental Healthcare Among Transgender Adults in the United States

Abstract

Transgender populations, comprised of individuals whose gender identity differs from their sex assigned at birth, face substantial mental health and substance use inequities compared with cisgender (i.e., non-transgender) people in the United States (US). Research has consistently linked stigma-related stress at the individual and interpersonal levels to negative mental health and substance use outcomes. Fewer studies have considered structural stigma, defined as the systematic devaluation and marginalization of transgender people by institutional policies and practices (e.g., through state laws). Additionally, while research has investigated social stressors as correlates of suicidality among transgender populations, less work has focused on healthcare following suicide attempts – a critical point of intervention to prevent against future attempts. Leveraging health data from both self-report and electronic health records within the All of Us Research Program, and data on structural stigma from the Movement Advancement Project, this dissertation investigated the factors associated with mental health, including structural stigma and healthcare utilization, in transgender populations. In Chapter 1, I first investigated differences in a range of prevalent mental health and substance use outcomes between transgender and cisgender adults. I then evaluated the association between state-level structural stigma and mental health and substance use inequities, exploring differences by race/ethnicity. I found that inequities between transgender and cisgender adults persisted across all policy contexts for most mental health outcomes. Inequities were generally wider in states with low to medium policy protections compared to states with high protections, but were narrower in states with negative levels of protection. Moreover, there was heterogeneity by race/ethnicity, highlighting the importance of considering intersecting social identities in psychiatric epidemiology research. Chapter 2 extended this work to assess incident mental health outcomes, documenting that mental health inequities were most pronounced for transgender young adults. Using a falsification test with cisgender heterosexual participants as a comparison group, this chapter strengthens existing research and provides evidence that associations between structural stigma and incident depression and anxiety are specific to transgender populations. In Chapter 3, I then examined mental healthcare utilization via inpatient and emergency department visits for suicidal ideation and attempts. I found that transgender participants had higher hazards of suicidality-related rehospitalization compared to cisgender participants among those ages ≤25 years, whereas no difference was observed among adults >25 years. I also replicated prior findings demonstrating that the hazard of rehospitalization was highest within the first month post-discharge. Lastly, I identified predictors of rehospitalization among transgender and cisgender participants to contribute to limited existing research in this area. The findings of this dissertation underscore the need for policy interventions to reduce structural stigma, as well as healthcare interventions to ensure timely continuity of care after suicide-related hospitalizations, particularly for transgender young adults. Taken together, these chapters explored previously understudied areas in transgender health to paint a more comprehensive picture of mental health inequities, gaps in psychiatric care, and opportunities to improve health and foster well-being for transgender people.