(WITHDRAWN) More Than an Apple a Day: Health Care Utilization Among Transgender People in the U.S

Background and Purpose
Transgender people often experience risk for chronic diseases such as diabetes mellitus, cardiovascular disease, cancer, and osteoporosis at similar rates to cisgender (non-transgender) people. Nevertheless, transgender people tend not to utilize health care at rates similar to the non-transgender population. This lack of utilization has been attributed to discrimination and negative experiences with health care providers (HCPs), and it commonly results in short-term and long-term unfavorable health outcomes. In 2015, the National Center for Transgender Equality launched the U.S. Trans Survey (USTS), the largest study to date (n=27,715) of the health care experiences of transgender people living in the U.S.

Methods
The current study was a secondary analysis of the USTS dataset, with a nonprobability sample of self-identified transgender adults who reported being 18 or older and living in the U.S., an overseas military base, or the territories of American Samoa, Guam, or Puerto Rico. Andersen’s Behavioral Model of Health Services Use (BMHS) provides a theoretical underpinning for the current study. This model attempts to explain how both the characteristics of a population and their environment lead to specific health behaviors. Hierarchical regression was used in order to test a conceptual model of independent variables including demographic factors, perceptions of gender conformance, psychological distress, perceptions of health care provider (HCP) knowledge, perceptions of HCP discrimination, cost, and health insurance status on the dependent variable of utilization of health care.  

Results
Nearly one-eighth (12.3%) of the sample reported not seeing a doctor or HCP at all in the past year. Many participants (38.5%) had experienced serious psychological distress, and more than half of them (55.5%) had been verbally harassed. Nearly half of participants (48.2%) did not have a transgender-related HCP. Almost a third (31.5%) did not visit a doctor or HCP at some point in the past year due to cost. Health insurance (OR=3.92, p<0.001), perception of provider knowledge (OR=3.20-11.04, p<0.001), educating a provider (OR=1.96, p<0.001) and cost (OR=1.37, p<0.001) were significant predictors of utilization of health care.  

Conclusions and Implications

The current study showed the major impact that perception of HCP knowledge, health insurance, and cost have on utilization of health care among transgender people. Providers’ level of knowledge about transgender health concerns produced the strongest effect sizes. This finding is highly relevant for health professional schools, including schools of social work, and they should provide more stand-alone content focused on serving transgender individuals while reducing transphobia through direct contact with transgender people. A lack of visibility of transgender people in the curriculum contributes to the structural discrimination and institutional erasure that transgender people must constantly navigate in a transphobic society. Additionally health insurance policies in the U.S. must provide comprehensive coverage for transgender affirming, medically necessary care so that the burden of health care costs for transgender people can be significantly reduced.