The Direct and Indirect Effects of Enacted Stigma on Psychological Distress and Healthcare Satisfaction Among Transgender Adults in the United States

Introduction: Transgender persons in the United States experience multiple stigmas due to their gender identity. These experiences heighten discrimination and victimization, resulting in higher levels of anxiety and depression and avoidance of seeking healthcare services. Additionally, transphobia in healthcare settings manifests as misgendering, denial of access to services, and unequal treatment, contributing to decreased healthcare satisfaction and increased healthcare underutilization and treatment attrition. Despite the high prevalence of enacted stigma or discrimination experienced by transgender persons, its direct and indirect roles in mental health and healthcare satisfaction remain understudied. This study seeks to fill this gap by examining the direct and indirect effect of enacted stigma on psychological distress and healthcare satisfaction. Study findings may inform the development of effective interventions that address the multifaceted experiences of transgender persons when accessing healthcare services.

Methods: Data from TransPop (2016–2018), a nationally representative survey of transgender persons (n=274) in the United States were analyzed using Structural Equation Modeling (SEM). Enacted stigma was measured using items assessing participants’ experiences of victimization and discrimination. Psychological distress was measured using the Kessler-6 (K6) scale, a widely recognized tool for assessing non-specific psychological distress in population surveys. Healthcare satisfaction was a self-reported measure of participants’ overall satisfaction with the healthcare they received. Model covariates included race, education, poverty, and visual conformity based on appearance and mannerisms.

Results: Results indicated a good model fit of our hypothesized structural relationship with the observed data (CFI = 0.973, TLI = 0.969, RMSEA = 0.056). Frequent experiences of enacted stigma were associated with higher psychological distress (β=0.34, p<.001), whereas higher psychological distress was associated with lower healthcare satisfaction (β=-0.28, p < .001). Although enacted stigma was not directly associated with healthcare satisfaction (p=.127), it was indirectly associated with healthcare satisfaction via psychological distress (β=0.093, p<.001), indicating a partial mediation.

Conclusion: Enacted stigma is a critical factor directly affecting mental health and indirectly affecting healthcare satisfaction. These results highlight the psychological burden of stigma and its downstream effects on healthcare access and utilization among transgender persons. Our findings also emphasize the importance of assessing the role of different manifestations of transgender stigma, for example, enacted, internalized, and anticipated, as they might have different effects on mental health and healthcare satisfaction—reflecting both risk and resiliency among transgender persons. Finally, our findings underscore the need for transformative change in social work by addressing stigma, particularly enacted stigma, as a determinant of mental health and healthcare satisfaction. Interventions must target enacted stigma to reduce psychological distress, which in turn can improve healthcare experiences. Policies and practices should integrate trauma-informed, anti-stigma approaches that value mental well-being and promote affirming care environments.