Assessing access to care for transgender and gender nonconforming people: A consideration of diversity in combating discrimination

Highlights

• Transgender/gender-nonconforming individuals postpone seeking care at high rates.

• Different predictors are associated with different reasons for postponement.

• Use of broad gender categories masks considerable differences among this population.

• Diversity among this population needs to be taken into account in future research.

Abstract

Transgender and gender nonconforming people face stigma and discrimination from a wide variety of sources and through numerous social realms. Stigma and discrimination originating from biomedicine and health care provision may impact this group's access to primary care. Such stigma and discrimination may originate not only from direct events and past negative experiences, but also through medicine's role in providing treatments of transitioning, the development of formal diagnoses to provide access to such treatments, and the medical language used to describe this diverse group. This paper examines the postponement of primary curative care among this marginalized group of people by drawing from the National Transgender Discrimination Survey, one of the largest available datasets for this underserved group. This paper also proposes an innovate categorization system to account for differences in self-conceptualization and identity, which has been of considerable concern for transgender and gender nonconforming communities but remains underexplored in social and health research. Results suggest that experience, identity, state of transition, and disclosure of transgender or gender nonconforming status are associated with postponement due to discrimination. Other findings suggest that postponement associated with primary place of seeking care and health insurance has ties to both discrimination and affordability. These findings highlight the importance of combating stigma and discrimination generated from within or experienced at sites of biomedicine or health care provision in improving access to care for this group of people. Improving access to care for all gender variant people requires a critical evaluation of existing research practices and health care provision to ensure that care is tailored as needed to each person's perspective in relation to larger social processes.

Introduction

This paper seeks to explore access to care among transgender and gender nonconforming (trans and GNC) people through a quantitative analysis of primary care postponement. Trans and GNC people face stigma and discrimination across numerous areas of life, which shapes their social experiences and realities (Bradford et al., 2013, Bauer et al., 2009). Real or perceived stigma and discrimination originating from within biomedicine and health care provision may impact this marginalized group of people's access to care (Bockting et al., 2004, Cobos and Jones, 2009). Additionally, stigma and discrimination may be experienced differently among this diverse group of people along the lines of identity, experience, and social positioning (Lombardi, 2009, Lombardi et al., 2002). Given trans and GNC people's historically uneasy relationship with biomedicine due to social stigma originating from formal diagnoses and the barriers encountered in receiving hormones, surgeries, and other treatments of transition (Drescher et al., 2012), this group of people faces unique considerations in addressing access to primary care issues. However, newer forms of identification and organization among this group of people potentially pose new and different social relations toward health care providers and treatments of transitioning than those often described in existing medical discourse and research. The purpose of this study is two-fold: first, to define and incorporate what diversity means in this population in an adequate and comprehensive manner by introducing a new categorization scheme of difference, and second, to determine how such diversity impacts the postponement of care.

I begin by reviewing the literature on stigma, discrimination, and access to care for this group of people, and follow by describing differences among trans and GNC people along the lines of identity and experience. I then conduct regression analyses using data from the National Transgender Discrimination Survey to explore associations between these and other points of difference and postponement of primary curative care, including the reason provided for such postponement. Finally, I discuss implications of these findings for access to care among trans and GNC people and for health research with this group more broadly.