Skip to main content
Full access
Articles
Published Online: 29 October 2019

Health Insurance and Mental Health Care Utilization Among Adults Who Identify as Transgender and Gender Diverse

Abstract

Objective:

Transgender people are less likely to have health insurance, which has been associated with reduced utilization of health care. In the current study, the authors sought to assess the role of health insurance in mental health care utilization among transgender individuals.

Methods:

A total of 4,334 adults who self-identified as transgender or gender diverse (neither male nor female) participated in the 2017 Trans Lifeline Mental Health Survey, which included self-report measures of current insurance type and lifetime history of having seen a therapist or psychiatric provider. Logistic regression analyses assessed the association of insurance status with lifetime utilization of a mental health therapist or psychiatric provider.

Results:

Although only 8% of the sample were uninsured, these individuals were significantly less likely to have seen a therapist or psychiatric provider in their lifetime compared with those with health insurance, even after the analyses were adjusted for sociodemographic factors. Conversely, those with insurance through the military or the Veterans Health Administration were more than twice as likely as those with employer-provided insurance to have seen a therapist or psychiatric provider. There were no significant differences in mental health care utilization between those with employer-provided insurance versus public or privately purchased insurance.

Conclusions:

Rates of being uninsured were lower than in earlier assessments of transgender adults and adults who identify as gender diverse. However, type of health insurance also appeared to be a notable structural factor contributing to disparities in mental health care utilization among transgender individuals.

HIGHLIGHTS

People who identify as transgender and gender diverse (TGD) with no health insurance were significantly less likely to have seen a therapist or psychiatrist in their lifetime.
Having insurance through the military or the Veterans Health Administration was associated with the highest rates of mental health care utilization.
There were significantly fewer people of color among participants with employer- and military- or VHA-provided insurance, which were the only insurance types to be provided directly through employment.
Individuals who identify as sexual and gender minorities are at elevated risk of a range of mental health disparities, including higher rates of mental illness symptoms and mental health care needs (1, 2). Individuals who identify as transgender and gender diverse (TGD) (neither male nor female) in particular have been found to have elevated frequency and intensity of suicidal thoughts and behaviors as well as symptoms of depression and anxiety (36). People who identify as TGD are significantly more likely to have unmet mental health needs compared with people who identify as heterosexual and people whose gender identity and birth sex align (cisgender) (2, 7), although more than 90% have reported wanting to receive or are currently receiving mental health counseling (8). Leading models of sexual- and gender-minority health disparities emphasize the ways in which structural factors such as laws and policies can contribute to disparities in mental health symptoms and related care (9, 10).
Inequalities in health insurance coverage are a major structural contributor to disparities in health symptoms and treatment (11, 12). People who identify as TGD have higher rates of being uninsured (14%–19%) than the general public (11%–17%; 8, 13, 14), which, in turn, is associated with disparities in access to care (15). Individuals who identify as TGD have also qualitatively described the lack of health insurance as a notable barrier to utilizing mental health care (16, 17).
Even among insured individuals, the type of health insurance may influence utilization of care. Among the general population, public health insurance such as Medicaid has historically been associated with increased access to mental health services compared with private insurance (12). However, individuals who identify as TGD may diverge from this pattern. Among persons who identify as TGD, those with public health insurance have reported more frequent occurrences of discrimination by medical providers and postponing care because of costs compared with those with private insurance (8). Among the privately insured, there may also be differences in access to mental health services depending on the insurance type. Individuals with privately purchased insurance are more likely to be underinsured compared with those with employer-based health care (18).
To date, few studies have assessed associations between health insurance and health disparities with TGD. Findings primarily established that individuals who identify as TGD are more likely to be uninsured than cisgender individuals and the general population (8, 1315). However, these studies were not able to indicate how insurance influenced subsequent utilization of care. In the largest survey of TGD experiences (N=27,715), the respondents again had higher rates of being uninsured than the general public (13). Additionally, treatment utilization varied by insurance type. For instance, individuals with Medicare were significantly less likely to be denied gender-affirming care (i.e., hormone therapy, surgery) than those with other insurance types, suggesting that not all insurance types offer equitable access to care. Despite this disparity in health insurance coverage, no known research has assessed how insurance coverage may influence disparities in mental health treatment among persons who identify as TGD.
The current study sought to better understand the role of health insurance in mental health care utilization among individuals who identify as TGD. Given that previous research has shown disparities in health care access among those without insurance, it was hypothesized that uninsured individuals would have a higher likelihood of having never seen a therapist or psychiatric provider than those with health insurance. Exploratory analyses then considered how mental health care utilization differed among individuals on the basis of insurance type.
Insurance type has often been grouped on the basis of whether the insurer is private or public (12). However, the Patient Protection and Affordable Care Act of 2010 (ACA) has led to an increase in the proportion of individuals who receive privately purchased insurance, which often provides significantly less coverage than employer-based insurance (18). Thus, employer-based and privately purchased insurance were assessed separately. Additionally, given that individuals who identify as TGD are overrepresented in military and veteran populations and are receiving care from the Veterans Health Administration (VHA) at rapidly increasing rates, we assessed public and military/VHA insurance separately (19). Thus differences in mental health treatment utilization were assessed on the basis of whether an individual was insured through employer, privately purchased, public, military, VHA, or other insurance.

Methods

Participants and Procedures

The current study utilized data collected in the 2017 Trans Lifeline Mental Health Survey, a collaboration between the National Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Task Force and the Trans Lifeline (20). Participants were primarily recruited online via listservs and social media to complete an online survey. Individuals were eligible if they self-identified as TGD, were older than age 18, and lived in the United States. Participants totaled 4,350 individuals who varied in their gender identity: 24% (N=1,027) masculine, 33% (N=1,442) feminine, 36% (N=1,552) nonbinary, and 6% (N=269) unspecified. Most participants self-identified as white (N=3,237, 74%). Although the rest of the sample identified themselves across more than 20 racial-ethnic minority groups, broadly speaking, 10% (N=421) identified as Hispanic (e.g., Latinx), 7% (N=322) as Native American (e.g., indigenous, American Indian), 6% (N=246) as Asian (e.g., Korean, Chinese), 6% (N=270) as multiracial (e.g., biracial, Afro-Latinx), and 5% (N=201) as black (e.g., African American, Caribbean). The most common education level was a high school degree (41%, N=1,781), with 5% (N=202) reporting less than a high school degree; 10% (N=416), an associate or technical school degree; 29% (N=1,261), a bachelor’s degree; and 16% (N=681), a graduate degree. When asked to identify all employment descriptions that applied, most participants were working at least part-time (64%, N=2,780), 11% (N= 478) were unemployed and actively looking, 24% (N=1,073) were students, 8% (N= 367) were unable to work, and 6% (N=253) were engaged in unpaid work (e.g., homemaker, retired). Participants had a mean±SD age of 32.36±13.29. Sixteen participants did not endorse an insurance category, resulting in a sample of 4,334 participants for the current study. Use of the survey data was approved as an exempt study by the University of Kentucky review board. Additional information about the sample can be found in a previous publication (20).

Measures

Sociodemographic information included gender identity, ethnic identity, yearly household income, disability identity, and sexual orientation. Questions about gender identity and sexual orientation were open ended, with the responses qualitatively coded. Gender identity was coded as masculine expression, feminine expression, nonbinary expression, or unspecified. Sexual orientation was coded as heterosexual, gay, androphilic, gynephilic, bisexual or pansexual, asexual or aromantic spectrum, or an additional or unspecified category. Racial-ethnic identity was assessed with 29 possible options (e.g., black, Afro Latinx, indigenous, Japanese, Korean); participants were able to select all that applied. Because the sample sizes in the racial-ethnic categories were not sufficient to permit analysis on the basis of racial-ethnic identity, the variable was dichotomized such that if any non-white identity was selected, the participant was categorized as a person of color.
Insurance status was a self-report question with 10 possible options that were combined into six categories: uninsured, employer insurance, purchased insurance, public insurance, military or VHA insurance, and other insurance. Insurance through a current or former employer, or someone else’s employer, was grouped under employer insurance; insurance purchased by the participant or family member and student insurance were grouped under purchased insurance; Medicare, Medicaid, state public insurance, and other public insurance were grouped under public insurance.
Mental health care utilization was assessed with two dichotomous questions. Participants were asked whether they currently or in the past had a therapist (e.g., psychologist, social worker, counselor). A second question asked whether they currently or in the past had a psychiatric provider (e.g., medication management, such as a psychiatric provider, psychiatric nurse practitioner, psychiatric physician assistant).

Analytical Strategy

Chi-square tests assessed for differences in sociodemographic characteristics of individuals on the basis of insurance status; Bonferroni-corrected, post hoc comparisons compared sociodemographic characteristics among each of the six groups. Logistic regression analyses assessed the association of insurance status with lifetime utilization of a mental health therapist or psychiatric provider while adjusting for sociodemographic characteristics (gender identity, person of color status, household income, disability, sexual orientation). In all categories, the identity with the greatest societal privilege was considered the reference (e.g., no disability, highest income bracket).

Results

Overall, the majority of the sample reported currently or previously seeing a therapist (89%, N=3,266) or psychiatric provider (52%, N=2,255). Additionally, the majority of the sample reported being insured through an employer, either their own or someone else’s (53%). The next most common insurance type was public insurance (23%), followed by purchased insurance (13%), military or VHA insurance (2%), and other insurance (1%). Of the sample, 8% reported having no insurance. Uninsured individuals were significantly more likely than those with employer-based insurance to be a person of color and to have an income of less than or equal to $19,999 (Table 1). Compared with all other insurance types, uninsured individuals were also less likely to identify as gay and more likely to identify as bisexual/pansexual or heterosexual. Those who were uninsured did not significantly differ from those with purchased insurance on the majority of demographic factors.
TABLE 1. Characteristics of 4,334 individuals who identified as transgender and gender diverse, by type of health insurancea
 No insurance (N=345)Employer- provided insurance (N=2,293)Public insurance (N=994)Purchased insurance (N=553)Military or VHA insurance (N=106)bOther insurance (N=43) 
CharacteristicN%N%N%N%N%N%p
Gender identity            <.001
 Masculine expression8525a55625b22423c12523a1918d1535d 
 Feminine expression11433a71832b38239c15629a5855d1126e 
 Nonbinary expression11133a84637b32933c22942d2019e921e 
 Unspecified329a,c1487b556a387a99a,c,d819d 
Person of color9427a54124b27928c15428d2423e1535e.026
Household income            <.001
 ≤$19,99921263a46020b65166c21740a2928d215d 
 $20,000–$49,9999127a75633b22923c17833c3837d1331d 
 $50,000–$74,999206a39818b535c6512c410a410a 
 ≥$75,000144a64729b475c,d7915c,d2120a,c410a 
Disability11935a74132b53955c21439d4946e2149f 
Sexual orientation            <.001
 Heterosexual4613a,c1627b727c244a,d55d49d 
 Gay4814a60527b21221c13625d1110e921e 
 Androphilic62a301b131a,b61a22a12a 
 Gynephilic4112a31614b14114c6812a3230a716d 
 Bisexual or pansexual14141a83036b37238c19836a4240d1740d 
 Asexual or aromantic spectrum402a23610b12112c7814a,c66d37d 
 Additional category216a,d1025b606c377a,c,d88a25a 
Mental health care utilization             
 Psychiatric provider12174a1,14590b58391c30691d7395e2278f<.001
 Therapist21735a1,70450b78859c43056d8669e3251f<.001
a
Subscripted letters within the same row denote significant differences between proportions on the basis of Bonferroni-corrected, post hoc comparisons.
b
VHA, Veterans Health Administration.
The crude prevalence rates of seeing a therapist and psychiatric provider were lowest among the uninsured individuals. In logistic regressions adjusting for sociodemographic information, individuals without insurance were significantly less likely than those insured by an employer to have seen a therapist or psychiatric provider (Table 2).
TABLE 2. Predictors of lifetime mental health treatment among individuals who identified as transgender and gender diverse, by type of provider
 TherapistPsychiatric provider
CharacteristicAORa95% CIAORa95% CI
Constant7.34***4.60–12.06.76.55–1.05
Gender identity (reference: masculine expression)    
 Feminine expression.98.72–1.33.88.72–1.07
 Nonbinary expression.86.64–1.15.88.73–1.06
 Unspecified.89.57–1.41.75.56–1.02
Person of color (reference: white)1.03.80–1.32.97.82–1.13
Household income (reference: ≥$75,000)    
 ≤$19,999.78.55–1.101.07.86–1.33
 $20,000–$49,999.76.54–1.06.97.79–1.19
 $50,000–$74,9991.32.85–2.09.89.69–1.14
Disability (reference: no)1.66***1.32–2.102.69***2.32–3.12
Sexual orientation (reference: heterosexual)    
 Gay1.77*1.10–2.811.35.99–1.85
 Androphilic1.32.52–4.081.16.61–2.21
 Gynephilic1.16.70–1.901.45*1.03–2.04
 Bisexual or pansexual1.06.68–1.601.17.87–1.58
 Asexual or aromantic spectrum1.23.74–2.051.27.90–1.81
 Additional category.95.54–1.711.02.68–1.53
Insurance (reference: employer-provided insurance)    
 No insurance.38***.27–.53.48***.36–.63
 Public insurance1.13.83–1.541.16.96–1.41
 Purchased insurance1.14.80–1.651.12.90–1.40
 Military or VHA insuranceb2.471.01–8.192.18**1.34–3.65
 Other insurance.40*.19–.91.82.43–1.59
a
AOR, adjusted odds ratio.
b
VHA, Veterans Health Administration.
*
p<.05, **p<.01, ***p<.001.
Crude rates of having seen a therapist or psychiatric provider significantly differed among all insurance types, with the highest rates among those with military or VHA insurance (Table 1). Those with military or VHA insurance were also significantly more likely to have feminine gender expression and were least likely to identify as nonbinary or as a person of color (Table 1). The majority of individuals with military or VHA insurance reported having seen a therapist in their lifetime (69%), and nearly all reported having seen a psychiatric provider (95%). In logistic regressions adjusting for demographic factors, there were no significant differences in rates of having seen a therapist or psychiatric provider among individuals with employer-provided, purchased, or public insurance (Table 2). These analyses showed that only individuals with insurance through the military or VHA had significantly greater odds than individuals with employer insurance of seeing a psychiatric provider. Individuals with insurance through the military or VHA were 2.18 times more likely to have seen a psychiatric provider than those with employer insurance.

Discussion

The current study assessed the association between health insurance and lifetime mental health care utilization among individuals who identified as TGD. In line with previous studies, the majority of individuals had health insurance, with most reporting employer or public health insurance (13). Notably, only 8% of the sample were uninsured, which is substantially lower than previous studies that found that 13%–19% of individuals who identified as TGD were uninsured (8, 1315). Given that the current data were collected in 2017, which is 2 to 10 years after previous studies assessed insurance status (8, 1315), the lower rates of being uninsured may reflect an actual reduction in the number of uninsured individuals who identify as TGD. Supporting this point, the percentage of individuals in this sample who did not have insurance mirrors the most recent data on uninsurance rates in the broader U.S. population (9%), which has seen a significant reduction since the enactment of the ACA (21). Alternatively, it should be considered that the current sample may be distinct from the larger studies that identified higher rates of having no insurance (8, 14). The current study relied on Internet-based recruitment, which may have unintentionally been a barrier for those more likely to be uninsured. For instance, someone experiencing homelessness may be both uninsured and unable to complete the survey because of a lack of Internet access.
Demographic differences among individuals who identified as TGD emerged on the basis of insurance. Unsurprisingly, persons who were uninsured or had public insurance had the highest rates of incomes of less than or equal to $19,999. Notably, rates of identifying as a person of color were highest among those who were uninsured or utilizing public, purchased, or other insurance. By comparison, there were significantly fewer people of color among those with employer- or military- or VHA-provided insurance, which were the only insurance types to be provided directly through employment. Given that unemployment is elevated among people of color who identify as TGD (22), this finding may point toward unemployment as a potential driver in disparities in health insurance coverage among people of color who identify as TGD. Future research would benefit from a more thorough assessment of how engagement with employment influences mental health utilization and relates to intersecting identities.
Health insurance had a notable association with mental health care utilization among individuals who identified as TGD. Individuals with no insurance had significantly lower rates of seeing a therapist or psychiatric provider in their lifetime compared with individuals with all other insurance types. This disparity persisted even when adjusting for demographic factors; the odds of seeing a therapist (AOR=0.38) or psychiatric provider (AOR=0.48) were significantly less for those with no insurance compared with those with employer-based insurance. These findings are consistent with broader research suggesting that being uninsured is a major barrier to receiving mental health care (11). Notably, a disparity in mental health care utilization may have unique consequences for individuals who identify as TGD. Seeing a mental health professional is often a requirement for receiving gender-affirming medical treatments such as hormone-replacement treatment or gender-affirming surgeries (23). Thus, uninsured individuals who have lower rates of mental health care utilization may have additional barriers to receiving appropriate gender-affirming medical care, perpetuating high-risk practices such as taking nonprescribed hormones and self-performed surgeries (24, 25).
Striking differences emerged between individuals receiving military or VHA insurance and those receiving all other insurance types. Individuals with military or VHA insurance were more likely than those with any other insurance status to have reported seeing a therapist (69% compared with 35%–59%) or a psychiatric provider (95% compared with 74%–91%) in their lifetime. Even after adjusting for demographic factors, those with military or VHA insurance were twice as likely as those with employer health insurance to have seen a psychiatric provider. Although those with military or VHA insurance were also 2.47 times more likely than those with employer insurance to have seen a therapist, the finding was not significant. Given the relatively small number of individuals in the sample with military or VHA insurance, the analysis may have been underpowered. Taken together, findings point toward extraordinary utilization of mental health care among the individuals who were currently or had previously served in the military. This finding is particularly notable given recent policies disallowing transgender people to serve in the military (26), despite the fact that transgender individuals are two times more likely than cisgender individuals to serve in the military (27).
Although military and VHA insurance were assessed with a single variable, experiences likely differed between active duty service members and discharged veterans. Although many service members who identify as TGD receive support from command and fellow service members, there are also high rates of military sexual trauma, stigmatization, and forced discharge that may influence higher rates of mental health care utilization (2729). Additionally, the recent reinstatement of policies that ban transgender individuals from serving in the military may exacerbate these concerns given the psychological distress, discrimination, and victimization that occurred among sexual-minority service members serving under the similar policy of “Don’t ask, don’t tell” (29, 30).
For those who are no longer serving, higher rates of utilization may relate to the rapidly expanding availability of VHA services over the past decade for veterans who identify as TGD (31). Veterans who identify as TGD have reported being treated respectfully by VHA providers and have described being highly satisfied with their care (27, 32). It should also be considered that the higher rates of mental health care utilization may relate to structural differences in military and VHA mental health care as opposed to differences in distress among service members and veterans who identify as TGD. For instance, higher mental health care utilization may reflect the requirement that service members receive regular mental health evaluations to assess for deployment readiness.
Additionally, mental health utilization may simply be encouraged through VHA’s use of an integrated health care model, which has been associated with easier access and higher utilization of mental health services (33). It will be critical to further assess the availability and quality of VHA care in the coming years for veterans who identify as TGD. The number of individuals who identify as TGD who are served by the VHA has dramatically risen in the past 15 years (19). Rising rates may continue because recent policy changes banning TGD people from serving in the military may increase both the number of discharged service members who identify as TGD and the number who keep their identity secret until after discharge (26).
Findings should be considered within the context of several limitations. First, mental health care utilization was measured as whether individuals ever saw a psychiatric provider or therapist at any point in their lifetime. As a result, we were unable to assess when care occurred. Participants may have seen a provider in the past when their insurance status was different than their current insurance status. Similarly, only current gender identity was assessed, which cannot speak to how mental health utilization may differ on the basis of gender-identity fluidity or a transition in gender expression.
Additionally, our measure of mental health care utilization cannot speak to the quality of care. Given that the current study found a striking increase compared with earlier studies in the number of individuals who identify as TGD and who are covered by health insurance, future research must consider the range of barriers that may interfere with receipt of adequate mental health care for insured individuals who identify as TGD, such as providers who are uninformed, are discriminatory, or deny treatment (8, 17). Future research would benefit from a consideration of how insurance coverage may relate to the receipt of high-quality mental health care from informed providers.
Additionally, our data did not allow us to determine whether there were differences in the findings on the basis of intersecting marginalized identities. For instance, given that people of color had elevated rates of using public insurance, are there differences in mental health care utilization among people of color who identify as TGD and their white counterparts, even when both groups use public health care? It should also be considered that the current data were collected through a survey conducted by the Trans Lifeline, which may have attracted participants who were affected by mental health concerns.

Conclusions

Overall, the current study offers support for health insurance as a structural factor contributing to disparities in mental health care utilization among individuals who identified as TGD (34). Although rates of being uninsured were lower than in earlier studies, having no insurance was still a significant barrier to care and was associated with significantly lower odds of accessing mental health care compared with employer-provided insurance. Although employer-provided health insurance was the most common insurance status among the individuals surveyed, those with military or VHA insurance were more than twice as likely to utilize mental health care. Given that the VHA is the largest provider of mental health care services in the United States, findings may point toward accessibility as an important facilitator of mental health care utilization. Findings suggest that although being insured was associated with higher mental health care utilization than being uninsured, access to a robust mental health care system was most strongly associated with utilizing mental health care.

Footnote

These views represent the opinions of the authors and not necessarily those of the Department of Veterans Affairs or the U.S. government.

References

1.
Filice E, Meyer SB: Patterns, predictors, and outcomes of mental health service utilization among lesbians, gay men, and bisexuals: a scoping review. J Gay Lesbian Ment Health 2018; 22:162–195
2.
Steele LS, Daley A, Curling D, et al: LGBT identity, untreated depression, and unmet need for mental health services by sexual minority women and trans-identified people. J Womens Health 2017; 26:116–127
3.
Brown GR, Jones KT: Mental health and medical health disparities in 5,135 transgender veterans receiving healthcare in the Veterans Health Administration: a case-control study. LGBT Health 2016; 3:122–131
4.
Fredriksen-Goldsen KI, Kim HJ, Shiu C, et al: Successful aging among LGBT older adults: physical and mental health–related quality of life by age group. Gerontologist 2015; 55:154–168
5.
Reisner SL, White JM, Bradford JB, et al: Transgender health disparities: comparing full cohort and nested matched-pair study designs in a community health center. LGBT Health 2014; 1:177–184
6.
Su D, Irwin JA, Fisher C, et al: Mental health disparities within the LGBT population: a comparison between transgender and nontransgender individuals. Transgend Health 2016; 1:12–20
7.
Burgess D, Tran A, Lee R, et al: Effects of perceived discrimination on mental health and mental health services utilization among gay, lesbian, bisexual and transgender persons. J LGBT Health Res 2007; 3:1–14
8.
Grant JM, Mottet L, Tanis J, et al: Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington, DC, National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011
9.
Meyer IH: Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull 2003; 129:674–697
10.
Fredriksen-Goldsen KI, Simoni JM, Kim HJ, et al: The health equity promotion model: reconceptualization of lesbian, gay, bisexual, and transgender (LGBT) health disparities. Am J Orthopsychiatry 2014; 84:653–663
11.
Lillie-Blanton M, Hoffman C: The role of health insurance coverage in reducing racial/ethnic disparities in health care. Health Aff 2005; 24:398–408
12.
Rowan K, McAlpine DD, Blewett LA: Access and cost barriers to mental health care, by insurance status, 1999–2010. Health Aff 2013; 32:1723–1730
13.
James SE, Herman JL, Rankin S, et al: The Report of the 2015 US Transgender Survey. Washington, DC, National Center for Transgender Equality, 2016
14.
Meyer IH, Brown TNT, Herman JL, et al: Demographic characteristics and health status of transgender adults in select US regions: Behavioral Risk Factor Surveillance System, 2014. Am J Public Health 2017; 107:582–589
15.
Dickey LM, Budge SL, Katz-Wise SL, et al: Health disparities in the transgender community: exploring differences in insurance coverage. Psychol Sex Orientat Gend Divers 2016; 3:275–282
16.
Safer JD, Coleman E, Feldman J, et al: Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes 2016; 23:168–171
17.
Sanchez NF, Sanchez JP, Danoff A: Health care utilization, barriers to care, and hormone usage among male-to-female transgender persons in New York City. Am J Public Health 2009; 99:713–719
18.
Collins SR, Bhupal HK, Doty MM: Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, but More Underinsured. New York, Commonwealth Fund, 2019
19.
Blosnich JR, Brown GR, Shipherd JC, et al: Prevalence of gender identity disorder and suicide risk among transgender veterans utilizing Veterans Health Administration care. Am J Public Health 2013; 103:e27–e32
20.
Aboussouan A, Snow A, Cerel J, et al: Non-suicidal self-injury, suicide ideation, and past suicide attempts: comparison between transgender and gender diverse veterans and non-veterans. J Affect Disord 2019; 259:186–194
21.
Berchick ER, Hood E, Barnett JC: Health Insurance Coverage in the United States: 2017. Washington, DC, Census Bureau, 2018
22.
James SE, Brown C, Wilson I: 2015 US Transgender Survey: Report on the Experiences of Black Respondents. Washington, DC, National Center for Transgender Equality, Black Trans Advocacy, & National Black Justice Coalition, 2017
23.
Puckett JA, Cleary P, Rossman K, et al: Barriers to gender-affirming care for transgender and gender nonconforming individuals. Sex Res Soc Policy 2018; 15:48–59
24.
Rotondi NK, Bauer GR, Scanlon K, et al: Nonprescribed hormone use and self-performed surgeries: “do-it-yourself” transitions in transgender communities in Ontario, Canada. Am J Public Health 2013; 103:1830–1836
25.
de Haan G, Santos GM, Arayasirikul S, et al: Non-prescribed hormone use and barriers to care for transgender women in San Francisco. LGBT Health 2015; 2:313–323
26.
The Making of a Ban: How DTM-19-004 Works to Push Transgender People Out of Military Service. San Francisco, Palm Center, 2019
27.
Military Service by Transgender People: Data from the 2015 US Transgender Survey. Washington, DC, National Center for Transgender Equality, 2015. www.transequality.org/sites/default/files/docs/usts/USTS-VeteransDayReport.pdf. Accessed Sept 5, 2019
28.
Beckman K, Shipherd J, Simpson T, et al: Military sexual assault in transgender veterans: results from a nationwide survey. J Trauma Stress 2018; 31:181–190
29.
Johnson WB, Rosenstein JE, Buhrke RA, et al: After “Don’t ask, don’t tell”: competent care of lesbian, gay and bisexual military personnel during the DoD policy transition. Prof Psychol Res Pr 2015; 46:107–115
30.
Gurung S, Ventuneac A, Rendina HJ, et al: Prevalence of military sexual trauma and sexual orientation discrimination among lesbian, gay, bisexual, and transgender military personnel: a descriptive study. Sex Res Soc Policy 2018; 15:74–82
31.
Kauth MR, Blosnich JR, Marra J, et al: Transgender health care in the US military and Veterans Health Administration facilities. Curr Sex Health Rep 2017; 9:121–127
32.
Lehavot K, Katon JG, Simpson TL, et al: Transgender veterans’ satisfaction with care and unmet health needs. Med Care 2017; 55(suppl 2):S90–S96
33.
Johnson-Lawrence V, Zivin K, Szymanski BR, et al: VA primary care–mental health integration: patient characteristics and receipt of mental health services, 2008–2010. Psychiatr Serv 2012; 63:1137–1141
34.
White Hughto JM, Reisner SL, Pachankis JE: Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med 2015; 147:222–231

Information & Authors

Information

Published In

Go to Psychiatric Services
Go to Psychiatric Services
Psychiatric Services
Pages: 151 - 157
PubMed: 31658897

History

Received: 7 June 2019
Revision received: 18 July 2019
Accepted: 19 August 2019
Published online: 29 October 2019
Published in print: February 01, 2020

Keywords

  1. Transgender
  2. Insurance
  3. Mental health care
  4. Treatment utilization

Authors

Details

Sarah P. Carter, Ph.D. [email protected]
Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Services, Seattle (Carter); Department of Health Services, University of Washington, Seattle (Carter); Department of Psychology, Louisiana State University, Baton Rouge (Cowan, Tucker); College of Social Work, University of Kentucky, Lexington (Snow, Cerel).
Tovah Cowan, M.A.
Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Services, Seattle (Carter); Department of Health Services, University of Washington, Seattle (Carter); Department of Psychology, Louisiana State University, Baton Rouge (Cowan, Tucker); College of Social Work, University of Kentucky, Lexington (Snow, Cerel).
Annie Snow, M.A.
Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Services, Seattle (Carter); Department of Health Services, University of Washington, Seattle (Carter); Department of Psychology, Louisiana State University, Baton Rouge (Cowan, Tucker); College of Social Work, University of Kentucky, Lexington (Snow, Cerel).
Julie Cerel, Ph.D.
Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Services, Seattle (Carter); Department of Health Services, University of Washington, Seattle (Carter); Department of Psychology, Louisiana State University, Baton Rouge (Cowan, Tucker); College of Social Work, University of Kentucky, Lexington (Snow, Cerel).
Raymond Tucker, Ph.D.
Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Services, Seattle (Carter); Department of Health Services, University of Washington, Seattle (Carter); Department of Psychology, Louisiana State University, Baton Rouge (Cowan, Tucker); College of Social Work, University of Kentucky, Lexington (Snow, Cerel).

Notes

Send correspondence to Dr. Carter ([email protected]).

Competing Interests

The authors report no financial relationships with commercial interests.

Metrics & Citations

Metrics

Citations

Export Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.

For more information or tips please see 'Downloading to a citation manager' in the Help menu.

Format
Citation style
Style
Copy to clipboard

View Options

View options

PDF/EPUB

View PDF/EPUB

Get Access

Login options

Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.

Personal login Institutional Login Open Athens login
Purchase Options

Purchase this article to access the full text.

PPV Articles - Psychiatric Services

PPV Articles - Psychiatric Services

Not a subscriber?

Subscribe Now / Learn More

PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Media

Figures

Other

Tables

Share

Share

Share article link

Share