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Health and Care Utilization of Transgender and Gender Nonconformingg Health and Care Utilization of Transgender and Gender NonconformingG. Nicole Rider, PhD, a Barbara J. McMorris, PhD, b AmyYouth: L. Gower, PhD, c Eli Coleman, PhD, a Marla E. Eisenberg, ScD, MPHc BACKGROUND: A Population-Based Study abstract Transgender and gender nonconforming (TGNC) adolescents have difficulty accessing and receiving health care compared with cisgender youth, yet research is limited by a reliance on small and nonrepresentative samples. This study's purpose was to examine mental and physical health characteristics and care utilization between youth who are METHODS: TGNC and cisgender and across perceived gender expressions within the TGNC sample. n Data came from the 2016 Minnesota Student Survey, which consisted of 80929 students in ninth and 11th grade ( = 2168 TGNC, 2.7%). Students self-reported gender identity, perceived gender expression, 4 health status measures, and 3 care utilization measures. Chi-squares and multiple analysis of covariance tests (controlling for RESULTS: demographic covariates) were used to compare groups. We found that students who are TGNC reported significantly poorer health, lower rates of preventive health checkups, and more nurse office visits than cisgender youth. For χ Pexample, 62.1% of youth who are TGNC reported their general health as poor,2 fair, or good versus very good or excellent, compared with 33.1% of cisgender youth ( = 763.7, < .001). Among the TGNC sample, those whose gender presentation was perceived as very congruent with their birth-assigned sex were less likely to report poorer health and long- CONCLUSIONS: term mental health problems compared with those with other gender presentations. Health care utilization differs between TGNC versus cisgender youth and across gender presentations within TGNC youth. With our results, we suggest that health care providers should screen for health risks and identify barriers to care for TGNC youth while NIH promoting and bolstering wellness within this community. aProgram in Human Sexuality, Department of Family Medicine and Community Health, cDivision of General WHAT’SW KNO N ON THIS SUBJECT: Transgender and Pediatrics and Adolescent Health, Department of Pediatrics, School of Medicine, and bSchool of Nursing, gender nonconforming (TGNC) adolescents are significantly University of Minnesota, Minneapolis, Minnesota affected by mental health disparities and have difficulty accessing and receiving health care compared with Dr Rider assisted with conceptualizing and designing this study, conducted data analyses and cisgender youth. Previous research in this field is limited by interpretation, drafted the initial manuscript, and revised the manuscript; Drs McMorris, Gower, reliance on small, nonrepresentative, and adult samples. Coleman, and Eisenberg assisted with conceptualizing and designing the study and interpreting the data and reviewed and revised the manuscript; and all authors approved the final manuscript WHAT THIS STUDY AddS: TGNC adolescents reported as submitted and agree to be accountable for all aspects of the work. poorer health, fewer health checkups, and more nurse visits than their cisgender peers. TGNC adolescents whose Preliminary findings from this study were summarized in a symposium presentation at the gender expression strongly matched their birth-assigned Rainbow Health Initiative’s Opportunity Conference; February 27, 2017; Saint Paul, MN. sex had better health and fewer long-term mental health DOI: https:// doi. org/ 10. 1542/ peds. 2017- 1683 problems compared with other gender presentations. Accepted for publication Nov 30, 2017 To cite: Rider GN, McMorris BJ, Gower AL, et al. Health and Care Utilization of Transgender and Gender Nonconforming Youth: A Population-Based Study. Pediatrics. 2018;141(3): e20171683 Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 141, number 3, March 2018:e20171683 ARTICLE Youth who are transgender have a risk for bullying victimization and and expressions contribute to a gender identity and/or expression depressive symptoms. lack of knowledge and training for differing from societal expectations health care providers and thereby This vulnerability for poorer health based on their birth-assigned sex, place youth who are TGNC at risk outcomes reveals the importance whereas youth who are cisgender for poorer health outcomes. In of access to affordable, competent have a gender identity aligning with the current study, we address health care services for youth who their birth-assigned sex. Gender these concerns and illuminate are TGNC. However, historical nonconforming describes individuals health-related disparities in this marginalization in health care whose gender expression does not underserved youth population. settings and a lack of competent follow stereotypical conventions providers create barriers to of masculinity and femininity and Limitations in the extant research treatment and contribute– to delayed who may or may not identify as include reliance on samples of 1 access to care and longer-term health 2 transgender. Although research 11 18 adults, convenience samples, and consequences. For example, on youth who are transgender and 19 small sample sizes. Population- Gordon et al found that gender gender nonconforming (TGNC) is based studies with large samples of nonconformity was associated with in its nascence, studies indicate adolescents are needed to generalize an increased risk for problems with that adolescents who identify as findings and make accurate mobility, usual activities, pain or TGNC versus cisgender experience comparisons between gender identity 2 discomfort, anxiety, and depression. significant mental health disparities. groups (TGNC versus cisgender). Our Health scores were lower for Additional studies are needed to purpose in this study was to examine participants with moderate gender better understand other health risks, the prevalence of mental and physical conformity and lowest for those disparities, and access to health care health concerns and health care with low gender conformity when among youth who are TGNC. utilization among youth who identify compared with participants reporting as TGNC versus cisgender and across ’ high gender conformity. Given the A paucity of health research examines perceived gender expressions within limited research on perceived gender TGNC adolescents perceived our TGNC sample, using a large-scale, ’ nonconformity and health outcomes, gender expression (ie, the way 20 population-based sample. Wylie et al emphasized the others interpret a person s gender importance of assessing perceived presentation along a spectrum METHODS gender expression as a determinant from feminine to masculine). The of health disparities, particularly in authors of the gender minority 3 ’ population-based studies. Data Source and Study Design stress and resilience model theorize that misperceptions of a person s Previously, researchers have most gender expression may result in a often dichotomized gender into young individual feeling as if their binary categories (exclusively Data are from the Minnesota gendered experience is negated or masculine [man 13or boy] or feminine Student Survey (MSS), a statewide not affirmed. The young individual [woman or girl], which minimizes21 surveillance system coordinated may also be placed at an elevated risk the complexity of TGNC identities. by the Departments of Education, for harassment and victimization, In a recent study, researchers found Health, Human Services, and Public which in turn may contribute to a that 41% of a Canadian TGNC sample Safety that is used to assess health heightened risk for negative health identified as gender nonbinary and well-being among select grades ’ outcomes, such as depressive (ie, identifying as both, neither, or of public school students. In 2016, symptoms, self-harm, posttraumatic– somewhere between masculine 85% of the state s school districts stress, disordered eating, and 4 9 and feminine), which illustrates participated. Passive parental suicidal ideation and attempts10 . the importance of investigating the consent procedures were used in For example, Roberts et al found heterogeneity of gender identities accordance with federal laws. The 22 that youth who reported childhood and expressions among this group. analytic sample was composed of gender nonconformity were at Health researchers who do not 80929 students in ninth and 11th heightened risk for depressive incorporate options to indicate grade who were asked about their ’ symptoms during adolescence and nonbinary gender identities and gender identity. The University early adulthood compared with expressions are at risk for having of Minnesota s Institutional those reporting childhood gender categories that misclassify or exclude21 Review Board determined that conformity. Birth-assigned males certain gender diverse participants. this secondary analysis of existing who reported childhood gender This categorical invisibility and anonymous data was exempt from nonconformity were at the greatest erasure of diverse gender identities review. Downloaded from www.aappublications.org/news by guest on September 27, 2021 2 RIDER et al Survey Measures TABLE 1 MSS Health Status and Health Care Utilization Measures Measure Survey Item Dichotomized Responses Health status a Gender identity was assessed by using General health How would you describe your health in 1 = poor, fair, or good a modified version of the validated– general? 0 = very good or excellent 2-item
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