Material Type  

 학위논문

 

0016933095

Date and Time of Latest Transaction  

20240214101202

ISBN  

9798379957605

DDC  

614.4

Author  

Houghtaling, Laura M.

Title/Author  

State Healthcare Policy Environment and the Well-Being of Transgender and Gender Diverse Youth - [electronic resource]

Publish Info  

[S.l.] : University of Minnesota., 2023

Publish Info  

Ann Arbor : ProQuest Dissertations & Theses, 2023

Material Info  

1 online resource(255 p.)

General Note  

Source: Dissertations Abstracts International, Volume: 85-01, Section: B.

General Note  

Advisor: Osypuk, Theresa L.

학위논문주기  

Thesis (Ph.D.)--University of Minnesota, 2023.

Restrictions on Access Note  

This item must not be sold to any third party vendors.

Abstracts/Etc  

요약Poor mental health among children and adolescents is a significant public health concern in the U.S. There are significant disparities in mental health outcomes between LGBTQ+ adolescents and their heterosexual and cisgender peers. Transgender youth, in particular, have 2-3 times greater risk of anxiety, depression, suicidal ideation, suicide attempts and self-harming behaviors in comparison to cisgender youth. The developmental period of adolescence is a crucial time for not only the emergence of secondary sex characteristics but also the exploration of gender identity. One important but understudied predictor of adolescent mental health is policy that supports access to gender affirming healthcare (GAC). GAC is a model of care that seeks to affirm the experienced gender identity of youth and reduce psychological distress. Forms of GAC such as counseling, hormone therapy and surgery, can be lifesaving for some transgender youth.Policy is a key macrosocial determinant of health, and policies related to GAC likely affect mental health and drive disparities through the mechanisms of structural stigma and social safety. A small body of research has identified modifying effects of state-level laws regarding LGBTQ+ rights on health disparities in LGBTQ+ youth. Yet there are only a handful of studies evaluating the effect of policy on health outcomes in transgender and gender diverse (TGD) populations, and to the best of our knowledge none yet have evaluated the association between gender-affirming healthcare policy and health in TGD youth. There is existing evidence that delaying transition related care may contribute to higher psychological distress among adolescents and gender-affirming surgery improves quality of life and mental health among transgender individuals. Thus, policies affecting access to gender-affirming care may create excess stress that manifests as an increase in self-reported stress levels and physiologic stress responses.In the first manuscript, we created and validated novel state-level index measures that capture the supportiveness or restrictiveness of the policy environment across 50 states and Washington, D.C. regarding access to gender-affirming healthcare for transgender and gender diverse youth (Aim 1). The two indices we introduced, the Healthcare and Health Insurance Access index (Healthcare Index) and the Progression of Bans on Gender-Affirming Care Index (Ban Progression Index), conceptually quantify the degree of structural level stigma regarding medical affirmation of gender identity at the state level. The Healthcare Index includes private insurance nondiscrimination laws based on gender identity, Medicaid regulations for coverage of GAC, guidance regarding exclusion of coverage of GAC, and religious exemptions or denial of services laws. The Ban Progression Index quantifies the introduction and progression of bills that prohibit or restrict GAC for minors through state legislatures in 2020 and 2021 through categorization into treatment groups representing 1) strong and 2) weak progression of bills and a comparison group representing no progress of bills (no ban states). Empirically, both indices performed as hypothesized, in that they correlated strongly with other state level measures of non-healthcare policy that restrict the rights of gender diverse youth, as well as other measures of the social and political environment that capture the attitudes and social norms around diverse gender identities.In lieu of biologic data, in the following two manuscripts, we measured the impact of our novel state-level policy indices on individual level health with three self-reported outcomes that may be sensitive to acute and chronic stressors: depressive symptoms, stress management and health status, in a large convenience sample of LGBTQ+ youth in all 50 states and Washington, D.C. with diverse sexual and gender identities.In the second manuscript, we tested the main effects of the state-level Healthcare Index on individual-level health (poor stress management, Kutcher Adolescent Depression scale, poor or fair self-rated health status), in a cross-sectional, national survey with large numbers of LGBTQ+ youth; and whether these associations varied by gender identity (Aim 2). We found that a more supportive state policy environment for coverage of GAC was associated with fewer depressive symptoms in our sample of LGBTQ+ youth overall and in gender diverse youth, as hypothesized. Counterintuitively, we found that a higher score on the Healthcare Index was associated with higher odds of poor or fair health status among transgender youth compared to cisgender LGBQ+ youth. This counterintuitive finding and lack of other findings for transgender youth may be potentially due to pre-existing health differences, the intersection of other minoritized identities, or other factors such as family and friend support or school climate being more salient for health. Finally, we did not find evidence for an association between the Healthcare Index and our third health outcome: poor stress management. Additional research is needed to unpack explanations for these findings and corroborate them in other samples of LGBTQ+ youth.In the third manuscript, we estimated the average effect of the Ban Progression Index on differences in cross-sectional mean depressive symptoms over a 5-year period in repeated, nationwide surveys of LGBTQ+ youth overall and by gender identity, using a quasi-experimental approach (classic and triple difference-in-differences models). We did not find evidence for an independent effect of the Ban Progression Index on differences in depressive symptoms between 2017 and 2022 (the pre- and post-periods) among LGBTQ+ youth in states that introduced one or more bills banning GAC, adjusted for time-varying individual level demographic characteristics. Counterintuitively, we found a small decrease in depressive symptoms on average among gender diverse youth in states with strong progression of bills banning GAC. We speculate that this finding could be due to a violation of the common trends assumptions, the change in demographic composition of our repeat cross-sectional sample, different confounding structures by gender identity, unmodeled interactions by sexual orientation and/or racial/ethnic identity, or a higher prevalence of resilience and protective factors in the gender diverse sample.Overall, the findings of our research suggest distinct differences in the relationship between our policy indices and health by gender identity. More lag time between the introduction or passage of bills banning or restricting access to GAC for minors may be needed to detect a further differential effect by gender identity. Additional quasi-experimental approaches in other samples of LGBTQ+ youth and with a longer time horizon are needed to build the evidence base for a causal effect of discriminatory or alternatively protective policies on mental health outcomes for TGD youth. In addition, we need concurrent studies evaluating the mediating roles of school and community level factors, and social support from family, friends and other sources.Since we conducted this study in late 2021, there has been a marked increase in the introduction of bills and passage of laws prohibiting or limiting access to gender-affirming care. The discriminatory rhetoric and legislation targeting transgender and gender diverse youth is growing at a rapid pace, and state-level policies that protect legal access to gender-affirming care and its coverage by insurance are vital to combating widespread misinformation, ignorance and neglect of what we believe are basic human rights for transgender and gender diverse people.

Subject Added Entry-Topical Term  

Epidemiology.

Subject Added Entry-Topical Term  

Public policy.

Subject Added Entry-Topical Term  

LGBTQ studies.

Subject Added Entry-Topical Term  

Mental health.

Index Term-Uncontrolled  

Adolescent mental health

Index Term-Uncontrolled  

Gender affirming care

Index Term-Uncontrolled  

Gender diverse

Index Term-Uncontrolled  

Health policy

Index Term-Uncontrolled  

Structural stigma

Index Term-Uncontrolled  

Transgender

Added Entry-Corporate Name  

University of Minnesota Epidemiology

Host Item Entry  

Dissertations Abstracts International. 85-01B.

Host Item Entry  

Dissertation Abstract International

Electronic Location and Access  

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소장사항  

202402 2024

Control Number  

joongbu:642204