State healthcare policy environment and the well-being of transgender and gender diverse youth

Abstract

Significant disparities exist in mental health outcomes between LGBTQ+ adolescents and their heterosexual and cisgender peers, especially for transgender and gender diverse youth. One important but understudied predictor of adolescent mental health is policy that supports access to gender-affirming healthcare. Evidence is needed on the association between gender-affirming healthcare policy and health to inform research and policy. In the first manuscript, we created and validated two novel index measures across 50 states and Washington, D.C that quantify the supportiveness or restrictiveness of the state level policy environment regarding access to gender-affirming healthcare for transgender and gender diverse youth. In lieu of biologic data, in the following two manuscripts, we measured the impact of each policy index on 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. We found a modest inverse association between a more supportive state policy environment for gender-affirming healthcare and health insurance access and depressive symptoms among gender diverse youth in a cross-sectional analysis. Using repeated cross-sectional samples, our findings were mixed regarding the effect of greater progression of bills banning gender-affirming healthcare for minors during 2020 and 2021 state legislative sessions, on differences in depressive symptoms between 2017 and 2022 in LGBTQ+ youth. Overall, our research contributes to the evidence base on the public health importance of state level policy affecting access to gender-affirming healthcare, and to the literature on health differences between transgender and gender diverse identities. Additional quasi-experimental approaches in other samples of LGBTQ+ youth with a longer time horizon are needed to build the evidence base for a causal effect of gender-affirming healthcare policies on mental health outcomes for transgender and gender diverse youth.