In the United States (U.S.), policies with particular relevance to transgender populations have been in flux over the past decade. Policy surveillance organizations have noted the erosion of state-level protections for transgender populations [
1‐
3], a trend with direct implications for transgender population health. State-level protective policies, such as nondiscrimination laws and requirements that health insurance cover medical gender affirmation, are consistently associated with better health among transgender populations [
4‐
7]. In contrast, exclusionary policies, such as those that allow healthcare providers to deny care to transgender patients on religious grounds, have been linked to adverse health outcomes such as non-prescribed hormone use, healthcare avoidance, violent victimization, suicidality, and emotional and physical distress [
8‐
11]. Further, studies suggest that public debates surrounding adoption of transgender-related policies may heighten depression, anxiety, and PTSD symptoms among transgender populations [
1,
2,
12].
Little research has examined differences in the relationship between policies and health among subgroups of transgender people. In particular, the health effects of transgender-related policies on transgender people of color is largely unknown as many studies examining the health effects of transgender-related policies had samples that were upwards of 80% non-Latinx White (hereafter, White) [
1,
5,
6,
8]. Accumulating evidence suggests racial health inequities within transgender populations. Transgender people of color, compared to their White counterparts, have poorer HIV prevention and HIV care continua outcomes [
13], worse self-rated health [
14], more adverse mental health symptoms [
14,
15], lower access to healthcare [
16,
17], higher burden of chronic diseases [
18], and higher mortality risk [
19]. Thus, understanding which populations benefit from transgender-related policies is crucial to understanding structural solutions for health equity within transgender populations.
Theoretical framework
This study draws from Critical Race Theory’s
critique of liberalism to explore racial differences in the relationship between transgender-related state policies and health among transgender women. This critique holds that policies based in race-blind neoliberal frameworks of inclusion and rights expansion primarily benefit populations that are the least vulnerable to the harms of racism and intersectional oppression [
20,
21]. Many transgender-related policies are based on the liberal ideal of equal opportunity and may exacerbate social and health inequities [
22,
23]. For example, the 2020
Bostock v. Clayton County, Georgia decision resulted in transgender inclusion in employment nondiscrimination policies nationwide [
24]. Yet, anti-transgender employment discrimination remains highly prevalent despite transgender-inclusive nondiscrimination policies, and the actual enforcement of these laws does not provide redress for most transgender people who experience workplace discrimination [
23,
25,
26]. Employment nondiscrimination laws require complainants to prove employers’ discriminatory intent, a task difficult for those who have financial access to appropriate legal counsel and effectively impossible for those who do not [
23]. Given documented economic inequities between White transgender people and transgender people of color, and specifically Black and Latina transgender women [
27‐
29], Critical Race Theory’s
critique of liberalism would therefore suggest that transgender-inclusive employment nondiscrimination laws are more likely to benefit White transgender women than transgender women of color.
Furthermore, employment discrimination, hate crime laws, and other currently debated transgender-related policies do not address structural vulnerability among transgender people [
23]. Structural vulnerability refers to a depreciated social position created through discrimination and economic exploitation and marked by social, economic, and material hardships (e.g., poverty, violence) [
30,
31]. Large-scale national studies indicate that employment inequities impacting transgender adults have increased despite the expansion of nondiscrimination policies [
32,
33]. Similarly, growing lists of states have added gender identity as a protected class in hate crime laws and eliminated “trans panic” defenses (i.e., defendants’ use of discovery of a transgender person’s gender as exculpatory or mitigating evidence) in criminal proceedings; however, annual accounts of fatal violence against transgender women of color continue to grow [
34].
Responding to the noted inadequacies of liberal reforms based on ideals of inclusion and equality, transgender activists have proposed policy agendas focused on building coalitions across axes of oppression to transform or abolish the legal and administrative systems that directly control the lives of the most marginalized transgender people: prisons, welfare programs, job training centers, foster care, housing authorities, and healthcare [
23]. In particular, transgender women of color have identified potentially effective focal points for transgender-related policies. These include equitable access to public and private housing; cultural and structural competence in education, employment, and healthcare settings; and programs that promote safety and recovery from interpersonal violence and other traumas [
35‐
38]. These issues align with several existing transgender-related policies, namely those that govern insurance coverage for gender-affirming medical care, institutional sex segregation (e.g., in domestic violence programs), and identity document changes [
23]. In this study, we refer to these policies as
access policies because they have direct implications for transgender people’s access to resources critical for wellbeing. We use the term
equality policies to refer to policies that signal recognition of transgender people within the existing neoliberal order but without altering their lived experiences, such as nondiscrimination policies and hate crime laws.
Discussion
This analysis of adult transgender women in the U.S. found that several transgender-related state policies governing access to resources and equality under the law were associated with better self-rated health in bivariable regression models. When adjusting for individual- and state-level covariates including structural vulnerability, these associations did not persist. However, adding
policy x person of color interaction terms to the adjusted models revealed that race/ethnicity moderated the relationship between several transgender-related state policies and self-rated health such that the relationships were positive for White transgender women and negative for transgender women of color. Contrary to our hypotheses, this finding was true for both access and equality policies. Consistent with Critical Race Theory’s critique of liberalism [
20,
21], these findings suggest that transgender-related state policies may have a protective effect on self-rated health only for White transgender women.
All policies included in this analysis are nonracial in that they do not contain language about race or racism [
20]. This colorblindness disregards how violence, discrimination, and access to resources are qualitatively different for transgender women of color than White transgender women due to the centrality of racism in the political, economic, and cultural structures in the U.S. [
20,
55,
56]. For example, we found that the relationships between two policies regarding private health insurance and self-rated health was positive for White transgender women and negative for transgender women of color. This may be because White adults are more likely to have private insurance than Black or Latinx adults due to greater access to employer subsidies and greater ability to afford purchased insurance [
57]. Transgender-related policies regarding private insurance coverage are therefore potentially more relevant to White transgender women’s access to healthcare.
Our distinction between access and equality policies was based on prior literature highlighting how nondiscrimination and hate crime laws strengthen the carceral state and fail to redistribute resources from those in power to structurally vulnerable transgender people [
22,
23,
58]. We hypothesized that access policies would be more strongly associated with better self-rated health for transgender women of color than White transgender women because these policies aim to eliminate barriers to important social determinants of health for “all” transgender people, agnostic to racial differences: medical and legal gender affirmation and health insurance [
59]. However, the access policies included in this study may be ineffective for addressing barriers specific to transgender women of color such as structural, institutional, and interpersonal gendered racism in healthcare settings, schools, and the criminal-legal system that may influence their health status and drive racial health inequities within transgender populations [
37,
41,
60,
61].
Policies that structure the distribution of and access to social, economic, and political resources for all people of color may be more relevant to the lives of transgender women of color than the transgender-related ‘access policies’ we analyzed in this study [
62]. Structural-racism related policies may have unique impacts on transgender women of color as intersectional racism, cisgenderism, and misogyny impact how they are enforced. For example, compared to cisgender, heterosexual people, transgender women are disproportionately subject to police contact, harassment, and arrest for “walking while transgender” under the pretext of enforcing solicitation laws, and police hyper-surveillance of low-income communities of color compounds this risk [
63]. Critical legal scholars have described how solicitation laws and other policies used to justify ‘quality-of-life’ or ‘broken windows’ policing function to intimidate, control, and financially exploit people of color with intersecting marginalized identities, including transgender women of color [
64‐
67]. These include laws criminalizing behaviors deemed signifiers of disorder or immorality under hegemonic White supremacy and cisheteropatriarchy (e.g., loitering, vagrancy), laws criminalizing engagement in survival economies (e.g., sex work), laws governing law enforcement conduct (e.g., stop-and-frisk, racial and ethnic profiling), and laws structuring the legal systems through which those charged with de minimis offenses (i.e., those typically punished via fines and/or short incarceration periods) are sentenced [
62,
67‐
71]. How the full scope of these laws are enacted and enforced against transgender women of color remains poorly documented and understudied [
67]. Further research is needed on how these laws influence population level health outcomes [
72].
Overall, our results indicate that both access and equality policies may be more health-promoting for the self-rated health of White transgender women as compared to transgender women of color. These findings suggest that existing transgender-specific policies may create paths for less marginalized transgender women (e.g., White) to navigate existing oppressive structures such as healthcare, health insurance, and credit systems [
23]. Policies that effectively promote justice and liberation for all transgender people will need to reorder, disrupt, or dismantle these systems to effectively redistribute resources vital to structurally vulnerable transgender people’s wellbeing [
23]. For example, many of the policy demands in the Trans Agenda for Liberation concern abolition of the criminal-legal system in ways that would increase transgender people of color’s—specifically Black transgender women’s—access to employment, housing, and other economic resources and decrease their exposure to interpersonal violence [
38]. Such demands include decriminalizing sex work; ending practices such as monetary sanctions, cash bond, pretrial detention, and solitary confinement; removing immigration restrictions and eliminating immigrant detention; and redistributing public safety funds from policing to community-based alternatives based in restorative/transformative justice practices [
38]. The results of this study highlight the need for policy research pertaining to transgender health that uses intersectionality frameworks to understand how both transgender-specific and non-transgender specific laws differentially impact health for transgender women of color [
72‐
74].
Limitations
Findings must be interpreted in light of several limitations. First, our data came from a convenience sample of transgender women participating in a study of HIV incidence, and 21 states were not represented in the data. We chose this data source because national health surveillance systems do not allow for the identification of large enough samples of transgender people of color to adequately power analyses. Consequently, our findings lack generalizability to other geographies and transgender populations (e.g., transgender men). Additionally, although this study is among the first to decompose policy effects on health for White and transgender people of color, we acknowledge the diversity within the latter category which our analyses were not powered to explore.
Another major limitation is our use of self-reported general health as our primary outcome. This measure is an established predictor of many clinical outcomes and mortality and is widely used as outcomes in studies assessing the impact of social determinants of health [
75,
76]. Because self-reported general health measures reflect a range of potentially underlying health conditions, its use is also appropriate for research examining structural determinants of health. However, no studies have validated use of these measures in trans health research or with trans people of color. Notably, in this sample, participants of color reported better health than White participants, which may reflect established differences in how racial/ethnic groups respond to these survey items [
77]. Research on the burden and structural drivers of more specific health outcomes including cardiovascular disease, metabolic diseases, mental health conditions, and cancer among trans populations of color is urgently needed [
78].
Furthermore, while our use of LCA to operationalize and adjust for structural vulnerability is a notable strength of this study, some variables had different recall windows for online (6 months) and site-based (3 months) participants. Site-based participants may therefore have been more likely to be misclassified as Low Vulnerability as their recall windows for the items regarding risk environment, income sources, and difficulty finding a safe place to sleep were three months shorter than online participants. We attempted to mitigate this issue by adjusting for study modality in the LCA and all multivariable models. Additionally, our null findings regarding birth certificate gender marker changes likely reflect that these laws pertain to state of birth rather than current residence; future studies should consider mobility and migration among participants in evaluating this policy. Finally, our cross-sectional study design precludes any conclusions regarding causation, and we did not consider the length of time prior to data collection in which states had enacted these policies. Future research should consider quasi-experimental approaches to evaluating transgender-related policies’ health impact, including the potential mediating role of structural vulnerability or indicators of socioeconomic status.
Acknowledgements
The authors would like to express their gratitude to the transgender women who participated in this study. This study would not be possible without their experiences and participation. We appreciate the continued involvement and contributions of the Community Advisory Board that supports and guides this study. We also want to thank all the research staff who spent their time and effort to actualize this study and connect with study participants in meaningful ways.
American Cohort to Study HIV Acquisition Among Transgender Women (LITE) Study
Group
Sari L. Reisner, ScDb,g (consortium representative), Andrea L. Wirtz, PhD MHSh, Keri N. Althoff, PhD MPHh, Chris Beyrer, MDh, James Case, MHSi, Erin Cooney, PhDj, Meg Stevenson, MSPHh, Dee Adams, MSPHh, Oliver B. Laeyendecker, PhDk, Charlotte Gaydos, DrPHk, Tonia C. Poteat, PhD MPH PA-Cd, Kenneth Mayer, MDl, Asa E. Radix, MD PhDc, Christopher Cannon, MPH, ACRP-CPm, Jason Schneider, MD, FACPn, J. Sonya Haw, MDn, Allan Rodriguez, MDo, Andrew J. Wawrzyniak, PhDp, The LITE Community Advisory Board, which includes the following individuals: Sherri Meeks, Sydney Shackelford, Nala Toussaint, SaVanna Wanzer, as well as those who have remained anonymous
iDepartment of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
jDepartment of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
kJohns Hopkins University School of Medicine, 733 North Broadway, Baltimore, MD 21205, UAS
lFenway Health, 1340 Boylston St, Boston, MA 02215, USA
mWhitman-Walker, 1525 14th St. NW, Washington, DC, 20005, USA
nDepartment of Medicine, Emory University, 49 Jesse Hill Jr Dr SE, Atlanta, GA 30303, USA
oDepartment of Medicine, Miller School of Medicine, University of Miami, 1600 NW 10th Ave, #1140, Miami, FL, 33136, USA
pDepartment of Psychiatry and Behavioral Sciences, Miller School of Medicine, University of Miami, 1600 NW 10th Ave, #1140, Miami, FL, 33136, USA
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.