discussion
In the past year, seven in ten transgender women have experienced transphobic discrimination and one in three have reported employment discrimination. Difficulties finding employment because of being transgender were associated with poorer social determinants of health and lower access to and utilization of health care, including gender affirmation procedures.
NHBS – Prevalence of discrimination among trans people had similarities and differences with previous studies, including the 2015 United States Transgender Survey (USTS) (3). Compared to USTS participants, NHBS-trans participants reported a similar prevalence of employment discrimination (NHBS-trans participants 32% vs. USTS 30%). Higher prevalence of toilet discrimination (22% vs. 9%), poor treatment at work (39% vs. 31%), verbal abuse (59% vs. 12%), and physical abuse (27% vs. 1%) . and lower prevalence of housing discrimination (13% vs. 23%) and health care discrimination (11% vs. 33%). These differences may be partially explained by the sociodemographic composition of these two studies. Participants in the NHBS-Trans sample were primarily Black or Hispanic and had lower SES, whereas participants in the USTS sample were primarily White and higher SES. Additionally, from 2015 to 2019, transgender people reported increased discrimination and minority stress due to a hostile political climate towards transgender people (20). Finally, there were differences in the questionnaires between NHBS-Trans and USTS.
Employment discrimination occurs at the intersection of poverty, homelessness, incarceration, health insurance, disability, food insecurity, and survival sex work. These issues are interrelated. When economically marginalized transgender women are denied employment, this denial can lead to periodic economic hardship and lead them to engage in survival sex work (8), increase the likelihood of being imprisoned and facing further employment discrimination. For many people, sex work may be their primary form of employment, and employment discrimination can also occur as part of sex work. However, we were not able to examine that in this analysis. Furthermore, although it is illegal to discriminate against job applicants with disabilities, one in three transgender women with disabilities report that they struggle to find employment. Previous research has found that transgender people with disabilities experience high rates of employment discrimination (twenty one) Not being able to receive reasonable accommodation, etc.
Employment discrimination was associated with poorer access to health care, including being uninsured, having unmet health care needs due to cost, and not receiving transgender-specific health care. Private health insurance plans often offer more choice of providers and higher quality care (twenty two); employment may therefore influence an individual's ability and opportunity to choose a gender-affirming provider, which is associated with improved care engagement and health behaviors (twenty three,twenty four). Additionally, having a health care provider comfortable discussing gender issues is associated with the use of pre-exposure prophylaxis for HIV-negative transgender women (twenty five,26) and HIV care efforts for transgender women with HIV infection (twenty four). Transgender women who experience employment discrimination are more likely to have no health insurance or only receive Medicaid coverage, making it difficult to provide services to transgender patients regardless of their health insurance coverage. Improving the cultural competency and respect of medical staff and increasing staff representation The representation of transgender people in healthcare settings is important (27).
The majority of transgender women in NHBS-Trans were enrolled in Medicaid, the largest source of insurance coverage for people with HIV (28). Four out of 10 transgender women were diagnosed with HIV and half reported a disability. Therefore, the finding that Medicaid was the most common source of insurance was not unexpected. Employers may also discriminate against transgender women because they earn less (29), have been diagnosed with HIV (30), or have a disability (twenty one), which correlates with Medicaid eligibility.
The type of health insurance available to transgender women is related to their employment and disability status. For example, Medicaid acts as a safety net for people who suddenly find themselves unemployed (31). Expanding Medicaid could make it possible for transgender women without health insurance to qualify for Medicaid. However, Medicaid coverage for gender-affirming care varies by state (11,32). These variations can create barriers to medically necessary care for low-income transgender individuals (33). In NHBS-Trans, most participants lived in states where Medicaid programs explicitly cover gender-affirming care, with the exception of Georgia and Louisiana (18). This variable may be a proxy for larger structural factors, such as negative community attitudes toward transgender people (34), which can impact Medicaid policy in certain states (35). Additionally, states that have not expanded Medicaid are primarily located in the South and have large populations of blacks and Hispanics (36). Historically, Medicaid policy has been shaped by structural racism, which has contributed to health inequalities among Black and Hispanic populations (36).
Most transgender women seek medical care or are currently using hormone medications. No association was found between these experiences and employment discrimination. People seeking hormone therapy or other gender-affirming procedures typically require interaction with the health care system. Therefore, transgender women have a high motivation to seek medical care and pursue hormone therapy, sometimes at the expense of other basic needs (37,38). To achieve their transition goals, some transgender women may even seek out non-prescription hormones, which can be dangerous and unregulated (39,40), or rationing prescription hormones because of cost (41). Improving health insurance coverage of gender-affirming care in all states could help protect transgender women from pursuing dangerous alternatives to prescription hormones. However, undergoing gender reassignment procedures without health insurance is more difficult. Therefore, the relationship between unmet need for gender-affirming procedures and employment discrimination is noteworthy, as it may represent a structural barrier to health care access. Transgender women may have less access to gender affirmation procedures, in part because employers refuse to hire them and are therefore uninsured or underinsured.
