Health Equity Implications of Transgender Policies in the United States: A Legal Epidemiology Approach

Introduction

Transgender (trans) populations experience worse health outcomes compared to cis-gender populations, including higher rates of poor mental health, experiences of medical bias, and communicable diseases. These health disparities are broadly influenced by the political context within individual states that can perpetuate social exclusion. In the last five years, there has been a sharp increase in exclusionary legislation related to trans individuals that can deepen health inequality and exacerbate poor health outcomes. Using a legal epidemiological approach, we conducted a policy scan of state-level legislation in the United States to determine geographic distribution, frequency, and whether the legislation was trans affirming and/or exclusionary.

Methods

We searched the Westlaw policy database to identify proposed legislation in U.S. states between 2017-2021 using search terms related to "transgender.” The initial search identified 1280 results, of which, 698 proposed bills were included in the final analysis. Five researchers reviewed the proposed legislation and categorized each bill into "affirming” or "exclusionary” categories. Using a priori themes identified in the grey literature and refined among the research team, bills were further categorized by the theme of the legislation into 11 categories: athletics, bathrooms, administrative changes, affirmation care, religious claims, recognition, rights in the healthcare field, training revisions, criminal justice reform, education and school, and government augmentation. These categories were used to calculate affirming density, exclusionary density, and inclusivity scores and corresponding maps for legislation related to trans populations in each state.

Results

Of the 698 policies reviewed, 567 (81.23%) were affirming of trans identities while 131 (18.77%) were exclusionary of trans identities. Affirming legislation included policies related to government augmentation (20.81%), education/school (18.34%), administrative bills (18.17%), criminal justice reform/legal protections (15.34%), rights in the healthcare field (11.46%), training revisions (10.05%), recognition (4.94%) affirmation care (0.71%), and athletics (0.18%). Exclusionary legislation included policies related to athletics (58.78%), affirmation care (24.43%), bathrooms (7.63%), education/school (3.82%), religious claims (2.29%), administrative changes (1.53%) and rights in the healthcare field (1.53%). Affirming legislation was most prominent in the West Coast, the Northeast, and parts of the Midwest. Conversely, exclusionary legislation was highly prevalent among Southeast, South Central, and Mountain West regions.

Discussion

This study laid the foundation for further analysis of the political context and its influence on trans health. Exclusionary and affirming density maps indicate vastly different political contexts for trans individuals depending on US state. Such political contexts can contribute to social exclusion of trans individuals that exacerbates poor health outcomes. Further, the magnitude of legislation proposed was starkly different between affirming and exclusionary policies. Exclusionary policies focused on criminalization of trans-related issues such as gender-affirming care. Comparatively, affirming policies were largely focused on forms of representation related to local boards or governing committees (government augmentation). Representation of LGBTQ+ communities in government is incredibly important but may not negate the harm caused by the criminalization of trans-related care. Future research is needed to investigate legal etiologies of health disparities seen in trans populations compared to cisgendered populations.