title: Legal Protections in Public Accommodations Settings: A Critical Public Health Issue for Transgender and Gender-Nonconforming People.
abstract: CONCLUSIONS
  Since 2012, Massachusetts law has provided legal protections against discrimination on the basis of gender identity in employment, housing, credit, public education, and hate crimes. The law does not protect against discrimination based on gender identity in public accommodations settings such as transportation, retail stores, restaurants, health care facilities, and bathrooms. A 2013 survey of Massachusetts transgender and other gender minority adults found that in the past 12 months, 65% had experienced public accommodations discrimination since the law was passed. This discrimination was associated with a greater risk of adverse emotional and physical symptoms in the past 30 days. Nondiscrimination laws inclusive of gender identity should protect against discrimination in public accommodations settings to support transgender people's health and their ability to access health care.
  
  
  BACKGROUND
  Gender minority people who are transgender or gender nonconforming experience widespread discrimination and health inequities. Since 2012, Massachusetts law has provided protections against discrimination on the basis of gender identity in employment, housing, credit, public education, and hate crimes. The law does not, however, protect against discrimination in public accommodations (eg, hospitals, health centers, transportation, nursing homes, supermarkets, retail establishments). For this article, we examined the frequency and health correlates of public accommodations discrimination among gender minority adults in Massachusetts, with attention to discrimination in health care settings.
  
  
  METHODS
  In 2013, we recruited a community-based sample (n = 452) both online and in person. The respondents completed a 1-time, electronic survey assessing demographics, health, health care utilization, and discrimination in public accommodations venues in the past 12 months. Using adjusted multivariable logistic regression models, we examined whether experiencing public accommodations discrimination in health care was independently associated with adverse self-reported health, adjusting for discrimination in other public accommodations settings.
  
  
  RESULTS
  Overall, 65% of respondents reported public accommodations discrimination in the past 12 months. The 5 most prevalent discrimination settings were transportation (36%), retail (28%), restaurants (26%), public gatherings (25%), and health care (24%). Public accommodations discrimination in the past 12 months in health care settings was independently associated with a 31% to 81% increased risk of adverse emotional and physical symptoms and a 2-fold to 3-fold increased risk of postponement of needed care when sick or injured and of preventive or routine health care, adjusting for discrimination in other public accommodations settings (which also conferred an additional 20% to 77% risk per discrimination setting endorsed).
  
  
  CONCLUSIONS
  Discrimination in public accommodations is common and is associated with adverse health outcomes among transgender and gender-nonconforming adults in Massachusetts. Discrimination in health care settings creates a unique health risk for gender minority people. The passage and enforcement of transgender rights laws that include protections against discrimination in public accommodations-inclusive of health care-are a public health policy approach critically needed to address transgender health inequities.
authors.affiliation: Harvard T.H. Chan School of Public Health.|Fenway Health.
authors.forename: Sari L
authors.initials: SL
authors.lastname: Reisner
authors.affiliation: Fenway Health.|Yale School of Public Health.
authors.forename: Jaclyn M White
authors.initials: JM
authors.lastname: Hughto
authors.affiliation: Fenway Health.|Heller School for Social Policy and Management, Brandeis University.
authors.forename: Emilia E
authors.initials: EE
authors.lastname: Dunham
authors.affiliation: Harvard T.H. Chan School of Public Health.
authors.forename: Katherine J
authors.initials: KJ
authors.lastname: Heflin
authors.affiliation: Massachusetts Transgender Political Coalition.
authors.forename: Jesse Blue Glass
authors.initials: JB
authors.lastname: Begenyi
authors.affiliation: Fenway Health.
authors.forename: Julia
authors.initials: J
authors.lastname: Coffey-Esquivel
authors.affiliation: Fenway Health.|Heller School for Social Policy and Management, Brandeis University.|Wagner School of Public Service, New York University.
authors.forename: Sean
authors.initials: S
authors.lastname: Cahill
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D005783:Gender Identity; D062985:Health Services for Transgender Persons; D006801:Humans; D008297:Male; D008875:Middle Aged; D011287:Prejudice; D011633:Public Facilities / Q000331:legislation & jurisprudence*; D011634:Public Health; D012147:Restaurants; D063508:Social Discrimination / Q000331:legislation & jurisprudence*; D057545:Social Stigma; D013315:Stress, Psychological / Q000453:epidemiology; D063106:Transgender Persons / Q000331:legislation & jurisprudence* / Q000523:psychology; D014481:United States; D055815:Young Adult
keywords: discrimination; health; policy; transgender