title: Geographic and Individual Differences in Healthcare Access for U.S. Transgender Adults: A Multilevel Analysis.
abstract: To identify geographic and individual-level factors associated with healthcare access among transgender people in the United States.
  
  
  
  Multilevel analyses were conducted to investigate lifetime healthcare refusal using national data from 5831 U.S. transgender adults. Hierarchical generalized linear models examined associations between individual (age, gender, race, income, insurance, and healthcare avoidance) and state-level factors (percent voting Republican, percent same-sex couple households, income inequality, and transgender protective laws) and lifetime refusal of care.
  
  
  
  Results show that individual-level factors (being older; trans feminine; Native American, multiracial, or other racial/ethnic minority; having low income; and avoiding care due to discrimination) are positively associated with care refusal (all P-values <0.05). Adjusting for individual-level factors, variation was observed across U.S. states, with a greater proportion of states in the Southern and Western United States with transgender residents at increased odds of experiencing care refusal, relative to other regions of the United States. When adjusting for state-level factors, the percentage of the state population voting Republican was positively associated with care refusal among the transgender adults sampled (P < 0.01).
  
  
  
  Transgender adults surveyed reported differential access to healthcare by geographic region. Identifying geographic and individual-level factors associated with healthcare barriers allows for the development of targeted educational and policy interventions to improve healthcare access for transgender people most in need of services.
authors.affiliation: 1 Chronic Disease Epidemiology, Yale School of Public Health , New Haven, Connecticut.|2 The Fenway Institute , Fenway Health, Boston, Massachusetts.
authors.forename: Jaclyn M
authors.initials: JM
authors.lastname: White Hughto
authors.affiliation: 1 Chronic Disease Epidemiology, Yale School of Public Health , New Haven, Connecticut.
authors.forename: Gabriel R
authors.initials: GR
authors.lastname: Murchison
authors.affiliation: 1 Chronic Disease Epidemiology, Yale School of Public Health , New Haven, Connecticut.
authors.forename: Kirsty
authors.initials: K
authors.lastname: Clark
authors.affiliation: 1 Chronic Disease Epidemiology, Yale School of Public Health , New Haven, Connecticut.
authors.forename: John E
authors.initials: JE
authors.lastname: Pachankis
authors.affiliation: 2 The Fenway Institute , Fenway Health, Boston, Massachusetts.|3 Division of General Pediatrics, Boston Children's Hospital and Harvard Medical School , Boston, Massachusetts.|4 Department of Epidemiology, Harvard T.H. Chan School of Public Health , Boston, Massachusetts.
authors.forename: Sari L
authors.initials: SL
authors.lastname: Reisner
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D003469:Culture; D004192:Discrimination, Psychological; D005260:Female; D062306:Geography, Medical; D006297:Health Services Accessibility; D054625:Healthcare Disparities; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D055361:Multilevel Analysis; D011057:Politics; D012959:Socioeconomic Factors; D063106:Transgender Persons; D014481:United States; D055815:Young Adult
keywords: access to care; healthcare; transgender