A Mediational Analysis of Insurance and Anticipated Stigma.

15. Draw a DAG to represent the findings of this study. Hughes LD, Gamarel KE, King WM, Goldenberg T, Jaccard J, Geronimus AT. State-Level Policy Stigma and Non-Prescribed Hormones Use among Trans Populations in the United States: A Mediational Analysis of Insurance and Anticipated Stigma. Ann Behav Med. 2022 Jun 29;56(6):592-604. doi: 10.1093/abm/kaab063. Background: Medical gender affirmation (i.e., hormone use) is one-way transgender (trans) people affirm their gender and has been associated with health benefits. However, trans people face stigmatization when accessing gender-affirming healthcare, which leads some to use non- prescribed hormones (NPHs) that increase their risk for poor health. Purpose: We examined whether healthcare policy stigma, as measured by state-level trans-specific policies, was associated with NPHs use and tested mediational paths that might explain these associations. Because stigmatizing healthcare policies prevent trans people from participation in healthcare systems and allow for discrimination by healthcare providers, we hypothesized that healthcare policy stigma would be associated with NPHs use by operating through three main pathways: skipping care due to anticipated stigma in healthcare settings, skipping care due to cost, and being uninsured. Methods: We conducted analyses using data from the 2015 U.S. Transgender Survey. The analytic sample included trans adults using hormones (N = 11,994). We fit a multinomial structural equation model to examine associations. Results: Among trans adults using hormones, we found that healthcare policy stigma was positively associated with NPHs use and operated through insurance coverage and anticipating stigma in healthcare settings. The effect sizes on key predictor variables varied significantly between those who use supplemental NPHs and those who only use NPHs suggesting the need to treat NPHs use as distinct from those who use supplemental NPHs. Conclusions: Our work highlights the importance of healthcare policy stigma in understanding health inequities among trans people in the USA, specifically NPHs use.