Natalie Mac Arthur
Senior Research Associate

e shadac@umn.edu

Provider Discrimination Based on Sexual Orientation and Gender Identity: Experiences of Transgender/Nonbinary Adults and Sexually Minoritized Adults in Minnesota

Background

Understanding the experiences of people with minoritized sexual and gender identities matters for public health. Compared with straight and cisgender adults, these populations face inequitable barriers to health care access^1,2 and disparities in health outcomes, including mental and physical health, activity limitations, and chronic conditions.^3,4 Accordingly, Sexual Orientation and Gender Identity (SOGI) data collection is foundational in advancing population health and health equity in order to better understand the disparities and inequities these populations face.

As highlighted in our previous blogs, one focused on populations by sexual orientation and the other focused on populations by gender identity, reports of discrimination from health care providers based on sexual orientation or gender identity are high among people with minoritized sexual and gender identities. This discrimination is associated with barriers to health care access. For example, individuals who report discrimination may not receive proper treatment from discriminatory providers, and they may forgo or delay health care to avoid discrimination. Across populations, experiencing discrimination has been shown to negatively affect mental and physical health.⁵

In this blog, we build on these results by pooling two years of data to look at people’s experiences at the intersection of minoritized sexual and gender identities in reports of provider discrimination based on gender or sexual orientation. We used a survey question asking, ‘how often their gender, sexual orientation, gender identity or gender expression cause health care providers to treat them unfairly.’ Our analysis also illustrates how the commonly used measures for sexual orientation do not adequately encompass the range of options for sexually minoritized people, and how these limitations disproportionately impact the transgender and nonbinary populations.

Study Approach

We used 2021-2023 data from the biennial Minnesota Health Access Survey (MNHA). See Methods here.  

Results 

Among all adults in Minnesota, over half of the transgender/nonbinary population (56.3%) reported experiencing provider discrimination based on sexual orientation or gender identity – significantly higher compared with cisgender adults’ reported experiences of discrimination (6.7%) (Table 1). 

Table 1. Rates of SOGI-Based Provider Discrimination by Sexual Orientation Among Cisgender Adults and Transgender/Nonbinary Adults in Minnesota, 2021-2023.

* Significant difference between cisgender and transgender/nonbinary adults in reports of provider discrimination.
† Estimate may be unreliable due to limited data (relative standard error greater than or equal to 30%).
-- Estimate not available to limited data.
Source: SHADAC analysis of the 2021-2023 Minnesota Health Access Survey.

When delving into experiences of provider discrimination among people with diverse gender and sexual identities, we found that reports of provider discrimination from transgender/nonbinary adults who identified as gay/lesbian or ‘none of these’ were significantly higher than for cisgender adults who identify as gay/lesbian or ‘none of these.’ 

Specifically, provider discrimination based on gender or sexual orientation was reported by:

• Nearly 9 in 10 transgender/nonbinary adults (88.1%) and about one in four (24.1%) cisgender adults who identified as gay/lesbian 
• Two thirds of transgender/nonbinary adults (66.1%) and about a quarter of cisgender adults (23.9%) that chose the ‘none of these’ option for sexual orientation

Provider discrimination was also high for people who identified as bisexual/pansexual, and, for this group, not significantly different for transgender/nonbinary adults (40.5%) and cisgender adults (31.6%).

The lowest rates of provider discrimination were reported by straight cisgender adults at 4.9%.

Please note that sample sizes were limited, particularly for comparing straight or bisexual/pansexual adults by gender. 

Discussion  

Consistently across sexual orientations, reports of provider discrimination based on gender or sexual orientation were higher for transgender/nonbinary adults compared with cisgender adults. This suggests that discrimination associated with sexual minoritization may disproportionately impact transgender/nonbinary populations. 

Individuals that experience multiple minoritized identities must contend with discrimination on multiple levels. For example, someone may experience discrimination based on a combination of their sexual orientation, gender identity, race, and/or disability status. Looking at the data from this study, we can illustrate this idea looking at provider discrimination reported by gay/lesbian cisgender adults and gay/lesbian transgender/nonbinary adults. Both of these groups share the same sexual orientation, but differ in gender identity. The group with multiple minoritized identities, the gay/lesbian transgender/nonbinary group, reported significantly higher rates of discrimination (88.1%) compared to cisgender gay/lesbian adults (24.1%), which may be related to their multiple levels of marginalization.

Overall, though, our analysis finds that discrimination remains alarmingly high across all groups of people with minoritized sexual and/or gender identities. Looking across the Minnesota population, this study documents provider discrimination among both transgender/nonbinary and cisgender sexual minorities, including people who identify as gay/lesbian, bisexual/pansexual, or ‘none of these.’ 

Our study also shows the importance of providing data for groups outside of the largest categories such straight, gay/lesbian, or bisexual. For example, by pooling multiple years of data, we were able to produce estimates for gender and sexual minorities including people who responded ‘none of these’ for sexual orientation. This latter group is important to highlight considering the wide range of sexual identities beyond gay/lesbian, straight, and bisexual. Reports of discrimination were high for both transgender/nonbinary and cisgender people who responded ‘none of these’ for sexual orientation, and significantly higher for the transgender/nonbinary people compared with cisgender.

This study highlights continued evidence of health care provider discrimination in Minnesota, with transgender/nonbinary sexual minorities being particularly impacted. Policies are urgently needed to address this discrimination, particularly for transgender/nonbinary Minnesotans who already face barriers to health care access and disparities in health outcomes compared to cisgender adults.

METHODS 

Data

The 2021-2023 Minnesota Health Access (MNHA) survey is a biennial population-based survey on health insurance coverage and access conducted in collaboration with the Minnesota Department of Health. We limited the analysis to adults responding for themselves about experiences of discrimination (n=17,828), and we excluded proxy reports (e.g., a household member answering for a spouse or roommate). 

Discrimination Based on Sexual Orientation and Gender Identity in the MNHA Survey 

To study discrimination, we looked at a survey question that asks respondents ‘how often their gender, sexual orientation, gender identity or gender expression cause health care providers to treat them unfairly.’ Responses of ‘never’ were coded as no discrimination, and responses of ‘always,’ ‘usually,’ or ‘sometimes’ were coded as discrimination. 

Sexual Orientation Measures in the MNHA Survey

Similar to other surveys that collect sexual orientation data, the MNHA asks about sexual orientation using three main response options: ‘gay or lesbian’; ‘straight, that is, not gay or lesbian’; and, ‘bisexual or pansexual.’ Survey respondents could also select ‘don’t know’ or ‘none of these,’ with an option to write in their own answer. We reviewed write-in responses and, when possible, recoded these responses to align with the existing categories.

Recoding write-in responses was a key step in reducing the risk of misclassification in order to include people who selected ‘none of these’ for sexual orientation in analysis. Some straight adults are unfamiliar with terminology for sexual orientation, which can lead to inaccurate responses.⁶ We reclassified inappropriate write-in answers (such as man, woman, married, or offensive comments) as ‘refused.’ 

After this step in cleaning the data, we tabulated results separately for two groups: people who responded ‘none of these’ with no write-in, and those who responded ‘none of these’ with an LGBTQ+ write-in response such as ‘queer’ or ‘asexual.’ Rates were similar, which helped to justify combining these subgroups into a single ‘none of these’ variable to improve sample size and produce estimates of reported discrimination for this subpopulation.

MNHA measures of sexual orientation were generally consistent with current best practices (for more information on SOGI data collection practices in Medicaid click here, and click here for our brief on federal survey sample size analysis), our analysis highlights some limitations of commonly used survey measures for sexual orientation. A small difference in the MNHA from typical measures is the inclusion of ‘bisexual or pansexual’ rather than only ‘bisexual’ as a response option. Current recommendations suggest using the phrasing, ‘I use a different term,’ rather than ‘none of these’ as a response option.⁷

Gender Identity Measures in the MNHA Survey

In 2023, the MNHA switched from a single question measuring gender to a two-step question asking first, ‘how do you describe your gender,’ and second, ‘are you transgender.’ As described in a previous blog, this approach was developed by the Oregon Health Authority through extensive community engagement and has advantages of being clear and inclusive.⁸ Response options for gender were:

1. Man
2. Woman
3. Gender non-binary or two-spirit
4. Agender/no gender
5. Another gender (optional write in response)  

In contrast, 2021 response options included ‘transmale/transman’ and ‘transfemale/transwoman’ listed after ‘male/man’ and ‘female/woman,’. Although current best practice recommendations for federal surveys list ‘transgender’ as response option after male/female, this approach has the limitation of implying that being transgender is ‘other’ and mutually exclusive from male/female. Similarly, the two-step question currently recommended for federal surveys asks about ‘sex assigned at birth,’ which may be perceived as invalidating and adds cognitive burden, especially for people with low literacy. Using accessible language in survey questions supports user experiences and overall response rates, and helps to reduce data quality problems such as item non-response and misclassifications. Guidance developed by the state of Oregon offers an inclusive approach to measuring gender on population surveys. 

Analysis

We tabulated gender and sexual orientation based discrimination by sexual orientation for cisgender and transgender/nonbinary adults in Minnesota. For transparency, we present results for all response categories, even if estimates must be suppressed due to lack of data. Tests for statistical significance were conducted at the 95% confidence level.

References

[1] Bosworth, A., Turrini, G., Pyda, S., Strickland, K., Chappel, A., De Lew, N., Sommers, B.D.. (June 2021). Health Insurance Coverage and Access to Care for LGBTQ+ Individuals: Current Trends and Key Challenges. https://aspe.hhs.gov/sites/default/files/2021-07/lgbt-health-ib.pdf

[2] Kates, J., & Ranji, U. (2024). Health Care Access and Coverage for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community in the United States: Opportunities and Challenges in a New Era. https://www.kff.org/racial-equity-and-health-policy/perspective/health-care-access-and-coverage-for-the-lesbian-gay-bisexual-and-transgender-lgbt-community-in-the-united-states-opportunities-and-challenges-in-a-new-era/

[3] Baptiste-Roberts, K., Oranuba, E., Werts, N., & Edwards, L. V. (2017). Addressing health care disparities among sexual minorities. Obstetrics and Gynecology Clinics, 44(1), 71-80. 

[4] Feir, D., & Mann, S. (2024). Temporal Trends in Mental Health in the United States by Gender Identity, 2014–2021. American Journal of Public Health, (0), e1-e4. 

[5] Pascoe, E. A., & Smart Richman, L. (2009). Perceived discrimination and health: a meta-analytic review. Psychological bulletin, 135(4), 531.

[6] Miller, K., & Ryan, J. M. (2011). Design, development and testing of the NHIS sexual identity question. National Center for Health Statistics, 1-33.

[7] Office of the Chief Statistician of the United States. (n.d.). Recommendations on the Best Practices for the Collection of Sexual Orientation and Gender Identity Data on Federal Statistical Surveys. (Washington, D.C.) https://www.whitehouse.gov/wp-content/uploads/2023/01/SOGI-Best-Practices.pdf

[8] Oregon Health Authority. (2021, December 21). OHA/ODHS SOGI Committee Structure and Process used to Develop SOGI Data Recommendations (December 2021). https://www.oregon.gov/oha/EI/Documents/SOGI-Data-Committee-Survey.pdf