Blog & News
Provider Discrimination by Sexual Orientation Among Cisgender and Transgender/Nonbinary Adults in Minnesota
June 28, 2024: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 access1,2 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 discrimination by sexual orientation and the other focused on discrimination by gender identity, reports of discrimination from health care providers based on sexual orientation and 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 examine the experiences of discrimination for cisgender and transgender/nonbinary adults in Minnesota by sexual orientation. 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 SOGI-based discrimination from health care providers – 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.
Cisgender | Transgender/Nonbinary | ||
All Adults (18+) | 6.7% | 56.3% | * |
Sexual Orientation | |||
Straight | 4.9% | -- | -- |
Gay or Lesbian | 24.1% | 88.1% | * |
Bisexual or Pansexual | 31.6% | 40.5% | |
None of These | 23.9%† | 66.2% | * |
* 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 reported discrimination by sexual orientation for different gender identities, we found that rates of reported 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, discrimination 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
Discrimination was also high 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 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 SOGI 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 who 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 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 SOGI 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. Additionally, 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:
- Man
- Woman
- Gender non-binary or two-spirit
- Agender/no gender
- 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 SOGI-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
Publication
Sexual Orientation, Gender Identity, and Gender Affirming Care Discrimination: Underlying Factors of Medicaid Inequities Annotated Bibliography
*Click here to jump to the 'Sexual Orientation, Gender Identity, and Gender Affirming Care Discrimination' annotated bibliography*
The State Health Access Data Assistance Center (SHADAC) with support from the Robert Wood Johnson Foundation (RWJF) and in collaboration with partner organizations is exploring whether a new national Medicaid Equity Monitoring Tool could increase accountability for state Medicaid programs to advance health equity while also improving population health.
During the first phase of this project, a conceptual wireframe for the potential tool was created. This wireframe includes five larger sections, organized by various smaller domains, which would house the many individual concepts, measures, and factors that can influence equitable experiences and outcomes within Medicaid (see full wireframe below).
While project leaders and the Advisory Committee appointed at the beginning of the project all agree that the Medicaid program is a critical safety net, they specifically identified the importance and the need for an “Underlying Factors” section of the tool. This section aims to compile academic research and grey literature sources that explain and provide analysis for the underlying factors and root causes that may contribute to inequities in Medicaid.
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- Historical context of Medicaid inequities
- Information on how underlying factors perpetuate inequities in Medicaid
- Potential solutions for alleviating inequities within Medicaid
Once selected, researchers compiled sources in an organized annotated bibliography, providing a summary of each source and its general findings. This provides users with a curated and thorough list of resources they can use to understand the varied and interconnecting root causes of Medicaid inequities. Researchers plan to continually update this curated selection as new research and findings are identified and/or released.
Sections of the full annotated bibliography include:
- Systemic Racism
- Systemic / Structural Ableism
- Sexual Orientation, Gender Identity, and Gender Affirming Care Discrimination
- Reproductive Oppression in Health Care (webpage forthcoming)
- Impact on Vital Community Conditions (webpage forthcoming)
This page is dedicated to a single section from the full annotated bibliography:
Sexual Orientation, Gender Identity, and Gender Affirming Care Discrimination
![](https://www.shadac.org/sites/default/files/publications/annotated%20bib%20topic%20box%20graphic%20sogi-1.png)
Underlying Factors Annotated Bibliography: Sexual Orientation, Gender Identity, and Gender Affirming Care Discrimination
Have a source you'd like to submit for inclusion in our annotated bibliography? Contact us here to propose a source for inclusion.
Click on the arrows to expand / collapse each source.
Mallory, C., & Tentindo, W. (2022). Medicaid Coverage for Gender-Affirming Care. Williams Institute UCLA School of Law. https://escholarship.org/content/qt4ng3j6st/qt4ng3j6st.pdf
Author(s): Christy Mallory and Will Tentindo, Williams Institute at University of California - Los Angeles
Article Type: Report
This report highlights key factors related to Medicaid coverage of gender affirming care. Emphasis is placed on the sheer number of individuals who identify as transgender or gender non-conforming that are covered by Medicaid – about one fourth of those who identify as transgender or gender non-conforming in the United States rely on Medicaid for their gender affirming care. Underlying factors contributing to inequities for this group include unclear language about what services are covered, and/or gender affirming care services are not covered at all in their state. Authors urge all states to fully expand their Medicaid program under the Affordable Care Act.
Kempf, R., Elias, N., & Rubin-DeSimone, A. (2021). Transgender and Gender Non-Binary Healthcare Coverage in State Medicaid Programs: Recommendations for More Equitable Approaches. Journal of Health and Human Services Administration, 44(1), 86–108. https://doi.org/10.37808/jhhsa.44.1.5
Author(s): Robin J. Kempf, Assistant Professor in the College of Public Service at the University of Colorado - Colorado Springs; Nicole M. Elias, Associate Professor in the Department of Public Management at John Jay College of Criminal Justice, City University of New York; Alonso J. Rubin-DeSimone, John Jay College of Criminal Justice, City University of New York
Article Type: Peer-reviewed journal
This peer reviewed journal article describes how transgender and gender non-binary individuals have been marginalized historically in U.S. society, including in terms of institutional or informal “erasure” as well as through isolation and “hypervisibility.” In health care, this discrimination translates into lack of access to qualified professionals and lack of coverage for a continuum of needed services. Authors chose to review state Medicaid program coverage policies to identify opportunities to build equity for all U.S. residents and noted that discrimination of individuals identifying as non-cisnormative gender can be compounded by the intersectionality of race, sexual orientation, socioeconomic status, and geographical location. They assessed comprehensiveness of state Medicaid coverage in accordance with the World Professional Association for Transgender Health (WPATH) standards. Authors found that the five states in their sample varied widely in terms of health coverage to transgender and gender non-binary Medicaid beneficiaries, however, there were stand out states in terms of the continuum of services offered as well as opportunities for improvement. Authors recommend removal of barriers to needed care such as prior authorization requirements as well as additional training for providers and individuals making coverage determinations.
Yuan, N., Chung, T., Ray, E. C., Sioni, C., Jimenez-Eichelberger, A., & Garcia, M. M. (2021). Requirement of mental health referral letters for staged and revision genital gender-affirming surgeries: An unsanctioned barrier to care. Andrology, 9(6), 1765–1772. https://doi.org/10.1111/andr.13028
Author(s): Nance Yuan, Cedars-Sinai Transgender Surgery and Health Program, and member of the Urology and Plastic Surgery Divisions at Cedars-Sinai Medical Center; Theodore Chung, David Geffen School of Medicine, University of California, Los Angeles; Alma Jimenez-Eichelberger and Caitlin Sioni, Cedars-Sinai Transgender Surgery and Health Program and the Division of Urology at Cedars-Sinai Medical Center; Edward C. Ray, Division of Plastic Surgery, Cedars-Sinai Medical Center; Maurice M. Garcia, Departments of Urology and Anatomy, University of California, San Francisco
Article Type: Peer-reviewed journal
This peer reviewed article investigates and discusses insurance requirements for referral letters from mental health providers prior to genital gender affirming surgeries for trans and non-binary individuals. In this study, half of the participants had federally funded insurance, such as Medicaid. Most plans, both public and private, required at least two referral letters at every stage of surgery (there may be four to five stages depending on the operation). Authors state that it took office staff, “an average of 2.5 hours per patient, per surgery, dedicated to coordinating submission of updated referral letters”. Some participants had to cancel or reschedule an operation due to lack of coordination of care, and/or administration not receiving referral letters. This resulted in patients being forced to pay for surgeries out-of-pocket instead of using insurance coverage. The authors discuss how multiple letters for each stage of a surgery is unnecessary, when no participant was deemed mentally unfit for any previously performed procedure. Authors state that requiring updated letters for each year was also a point of stress for participants as these administrative burdens were “costly and burdensome” to patients and providers alike. The authors urge organizations such as the World Professional Association for Transgender Health (WPATH) to revisit their recommendations for referral letter requirements to alleviate the burdens on both administrators and patients alike.
Mann, S. J., Carpenter, C. S., Gonzales, G., Harrell, B., & Deal, C. (2022). Effects of the affordable care Act’s Medicaid expansion on health insurance coverage for individuals in same-sex couples. Health Services Research, 58(3), 612–621. https://doi.org/10.1111/1475-6773.14128
Author(s): Samuel Mann, Christopher S. Carpenter, Benjamin Harrell, and Cameron Deal are all from the Department of Economics, LGBTQ+ Policy Lab, Vanderbilt University, Nashville, Tennessee; Gilbert Gonzales is also a member of the Department of Medicine, Health & Society, and Department of Health Policy at Vanderbilt University.
Article type: Peer-reviewed journal
This peer reviewed journal article analyzes how Medicaid expansion influenced health insurance coverage for individuals in same-sex partnerships. Using data from the American Community Survey, authors found that there was a significant increase in coverage between 2009 and 2018 for low-income adults who were in a same-sex relationship, especially for women. The authors attribute this to a much higher prevalence of children being in households of women same-sex couples compared to men. The authors also state that sexual minority women may have stronger social ties that reduce stigma surrounding Medicaid or public options compared to sexual minority men. This research has implications that are important for policymaking and underlying factors of inequity within Medicaid in terms of barriers to seeking health insurance coverage and accessibility of services for those individuals in same-sex partnerships.
[1] Human Rights Campaign. (n.d.). Sexual Orientation and Gender Identity Definitions. Human Rights Campaign; HRC Foundation. https://www.hrc.org/resources/sexual-orientation-and-gender-identity-terminology-and-definitions
[2] Ibid.
[3] HHS Office of Population Affairs. (n.d.). Gender-Affirming Care and Young People. U.S. Department of Health & Human Services. https://opa.hhs.gov/sites/default/files/2023-08/gender-affirming-care-young-people.pdf