UC Santa Barbara

Sexual and gender minorities (SGM), a population which includes persons who consider themselves lesbian, gay, bisexual, transgender, and queer (LGBTQ+), were formally designated a “health disparity population” by the National Institutes of Health (NIH) in 2016 (Pérez-Stable 2016). In order to better understand what explains SGM health disparities and how we may better achieve health equity, I examine three aspects of SGM health and wellbeing in closer detail: 1) the effect of the Affordable Care Act’s Medicaid expansion on HIV viral suppression and HIV diagnoses, 2) the relationship of structural stigma (anti-transgender state policies) with transgender mental and physical health, and 3) the social determinants of transgender community connectedness and gender identity pride.The first empirical chapter of this dissertation employs data from the Centers for Disease Control and Prevention to assess how the differential state-level implementation of the Affordable Care Act’s Medicaid expansion impacts HIV viral suppression and HIV diagnoses outcomes among White, Black, and Latinx individuals and gay, bisexual, and other cisgender men who have sex with men (GBMSM). I find a reduction in HIV diagnoses among Latinx individuals in the Medicaid expansion states, but no effect on White or Black individuals or GBMSM. Despite some reduction, substantial health disparities remain in the post-expansion period, as White Americans continue to have the highest viral suppression and lowest diagnosis rate compared to Black and Latinx Americans. The second empirical chapter uses the first national probability sample of transgender adults (TransPop) to evaluate the relationship between structural stigma and transgender mental and physical health. After linking respondents’ state of residence with transgender-related policies in that state, I find that, on average, transgender respondents fare worse on mental and physical health outcomes compared to their cisgender peers without taking into account structural stigma. In addition, I find that greater exposure to structural stigma (i.e., more anti-transgender policies in respondents’ state of residence) has a significant association with poorer mental health outcomes for transgender individuals only. The third empirical chapter continues to use the TransPop data to focus on the social determinants of two resilience factors, transgender community connectedness (TCC) and gender identity pride. I find that 1) variation in gender identity and socioeconomic status within the transgender community is linked with differences in resilience; 2) therapy is strongly linked to both higher TCC and pride; and 3) childhood bullying is linked to lower gender identity pride as an adult. Building on the work of others who call on researchers to expand their focus from only disparities and negative outcomes (e.g., Colpitts and Gahagan 2016), I argue that TCC and pride are not only valuable as resilience factors, but as measures of transgender wellbeing, or what may be called “trans joy” or “gender euphoria” (Beischel, Gauvin, and van Anders 2022; shuster and Westbrook 2022).