Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, CAP Research Centre, Stockholm, Sweden.
ANOVA Clinic, Karolinska University Hospital Stockholm, Norra Stationsgatan 69, 171 76, Stockholm, Sweden.
BMC Public Health. 2023 May 31;23(1):1031. doi: 10.1186/s12889-023-15856-9.
BACKGROUND: According to the minority stress theory, stigma affects the health of marginalized populations. Previous stigma research has focused on the health effects of individual and interpersonal stigma, paying less attention to structural factors. Laws on legal gender recognition affect the lives of transgender individuals in unique ways. The fact that these laws and population attitudes vary greatly between European countries, offer a unique opportunity to study the role of structural stigma in the lives of transgender individuals. Little is known about how transgender specific structural stigma relates to individual health determinants. Consequently, the aim of this study was to explore the association between structural stigma and access to gender affirming care, gender identity disclosure in health care, and experiences of discrimination in health care across 28 European countries. METHODS: By using multilevel regression, we combined data on health seeking behavior, transgender identity disclosure to health care providers, and experiences of discrimination in health care from 6,771 transgender individuals participating in the 2012 European Union Lesbian, Gay, Bisexual and Transgender survey with a structural stigma measure, consisting of population attitudes towards transgender individuals as well as national legislation on gender recognition. Reasons to refrain from seeking care and discrimination in health care were assessed by categorizing countries as low or high in structural stigma and using Chi-square statistics. RESULTS: Country-level structural stigma was negatively associated experiences of seeking gender affirming care and positively associated with concealment of being transgender to health care providers. Identity concealment was associated with a lower likelihood of exposure to discrimination in the health care setting across countries regardless of their level of structural stigma. The most prevalent reasons to forgo gender affirming care were shared between low and high structural stigma country groups and centered around fear. CONCLUSION: The results highlight the importance of changing stigmatizing legislation and population attitudes to promote access to gender affirming care as well as openness of being transgender towards providers. Measures to decrease discrimination in the health care setting are warranted in high as well as in low structural stigma countries.
背景：根据少数群体应激理论，污名会影响边缘群体的健康。先前的污名研究主要关注个体和人际污名对健康的影响，而较少关注结构性因素。关于法律性别认同的法律以独特的方式影响跨性别者的生活。这些法律和人口态度在欧洲国家之间存在巨大差异，这为研究结构性污名在跨性别者生活中的作用提供了独特的机会。人们对跨性别者特定的结构性污名与个体健康决定因素之间的关系知之甚少。因此，本研究旨在探讨结构性污名与获得性别肯定护理、在医疗保健中披露性别认同以及在 28 个欧洲国家的医疗保健中经历歧视之间的关联。
方法：我们使用多水平回归，将 6771 名参加 2012 年欧盟女同性恋、男同性恋、双性恋和跨性别调查的跨性别个体的健康寻求行为、向医疗保健提供者披露跨性别身份以及在医疗保健中经历歧视的数据与一个结构性污名指标相结合，该指标包括人口对跨性别者的态度以及关于性别认同的国家立法。通过将国家划分为结构性污名低或高，并使用卡方检验来评估拒绝寻求护理和在医疗保健中受到歧视的原因。
结果：国家层面的结构性污名与寻求性别肯定护理的经历呈负相关，与向医疗保健提供者隐瞒跨性别身份呈正相关。无论国家结构性污名水平如何，身份隐瞒都与在医疗保健环境中受到歧视的可能性降低相关。放弃性别肯定护理的最常见原因在低结构性污名和高结构性污名国家群体中是共同的，并且集中在恐惧上。
结论：研究结果强调了改变污名化立法和人口态度的重要性，以促进获得性别肯定护理以及向提供者公开跨性别身份。在高结构性污名和低结构性污名国家，都需要采取措施减少医疗保健中的歧视。
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