What you need to know
Thirty-three percent of the Canadians over 15 years old identify as transgender and non-binary. Transgender refers to individuals who do not identify with the sex assigned to them at birth, and non-binary individuals do not identify exclusively with a system of two genders, and may identify as both, neither, or some combination of the two. Based on the 2021 Canadian census nearly 39.1% of the total transgender population resides in Ontario, and transgender people experience higher rates of mental and physical health issues and higher health service use compared to cisgender people (i.e., individuals who identity with their sex assigned at birth). There is limited understanding of why this is the case. Therefore, researchers in this study looked at the extent to which neighbourhood-level marginalization affects mental health service use among transgender and non-binary individuals.
What is this research about?
According to previous studies, the rate of mental health and physical health issues and health service use among transgender and non-binary individuals is high compared to cisgender individuals, especially when looking at suicidality and self harm and chronic conditions, such as asthma, diabetes and HIV. Transgender individuals also experience difficulty accessing housing, employment and basic goods and services and social marginalization such as discrimination and stigma. Limited research has been conducted on how the marginalization of transgender individuals impacts their health outcomes. This study looks at the extent to which neighbourhood-level marginalization affects mental health service use among transgender and non-binary individuals.
What did the researchers do?
The researchers conducted a retrospective cohort study. Administrative health data was obtained from four outpatient community and hospital clinics in three large cities (Toronto, Ottawa and Thunder Bay) in Ontario between January 2015 and December 2019. The following outcome measures were analyzed from March 2020 to May 2022:
- mental health service utilization, including mental health-related visits to primary care providers, psychiatrists, mental health and self-harm related emergency department visits and mental health hospitalizations for the total number of each health service unit.
- ethnic concentration or the concentration of racialized individuals in a neighbourhood, residential instability, dependency or the proportion of individuals unable to work due to old age, young age or disability in the neighbourhood.
Other variables collected were the following:
- sociodemographic (e.g., sex and age)
- migrant status (e.g., immigrant, long-term resident, and refugee)
- medical comorbidities (e.g., arthritis, asthma, cancer, diabetes, HIV, psychosis)
- psychiatric and medical comorbidities.
What did the researchers find?
The researchers identified 2085 transgender individuals from outpatient community and hospital clinics. The mean age of participants was 33 years with 52.6% of individuals between 25 and 44 and 28.7% under 24. The participants were made up of individuals with a variety of gender identities including, transgender women, transgender men, non-binary, and unknown (included transgender individuals whose self-defined gender identity was missing).
The researchers found that transgender individuals had higher mental health service use and mental health primary care provider visits compared to the general population. Furthermore, there were differences in rates of marginalization between transgender individuals and general population, where transgender individuals lived in neighbourhoods with higher dependency, ethnic concentration, material deprivation and residential instability.
Overall, the researchers concluded that even though transgender individuals are more likely to be exposed to neighborhood-level marginalization and have higher rates of health service use across all outcome measures, the neighbourhood-level marginalization did not clinically affect mental health service use.
Limitations of the research
The researchers note that their study had several limitations. Few individuals were from rural settings, since the health clinics were located in urban centres in Ontario. The study was only able to identify transgender individuals who were connected to primary care and was unable to identify individuals who were so marginalized that they could not access primary care. Since gender identity data is not collected in most hospitals in Ontario, researchers were unable to identify transgender patients who do not have a primary care provider. Also, the focus of the study did not cover health service use in the private healthcare system and did not include community care, which transgender individuals are known to access.
How can you use this research?
The researchers suggest implementing and strengthening gender inclusive and race/ethnicity data collection tools in healthcare. There is a need to better understand higher rates of mental health service use at the individual level among transgender individuals and to ensure that mental health services are transgender inclusive and affirming. Lastly, more research is needed to understand the mental health outcomes and factors impacting transgender individuals in order to reduce healthcare disparities.
About the researchers
Alex Abramovich1,2,3, 4, W. Ariel Gould2, Nelson Pang1,5, Claire de Oliveira1,2,3,6,7, Tomisin Iwajomo 1,6, Myriam Vigny-Pau4, Kinnon MacKinnon8, June Sing Hong Lam2,4,6,9 and Paul Kurdyak 1,2,3,4,6
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Campbell Family Mental Health Research Institute, Toronto, Ontario, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
- ICES University of Toronto, Mental Health and Addictions Research Program, Toronto, Ontario, Canada
- Centre for Health Economics and Hull York Medical School, University of York, York, United Kingdom
- School of Social Work, York University, Toronto, Ontario, Canada
- General and Health Systems Psychiatry Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada