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Original Investigation
May 6, 2020

Association of Nondiscrimination Policies With Mental Health Among Gender Minority Individuals

Author Affiliations
  • 1PhD Program in Health Policy, Harvard University, Cambridge, Massachusetts
  • 2Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
  • 3Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts
  • 4Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
  • 5Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
JAMA Psychiatry. Published online May 6, 2020. doi:10.1001/jamapsychiatry.2020.0770
Key Points

Question  Are state-level nondiscrimination policies associated with changes in suicidality among gender minority individuals?

Findings  In this cohort study of 28 980 gender minority individuals, nondiscrimination policies were associated with a decrease in suicidality in the first postimplementation year among states that implemented policies in 2014-2016 compared with states that did not implement policies. Among states that implemented policies in 2013, there was no association with suicidality.

Meaning  The results of this study suggest that nondiscrimination policies appear to be associated with a decrease or no change in suicidality in all years following the policy implementation.

Abstract

Importance  In the past decade, many states have implemented policies prohibiting private health insurers from discriminating based on gender identity. Policies banning discrimination have the potential to improve access to care and health outcomes among gender minority (ie, transgender and gender diverse) populations.

Objective  To evaluate whether state-level nondiscrimination policies are associated with suicidality and inpatient mental health hospitalizations among privately insured gender minority individuals.

Design, Setting, and Participants  In this cohort study, difference-in-differences analysis comparing changes in mental health outcomes among gender minority enrollees before and after states implemented nondiscrimination policies in 2009-2017 was conducted. A sample of gender minority children and adults was identified using gender minority–related diagnosis codes obtained from private health insurance claims. The present study was conducted from August 1, 2018, to September 1, 2019.

Exposure  Living in states that implemented policies banning discrimination based on gender identity in 2013, 2014, 2015, and 2016.

Main Outcomes and Measures  The primary outcome was suicidality. The secondary outcome was inpatient mental health hospitalization.

Results  The study population included 28 980 unique gender minority enrollees (mean [SD] age, 26.5 [15] years) from 2009 to 2017. Relative to comparison states, suicidality decreased in the first year after policy implementation in the 2014 policy cohort (odds ratio [OR], 0.72; 95% CI, 0.58-0.90; P = .005), the 2015 policy cohort (OR, 0.50; 95% CI, 0.39-0.64; P < .001), and the 2016 policy cohort (OR, 0.61; 95% CI, 0.44-0.85; P = .004). This decrease persisted to the second postimplementation year for the 2014 policy cohort (OR, 0.48; 95% CI, 0.41-0.57; P < .001) but not for the 2015 policy cohort (OR, 0.81; 95% CI, 0.47-1.38; P = .43). The 2013 policy cohort experienced no significant change in suicidality after policy implementation in all 4 postimplementation years (2014: OR, 1.19; 95% CI, 0.85-1.67; P = .31; 2015: OR, 0.94; 95% CI, 0.73-1.20; P = .61; 2016: OR, 0.82; 95% CI, 0.65-1.03; P = .10; and 2017: OR, 1.29; 95% CI, 0.90-1.88; P = .18). Mental health hospitalization rates generally decreased or stayed the same for individuals living in policy states vs the comparison group.

Conclusions and Relevance  Implementation of a state-level nondiscrimination policy appears to be associated with decreased or no changes in suicidality among gender minority individuals living in states that implemented these policies from 2013 to 2016. Given high rates of suicidality among gender minority individuals in the US, health insurance nondiscrimination policies may offer a mechanism for reducing barriers to care and mitigating discrimination.

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