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The significance of structural stigma towards transgender people in health care encounters across Europe: Health care access, gender identity disclosure and discrimination in health care as a function of national legislation and public attitudes

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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 Europe 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 transgender health 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 psychological or medical health care for being transgender 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 transgender related health 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 transgender related health 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.
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The signicance of structural stigma towards
transgender people in health care encounters across
Europe: Health care access, gender identity disclosure
and discrimination in health care as a function of
national legislation and public attitudes
Felicitas Falck ( felicitas.falck@ki.se )
Karolinska Institute: Karolinska Institutet https://orcid.org/0000-0002-0330-1410
Richard Bränström
Karolinska Institutet
Research article
Keywords: transgender, discrimination, minority stress, stigma, policy, health care seeking
Posted Date: August 24th, 2022
DOI: https://doi.org/10.21203/rs.3.rs-1881534/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License.Read
Full License
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Abstract
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 Europe countries, offer a
unique opportunity to study the role of structural stigma in the lives of transgender individuals. Little is known
about how transgender specic structural stigma relates to individual health determinants. Consequently, the
aim of this study was to explore the association between structural stigma and access to transgender health
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 psychological or medical
health care for being transgender 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 transgender related health 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 transgender related health 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.
Background
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The term transgender refers to individuals whose gender identity or gender expression differ from the sex they
were legally assigned at birth (1, 2). The concept is an umbrella term which encompasses a broad range of
individuals with varying identities, gender expressions, experiences and needs (3). It includes individuals who
identify as male or female as well as those who position their gender identity as non-binary, i.e. between or
beyond male and female (4).
The treatment needs transgender individuals vary and constitute a highly personal matter. Some do not wish
to obtain any gender arming care while others wish to change their primary and/or secondary sex
characteristics through hormonal and/or surgical treatments (5–8). To be able to live and be perceived in
accordance their gender identity, transgender individuals may also wish to change their name, pronoun and
legal gender. The legislative situations regarding transgender individuals access to gender arming
treatment and change of legal gender varies greatly between difference countries (9). In recent years, laws
that require transgender individuals to undergo a psychiatric assessment, sterilization, hormonal treatment or
surgery to access legal gender recognition, regardless of the treatment wishes of the individual, have been
criticized and amended in some countries whereas they remain in others (10–15). While the repeal of such
legislation is essential from a human rights perspective (16, 17) its impact on individual level outcomes of
relevance to the health of transgender individuals remains to be scientically explored.
To align their body with their gender identity, some transgender individuals seek gender arming procedures
such as hormonal treatment or surgery (18–20). This type of treatment seems to be effective in alleviating
the distress that may arise when the gender identity, body and legal gender of an individual are incongruent
(21), which is called gender dysphoria, and treatment satisfaction is high (8). The initiation of gender
arming treatment is likely to be dependent on the access and accessibility of healthcare providers who can
prescribe such treatments as well as the quality, affordability and acceptability of their services.
Stigmatization of transgender populations can also affect treatment initiation. Studies indicate that
transgender individuals frequently experience stigma and discrimination in the health care setting (17, 22–
24), which has a negative impact on their health seeking behavior (25, 26). However, they also encounter
stigma, discrimination and violence in the wider society (27–29). Still the impact of societal stigma and
legislation on individual level outcomes such as openness to health care providers, health seeking behaviors
and experiences of discrimination during health care encounters is still limited and need to be further
explored.
What is stigma?
Stigma is the result of a process whereby certain groups of people are identied and labelled as different,
assigned stereotypical traits, and associated with undesirable characteristics. By creating a distinction
between us and them, those who are seen as different are devalued, rejected, excluded and labeled as
deviants, resulting in a loss of status, social, cultural, nancial and political power (30).
Stigma operated at structural, interpersonal and individual levels, as well as across these levels (31).
Individual level stigma involves cognitive, affective and behavioral responses to discrimination and
devaluation, and includes the perceptions that individuals have about themselves as well as their notions of
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what other people think and feel about them. Interpersonal stigma focuses on interactions between people
(32) involving exposure to verbal harassment, physical and sexual violence, unintentional demeaning
comments and a lack of family support (33). Structural stigma is a most distal form of stigma. It
encompasses societal norms, laws and policies which restrict the opportunities and resources of stigmatized
groups or fail to protect their equal rights (34).
Different stigma levels interact to increase vulnerabilities. For instance, individuals may internalize negative
population attitudes about themselves, labelled self-stigma, reducing self-esteem and self-ecacy (35, 36).
They may also attempt to conceal devalued traits to avoid victimization and may become vigilant to rejection
(37). Since an individual is more likely to encounter discrimination upon disclosure of a devalued trait in a
high stigma country (38), concealment may be more effective in reducing exposure discrimination and
victimization in such a setting as compared to a low stigma context. A study on sexual minorities found that
concealment was associated with reduced exposure to discrimination and violence in countries with a low as
well as a high degree of structural stigma, with higher effects in high stigma countries (39). This indicates
that structural stigma acts as a moderator on stigma at other levels. It is not known if structural stigma
affects experiences of discrimination in the health care setting among transgender individuals.
According to the minority stress model, the stigma and prejudice that marginalized populations face, act as a
stressor which drives morbidity and mortality, increasing the risk of mental health problems as well as
physical disorders (40–42). The expectation of being stigmatized may increase blood pressure (43, 44),
depression (45) and anxiety (22). Stigma also has indirect health effects as it restricts access to health
protective factors such as nancial capital, knowledge and power (46). This makes it essential to study if and
how the widespread stigma that transgender individuals face is related to their health seeking behavior,
openness of being transgender to a health care provider and experiences of discrimination in the clinical
settings as well as reasons for not seeking health care.
Existing stigma research has primarily focused on individual and interpersonal levels of stigma, with less
attention being paid to structural stigma (31). Research on structural level stigma often measure the attitudes
of dominant groups towards stigmatized populations or the contents of stigmatizing policies. However, such
stigma measures are rarely combined or linked to individual-level outcomes (34, 47). A limited number of
studies have begun to map the effects of structural stigma on individual level stigma processes, such as
concealment of sexual orientation (39) and disclosure concerns (48). However, studies on transgender
populations largely remain focused on individual and interpersonal stigma, linking them to adverse health
outcomes (27, 49), with fewer studies examining the impact of structural risk factors (50–52). Existing
structural level stigma studies among transgender individuals have explored the effects of US state level non-
discrimination policies on suicidality (53), mood disorders and self-directed violence (54). With one exception,
a study that looked at gender identity concealment, life satisfaction and everyday discrimination as a
function of structural stigma (55), most studies on stigma towards transgender populations have been
conducted in North or South America, highlighting the need to expand research initiatives to other contexts
(51). Furthermore, as studies of transgender populations often sample respondents in health care settings,
information on those who refrain from seeking care remains minimal.
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The aim of this study was threefold. First, based on the research gaps presented above we wanted to explore
how country level structural stigma, measured as discriminating country-level legislation pertaining to legal
gender recognition and population attitudes towards transgender people, is related to healthcare seeking
among transgender individuals and to describe if and how reasons to refrain from seeking transgender
healthcare differ between countries with a high vs a low degree of structural stigma. Second, we wanted to
examine how structural stigma is related to gender identity concealment towards health care workers and
individual experiences of discrimination in the health care setting. Third, we wanted to understand how
experiences of discrimination by a health care provider are affected by gender identity concealment.
We hypothesized that:
1. Transgender individuals living in a country with a high level of structural stigma will report lower
likelihood of seeking health care for being transgender and a higher probability of seeking gender-
arming treatment abroad.
2. A higher country-level structural stigma will predict a higher prevalence of gender identity concealment
and more frequent experiences of discrimination in health care settings.
3. Individuals who conceal their gender identity to a health provider will experience less discrimination in
the health care setting in low as well as in high stigma countries but concealment of ones gender identity
will be more effective in preventing exposure to discrimination in high stigma countries than in low
stigma countries.
Methods
Participants
This study relies on data from the European Union Lesbian, Gay, Bisexual and Transgender (EU-LGBT) survey,
which was conducted in 2012 by the European Union Agency for Fundamental Rights (17). The original aim
of the survey was to map discrimination and human rights violations against lesbian, gay, bisexual and
transgender (LGBT) people across the 27 European Union (EU) member states (i.e., Austria, Belgium, Bulgaria,
Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia,
Lithuania, Luxembourg, Malta, The Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain,
Sweden, and the United Kingdom) and Croatia. While some results from the survey have been published
previously by the European Union Agency for Fundamental Rights (FRA), they have not been analyzed in
relation to national legislation and policies for gender minorities. The topics of enquiry included in the survey
covered various rights issues with a focus on experiences of discrimination, violence, and harassment.
Respondents who indicated that they were transgender received questions on health care issues specic to
transgender people.
The questionnaire was developed by a multinational team of LGBT experts and was translated to the 27
languages of the EU member states. Translations were veried by back translation. Cognitive interviews were
conducted in ve countries to test the validity and relevance of the questionnaire for different subsets of the
LGBT population. Participants were recruited online. Invitations to participate in the study were disseminated
through local, national, and international LGBT websites. In addition, a Facebook page and a Twitter account
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were set up to share information about the study. Countries which attracted the fewest responses were
targeted with further awareness raising efforts about the study. Respondents completed the survey
questionnaire online after having conrmed their consent and understanding of the study purpose. The
average time needed to complete the survey was 28 minutes.
In total 93,079 individuals completed the study. Inclusion criteria in the survey were self-identication as
LGBT, being 18 years of age or older and residing in one of the 27 EU member states or Croatia. As the survey
was administered over the internet, internet access was a prerequisite to participate. Only respondents who
completed all questions of the survey were included in the data set. Of all survey respondents 6771
individuals dened themselves as transgender. It is the responses of those individuals that are included in
this study.
Country-Level Characteristics
Country-level structural stigma: Based on previous structural stigma research (39, 55–57) we created a
continuous measure of structural stigma for each country included in the study. The measure was based on
population attitudes towards transgender individuals for each country as well as the national legislation
pertaining to legal gender recognition and name change in that particular country in 2012. First, we developed
a country level legislation index, based on information on laws and policies collected by the International
Lesbian, Gay, Bisexual, Trans and Intersex Association in Europe (9). The index of laws was formed by
summarizing six items of legislation: 1. lack of legal/administrative procedures for legal gender recognition
(4 point)s, 2. inability to change legal gender on ocial documents (2 points), 3. inability to change name (1
point), 4. requirement of sterilization to change legal gender (1 point), 5. requirement of medical or surgical
interventions to change legal gender (1 point), and 6. requirement of gender identity disorder or
medical/psychological opinion (1 point). Each country could be assigned a maximum of 7 points. Certain
items were dependent on the existence of others (i.e., a requirement of sterilization, medical/surgical or
diagnostic requirement to change legal gender could only exist if a legal or administrative procedure to do so
was in place). The index was combined with a measure of population attitudes towards transgender people
based on an assessment by the European Commission. In their Eurobarometer survey for 2012, respondents
were asked how comfortable they would feel about having a transgender or transsexual person in the highest
elected political position in their country, on a scale from 1–10 where 1 meant “totally uncomfortable” and 10
meant “totally comfortable” (58). We combined the standardized law index with the standardized
Eurobarometer attitude measure to create our nal structural stigma variable. Both variables were coded so
that a higher score indicated greater degree of stigma against transgender individuals before the variables
were combined. The nal structural stigma variable was the averaged mean of the stigma laws variable and
public attitudes variable. The score was standardized into z-scores and higher scores indicated higher
structural stigma.
In addition to the continuous variable of country-level structural stigma, we categorized all countries based on
their score into either low or high stigma countries. High stigma countries included the 14 countries with the
highest structural stigma score (i.e., Czech Republic, Greece, Ireland, Italy, Cyrus, Latvia, Lithuania, Malta,
Slovenia, Slovakia, Finland, Bulgaria, Croatia, and Romania). Low stigma countries included the 14 countries
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with the lowest structural stigma score (i.e., Belgium, Denmark, Germany, Estonia, Spain, France, Luxembourg,
Hungary, Netherlands, Austria, Poland, Portugal, Sweden, and the United Kingdom).
Country-level income inequality:The Gini coecient for 2012 was used as a country-level covariate as it has
been shown to have a strong association with intolerance and country-level structural stigma in other studies
(59).
Self-Report Measures
Transgender identity: The transgender identity of survey respondents was identied based on their response
to the question: “Are/were you a transgender person?” with response options “yes” or “no”. Those who self-
identied as transgender were included in the current study. In the original survey participants were also
asked to provide more detailed information on their gender identities according to the predened categories
transwoman, transman, female cross dresser, male cross dresser, transgender, gender variant and
queer/other. When requesting permission to use the data from the EU LGBT survey, we were not granted
access to individual responses to this question. Consequently, while we know that they all study participants
regard themselves as transgender, we lack more detailed information on their gender identities.
Healthcare seeking behaviors: Readiness to seek health care for being transgender was assessed with the
question: “Have you ever sought psychological or medical help for being a trans (transgender) person?” with
the response options: “Yes,” “No,” or “Don´t know. Based on their response, participants were categorized into
two groups, those who had sought care for being trans and those who had not. Respondents who did not
know if they had sought care or not (n = 550, 8.1%) were recoded as missing information regarding healthcare
seeking and were excluded from further analyses.
Participants who indicated that they had not sought transgender related health care were presented with a list
of reasons for refraining to do so, and were asked to select all options pertaining to them. Possible responses
were: “I do not want/need help ,“It is not available in the country where you live, “It is not covered by my
country´s public health insurance,” “I cannot afford it due to nancial reasons,” “I do not dare to, “I do not
have condence in the services provided, “I do not know where to go, “It takes too much time (including
waiting lists),” “I am afraid of prejudice from the care providers,” “It is too complicated in terms of
bureaucracy,” and “I have had previous bad experiences with care providers,. Those who marked the
response option “I do not need/want such help” wereltered out in the analysis, leaving those who had an
unmet need for care in the statistical calculations.
Readiness to seek transgender related health care abroad was explored through the question: “Have you gone
abroad or considered going abroad for medical treatment to alter your physical appearance, including buying
hormones over the internet from other countries?”. Participants were presented with the response options:
“Yes, I have done, “Yes, I would do, “Maybe, “No, I have not done,” and “no, I would not do.” Responses were
categorized into two groups, with those who had gone abroad for medical treatment to alter their physical
appearance and those who would do so placed in one group and those who had not or would not do so in the
other group. Those who responded “maybe” were recorded as missing.
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Gender identity concealment was assessed based on participant responses to the question: “To how many
people among the following groups are you open about yourself being” transgender? Survey participants
would indicate their degree of openness towards “Medical staff/health care providers” with options being:
“none, a few, most, all, does not apply to me”. Concealment was dichotomized into 2 groups were participants
who indicated that they were open to “None” were labeled as concealing while those who indicated, “A few”,
“Most” or “All” were considered as open. Those who indicated “does not apply to me” were ltered
out/considered as missing.
Discrimination in the health care setting: In the survey participants were asked if they had “accessed health
services”. If they indicated “Yes” or “Don´t know” to this question, a follow up question was posed to assess if
they had felt discriminated against on the basis of being transgender when accessing these services during
the last year. This follow up question read: “During the last 12 months, have you personally felt discriminated
against because of being (transgender) in any of the following situations?”. This question was followed by a
list of situations and groups, one of which was “By health care personnel (e.g. a receptionist, nurse or doctor)”
Responses to this question were used as a basis for statistical analysis regarding experiences of
discrimination in the health care setting. The possible answers were “1. Yes, 2. No, 9. Don´t know”. Those who
did not know if they had felt discriminated against or not were recorded as missing.
To examine experiences of discrimination in health care participants were asked if they had “ever experienced
any of the following situations when using or trying to access health care services as a transgender person?”,
followed by a list of discriminatory practices. Participants were asked to tick all expels which applied to them.
The possible answers were: “Diculty in gaining access to healthcare. Having to change general practitioners
or other specialists due to their negative reaction. Receiving unequal treatment when dealing with medical
staff. Foregoing treatment for fear of discrimination or intolerant reactions. Specic needs ignored (not taken
into account). Inappropriate curiosity. Pressure or being forced to undergo any medical or psychological test. I
have never accessed health care services. None of the above”. Those who marked the response option “I have
never accessed health care services” were ltered out in the analysis, leaving only those who had interacted
with health care providers in the statistical calculations.
Individual-level covariates: Individual-level sociodemographic covariates included age, sex assigned at birth,
ethnic minority status, education, annual household income, urbanicity and relationship status. Participants
belonging to an ethnic minority identied themselves as such by ticking the option “ethnic minority (including
of migrant background)” after being prompted if they identied as such. Education level was assessed with
the question “What is the highest level of education you have achieved?”, response options being “1. No
formal education, 2. Primary education, 3. Secondary education, 4. Post-secondary education other than
college/university, 5. College/university/higher academic education and 6. Other”. Annual household income
was measured by asking participants to specify if their household´s net combined monthly income was “1.
Under lowest quartile, 2. Between lowest quartile and median, 3. Between median and highest quartile or 4.
Above highest quartile”, after tax and social insurance fees had been deducted. Urbanicity was measured by
asking participants if they currently lived in a ”. 1. City, 2. The suburbs or outskirts of a city, 3. A town, 4. A
country village, 5. A farm or home in the countryside. Participants indicated their relationship status by
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answering if they were currently: “1. Living together with a partner/spouse, 2. Involved in a relationship
without living together, of if they 3. Have no relationship/do not have a partner.
Statistical analysis
We used multi-level regression to account for the nested data structure of individuals´ responses within
countries. Variables reported on an individual level (i.e., having sought psychological or medical health care
for being transgender, having sought medical treatment abroad to change physical appearance, and
concealment about transgender identity in health care settings as well as experiences of discrimination from
health care staff during the last 12 months) were modelled at level 1, while the country-level structural stigma
variable was modelled at level 2. Multi-level model estimates are presented as odds ratios with 95%
condence intervals. Only participants with complete answers to all survey questions were included in
analyses. In the multi-level analyses, models were adjusted for age, sex assigned at birth, ethnic minority
status, education level, annual household income, relationship status, and urbanicity (Level 1) and for the Gini
coecient at country level (Level 2). To analyze participants responses to questions regarding reasons to not
seek health care and different experiences of discrimination, comparisons between countries categorized as
low and high structural-stigma countries were conducted using Chi-square calculations. The analyses were
conducted using SPSS, version 26.
Results
Descriptive Statistics
Socio-demographic characteristics of all participants in the EU LGBT Survey 2012 who identied as
transgender are presented in Table1. Most respondents (62%) were assigned male at birth. Younger
respondents were more prevalent than older, with 45.9% being 18–29 years old. The sample had a relatively
high educational level, with 46.2% indicating having a university education. However 63.3% reported a
household income below the median. The vast majority of participants lived in an urban area (86.3%) and
most had a partner (52.5%). Structural stigma ranged from − 1.5 for United Kingdom to 2.1 for Lithuania.
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Table 1
Sociodemographic characteristics of study participants identifying as transgender in
the EU LGBT Survey 2012 (n = 6,221)
n (%)
Sex assigned at birth Female 2 367 (38.0%)
Male 3 854 (62.0%)
Age 18–29 years 2 809 (45.2%)
30–39 years 1 416 (22.8%)
40–49 years 1 093 (17.6%)
50–59 years 647 (10.4%)
60 years or older 256 (4.1%)
Ethnic minority status Ethnic minority 435 (7.0%)
Level of education Less than university 3 350 (53.8%)
University education 2 871 (46.2%)
Household income Under the lowest quartile 2 391 (38.4%)
Between the lowest quartile and median 1 554 (25.0%)
Between the median and highest quartile 1 226 (19.7%)
Above the highest quartile 1 050 (16.9%)
Urbanicity Living in an urban area 5 351 (86.0%)
Living in a rural area 870 (14.0%)
Relationship status Single 2 959 (47.6%)
In a relationship, not living with a partner 1 422 (22.9%)
Live with a partner 1 840 (29.6%)
Sexual orientation Lesbian 1 111 (17.9%)
Gay 1 443 (23.2%)
Bisexual 1 752 (28.2%)
Heterosexual 894 (14.4%)
Other 736 (11.8%)
Don’t know 285 (4.6%)
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Country variation in healthcare seeking, identity concealment,
and experiences of discrimination from health care personnel
To analyze if healthcare seeking, identity concealment and experiences of discrimination in health varied
according to structural stigma levels, we calculated the association between country-level stigma and each of
these variables. Results on the association between country-level structural stigma towards transgender
individuals and having sought psychological or medical health care for being transgender, having sought
medical treatment abroad to change one´s physical appearance, concealment about one´s transgender
identity in health care settings and experienced discrimination from health care personnel in the last year are
presented in Table2.
Table 2
Association between country-level structural stigma and healthcare seeking, gender identity concealment and
discrimination in healthcare.
Multilevel-model estimates
Healthcare seeking for being transgender Adj.
ORa95% CI Sig.
County-level structural stigma 0.753 0.571,
0.993
P
 = 
0.045
Having gone abroad for medical treatment to alter physical appearance
or getting hormones Adj.
ORa95% CI Sig.
County-level structural stigma 0.786 0.428,
1.419
P
 = 
0.438
Gender identity concealment in health care settings Adj.
ORa95% CI Sig.
County-level structural stigma 1.286 1.027,
1.611
P
 = 
0.028
Experience of discrimination by health care personnel during the past 12
months Adj.
ORa95% CI Sig.
County-level structural stigma 0.994 0.835,
1.185
P
 = 
0.950
a All models are adjusted for age, sex assigned at birth, ethnicity, level of education, income, relationship
status, and urbanicity at Level 1 (i.e., individual level), and for Gini coecient at Level 2 (i.e., country level),
and estimates are presented as odds ratios with 95% condence intervals.
Health care seeking
Structural stigma was signicantly and negatively associated with seeking psychological or medical care for
being transgender (Adj OR = 0.753, 95% CI 0.571–0.993, P = 0.045). Essentially individuals living in a high
stigma country were about 25% less likely to seek transgender health care than those living in a low stigma
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country. The mean country level proportion of transgender individuals reporting having sought health care for
being trans by country-level stigma score is presented in Fig.1a.
Contrary to our hypothesis, we did not nd evidence that the likelihood of seeking medical treatment to
change one’s physical appearance abroad increases with the level of structural stigma in the country of
residence. This association was non-signicant (Adj OR = 0.786, 95% CI 0.428–1.428, P = 0.438).
Among those who wanted to seek care for being transgender, but had not done so, reasons for forsaking care
were explored for low and high stigma countries respectively (Table3). The most prevalent reasons to forgo
transgender related health care were shared between low and high structural stigma country groups. In the
low stigma country group 41% indicated that they did not dare to seek such services, while 31.9% in high
stigma countries gave this response. The second most prevalent response for low (33.3%) as well as high
stigma countries (27.2%) was being afraid of prejudice from the care provider. In the low structural stigma
country group 31.7% of respondents indicated that a lack of knowledge of where to obtain transgender health
care had prevented them from seeking care, while 26.7% of the respondents in the high structural stigma
country group did so. Participants in high stigma countries were signicantly more likely to report that
unavailability and a lack of national health insurance coverage for transgender health care prevented them
from seeking care. In contrast time and bureaucracy were more frequent barriers to care in low stigma
countries.
Table 3
Reasons for not seeking trans health care among those who would like to do so
Country of residence
Low stigma High stigma Sig.
It is not available in the country where I live. 2.6% 10.3% P < .001
It is not covered by my country´s public health insurance 9.6% 14.5% P = .005
I cannot afford it due to nancial reasons. 20.0% 20.4% P = .838
I do not dare to. 41.0% 31.9% P < .001
I do not have condence in the services provided. 26.1% 22.1% P = .087
I do not know where to go. 31.7% 26.7% P = .042
It takes too much time (including waiting lists). 16.2% 10.1% P < .001
I am afraid of prejudice from the care providers. 33.3% 27.2% P = .019
It is too complicated in terms of bureaucracy. 21.1% 14.9% P = .002
I have had previous bad experiences with care providers. 9.9% 8.4% P = .357
Openness of gender identity to a health care provider
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Structural stigma was signicantly and positively associated with concealment of ones gender identity in
health care settings (Adj OR = 1.286 95% CI 1.027–1.611, P = 0.028). Individuals living in countries with a high
structural stigma were 29% more likely to report concealing their gender identity to health care providers than
respondents living in countries with a low structural stigma index. In Lithuania and Croatia, the countries with
the highest level of structural stigma, about 60% concealed their gender identity in health care settings
whereas 25–35% of participants in the countries with the lowest stigma index, i.e. United Kingdom and Spain
did so. The mean country level proportion of transgender individuals hiding their gender identity to their
health care provider by country-level stigma score is presented in Fig.1b.
Experiences of discrimination in health care
Structural stigma was not signicantly associated with experiences of discrimination by health care
personnel during the last year (Adj OR² =0.994, 95% CI 0.835–1.185, P = 0.95). Instead, reports of
discrimination in health care settings were prevalent both in high and in low stigma countries.
Across countries and regardless of the level of structural stigma, individuals who concealed their gender
identity to health care providers were considerably less likely to report discrimination in health care as
compared to those who were open about being transgender (P < 0.001). Among those who concealed their
transgender status to their health provider 68.5% reported that they had not encountered any of the types of
discrimination in health care that was outlined in the survey. When looking at those who were open with their
transgender identity, the prevalence of transgender related discrimination in health care almost doubled.
Among respondents who were open about being transgender 36.8% reported no exposure to discrimination in
the health setting during the last year.
The mean proportion of trans individuals in each country reporting exposure to discrimination during the past
12 months, by country-level structural stigma, is shown stratied by openness about trans identity to health
care workers in Fig.1c.
Table4 details the types of discrimination that participants encountered in health care, according to
openness and by high vs low structural stigma country groups. The proportion of individuals who reported no
exposure to discrimination in health care while concealing their gender identity was similar for low stigma
countries (69,5%) and high stigma countries (66,9%). Likewise there was no statistically signicant difference
in being free from discrimination in health care among those who were open about being transgender to
health care providers when comparing low stigma countries (35,8%) and high stigma countries (39,7%).
Participants living in high vs low stigma countries who were open about being transgender to their health care
provider showed a similar pattern of what types of discrimination that were most commonly exposed to. The
most frequent forms of discrimination among these participants were inappropriate curiosity, having their
specic needs ignored and pressure or force to undergo medical or psychological tests. Among those who
concealed their gender identity in the health care setting in high as well as low stigma countries, foregoing
treatment due to a fear of discrimination or intolerant reactions, inappropriate curiosity and having their
specic needs ignored were the most prevalent types of discrimination reported.
Page 14/26
Table 4
Experiences of transgender related discrimination in health care according to openness towards health care
workers.
All countries Open in health care Not open in health care
Open
in
health
care
Not
open
in
health
care
Sig. Low-
stigma
country
High-
stigma
country
Sig Low-
stigma
country
High-
stigma
country
Sig.
Diculty in
gaining
access to
healthcare.
22.9% 5.5% P 
< .001 24.7% 17.3% P 
< .001 5.0% 6.2% P 
= .273
Having to
change
general
practitioners
or other
specialist due
to their
negative
reaction.
22.9% 6.7% P 
< .001 23.9% 20.1% P 
= .029 6.7% 6.7% P 
= .977
Receiving
unequal
treatment
when dealing
with medical
staff.
18.7% 6.6% P 
< .001 18.7% 18.6% P 
= .937 6.6% 6.4% P 
= .840
Foregoing
treatment for
fear of
discrimination
or intolerant
reactions.
22.5% 16.4% P 
< .001 22.4% 23.1% P 
= .688 16.2% 16.7% P 
= .803
Specic
needs ignored
(not taken
into account).
31.1% 10.5% P 
< .001 33.5% 23.9% P 
< .001 10.9% 9.8% P 
= .469
Inappropriate
curiosity. 35.1% 15.7% P 
< .001 34.8% 35.8% P 
= .639 13.3% 19.5% P 
< .001
Pressure or
being forced
to undergo
any medical
or
psychological
test.
27.6% 7.8% P 
< .001 29.1% 23.2% P 
= .002 7.9% 7.6% P 
= .840
None of the
above. 36.8% 68.5% P 
< .001 35.8% 39.7% P 
= .052 69.5% 66.9% P 
= .271
Page 15/26
Discussion
By combining an unusually large data set on gender identity disclosure, health seeking behaviors and
experiences of discrimination in the health setting among transgender individuals living in 28 countries
across Europe with an objective stigma index based on national laws and attitudes, we nd evidence that
structural stigma predicts whether a transgender individual will come out to their health provider as
transgender and seek related health care. The higher the level of structural stigma is the less likely
transgender individuals are to disclose their identity to their healthcare provider that they are transgender and
seek care for related needs. These ndings highlight the important role that general attitudes and laws
pertaining to transgender individuals play in shaping individual health outcomes, linking structural and
individual stigma levels.
Previous studies have identied individual and interpersonal level stigma as deterrents for health care
initiation in transgender individuals (25, 26, 60–64). Several qualitative studies also describe stigmatizing
policies and laws as barriers to gender arming care (64–66). However, with the exception of a previous
study that found an association between state level structural stigma and the odds of lifetime suicide events
in transgender individuals (50) and a study which identied lower odds for self-directed violence and mood
disorders in transgender individuals living in states that had enacted policies on non-discrimination in
employment compared to states that had not (54), the link between structural stigma and health outcomes in
transgender populations has remained largely unexplored. To our knowledge no previous study has examined
gender identity disclosure to a health care provider and access to transgender health care as a function of
differences in structural stigma across countries. As the rst multinational study to document the negative
association between transgender specic structural level stigma and transgender related health care initiation
this study lends important support to the minority stress theory which holds that structural conditions, such
as laws, policies and general attitudes towards a minority cause conditions which lead to poor physical (67,
68) and mental health outcomes (42).
Contrary to our hypothesis we did not nd evidence that structural stigma was associated with a greater
likelihood of seeking gender arming treatment abroad. An explanation for this may be that medical and
social gender transition is often a visible process. Depending on treatment aims and results as well as the
ability to change legal gender on ocial documents, transitioning may involve a life-long and repeated
involuntary coming out process. Individuals whom others can identify as transgender, are more exposed to
enacted stigma than those who are regarded by others as cisgender (52), making visual gender conformity
important to avoid the scrutiny of others. Existing theories and studies of stigma concealment, propose that
disclosure of stigmatized traits is dependent on the perceived threat which that openness entails (37, 69–71).
Transgender individuals who live openly in high structural stigma settings are more exposed to everyday
discrimination than those living in lower stigma countries, which has a negative effect on their life
satisfaction (55). Against this background it seems plausible that the readiness of an individual to transition
medically, regardless of whether the treatment is prescribed domestically or from abroad, is dependent on
what it is like to expose oneself as transgender in the context where one lives. This may be one of several
explanations for why transgender individuals in high stigma settings were less likely to seek care for being
transgender in the country in their country of residence in this study but also for why did not compensate for
Page 16/26
this unmet need of care by seeking gender arming treatment abroad to a greater extent when living in high
stigma countries as compared to low stigma countries.
As access to gender arming care is dependent on the ability of the individual to inform their health care
provider that they are transgender, openness is a central aspect of transgender health care. While previous
studies have linked gender identity non-disclosure to health care staff to stigmatization in health care (60,
64), less is known about health care disclosure as a function of structural stigma towards transgender
people. Studies on sexual minorities indicate that structural level stigma is associated with the willingness of
individuals to disclose their sexual orientation to health care providers (72–74). Sexual minority men living in
countries with a higher level of structural stigma, measured as national laws, policies and general attitudes
towards sexual minorities, had lower odds of disclosing their sexual orientation to providers when being
tested for HIV as compared to those living in lower stigma countries, suggesting that structural stigma may
affect openness to health care providers (75). The results of this study expand existing research that link
structural factors and identity concealment in health care to include transgender individuals. As such it
contributes to lling an important knowledge gap.
While structural stigma was negatively associated with the likelihood of being open to providers as
transgender, it was not statistically associated with experiences of discrimination in the hands of health care
providers. Instead discrimination from providers was rampant across countries. While it is possible that
structural stigma towards transgender individuals may be truly unrelated to how health care providers treat
their patients this appears unlikely. A previous study, although not on transgender individuals, show that the
attitudes of medical practitioners are similar to those of their countrymen (76). The fact that we did not nd a
statistically signicant association between structural stigma and experiences of discrimination in the hands
of health care providers may be caused by some of the weaknesses of this study. The data on enacted
discrimination in health care relied on reports of subjective experiences of discrimination rather than objective
measures of unfair treatment. We do not know if participants living in a low structural stigma country were
objectively exposed to discrimination with equal frequency or severity as those living in a country with a high
level of structural stigma or not or if their recollection of such events is different. Internalized stigma has been
associated with a low self-esteem and a greater acceptance of stereotyped attitudes in individuals with
mental health problems (77). It may well be that transgender individuals who live in countries where structural
stigma is rampant and justied by others fail to identify when they are exposed to differential treatment,
leading to them to underreport such instances. Similarly those who live in a setting where stigma towards
transgender individuals is considered inappropriate may be more prone to identify and remember such
instances as acts of discrimination. As such, the nding that structural stigma does not predict a higher risk
of stigma exposure in the health setting, may be inuenced by the scope of the survey questions as well as
recall bias.
Moreso, as participants living in high stigma countries were open to health care providers about being
transgender to a less extent than those living in lower stigma settings, they represent a more selected group.
Previous research indicates that socioeconomic, ethnic and other factors may inuence transgender
individuals´ exposure to bias (24, 78) and consequently their willingness to come out to a health care
professional as transgender (79). We do not know if the participants who chose to come out in high stigma
Page 17/26
nations were privileged in ways that compensate for the stigma that their gender identity entailed, and
whether this affects the study results. Moreso, transgender individuals in high stigma countries could be more
selective in choosing which health care professionals they come out to, leading them to experience less
stigma than if they were to come out more broadly. This could unfortunately not be examined more closely in
the present study, as it was limited by the questions that were posed in the EU LGBT survey.
The fact that fear of prejudice from health care providers was the second most prevalent reason to refrain
from seeking health care for being transgender in high as well as in low stigma countries, highlights the
importance of understanding the root causes of interpersonal stigma in health care. Although this study did
not nd an association between structural stigma and experiences of discrimination from providers, such a
link cannot be ruled out. Instead, the potential association between structural stigma and interpersonal
stigma from health care providers should be further explored in future studies.
While discrimination in the health setting was prevalent across countries, concealment of being transgender
was associated with a substantially reduced risk of encountering discrimination in the health care settings in
low as well as high structural stigma nations. Individuals who were open to health care providers were twice
as likely to report exposure to discrimination as compared to those who did not disclose their transgender
status. This nding adds to and follows previous studies which indicate that concealment can protect
transgender individuals against victimization (37) and everyday discrimination (55). Although non-disclosure
of a stigmatized trait can be a functional coping strategy, it has been associated with negative health
outcomes (80) such as depressive symptoms, (81), anxiety, a negative mood and poor self-esteem (82) as
well as increased psychological strain (83). Individuals who fail to tell their provider that they are transgender
may miss out on sex specic screenings (80), such as cervical pap smears and screening for prostate cancer
as well as referrals to gender armative health care services. As the desire to live and be accepted by others
in line with one´s gender identity is an inherent feature and a diagnostic criteria of gender dysphoria (84) and
failure to do so is associated with a lower life satisfaction in transgender populations(55), being able to come
out to a health care professional without the fear of stigma is also important in its own right. Consequently,
while the results of this study indicate that legal reform is important to ensure openness and health care
access for transgender individuals, active measures to combat stigma of transgender individuals in health
care remain warranted in low as well as in high structural stigma settings.
Conclusion
This study provides important new insights into the association between structural stigma and individual
level outcomes such as openness to a health care provider and health seeking behaviors among transgender
individuals. While the study was limited by the questions posed in the EU LGBT survey, it benets from an
extensive data set that is unusual to see in research on transgender individuals. Another strength is its
reliance on objective data regarding national legislation and population attitudes towards transgender
individuals.
The results of the study point to the importance of transgender friendly legislation and initiatives to affect the
attitudes of wider populations towards transgender individuals, in order to meet the health care needs or this
varied and marginalized population. Interventions to decrease stigma towards transgender individuals who
Page 18/26
come out to their health care provider are warranted in high as well as lower structural stigma settings. Since
transgender people face specic structural challenges, such as barriers to legal gender recognition and
gender arming treatment that meet their needs, it is essential to continue to explore how this affects their
health as well as health related needs.
Abbreviations
EU – European Union
EU – LGBT Survey - European Union Lesbian, Gay, Bisexual and Transgender survey
FRA – European Union Agency for Fundamental Rights
LGBT – Lesbian, Gay, Bisexual, Transgender
Declarations
Ethics approval and consent to participate: The study has been approved by the Swedish Ethical Review
Authority (No. 2017/1852-31/5). All individual participants consented to the study in writing after being
informed on the purpose of the study and its privacy policy.
Consent for publication:Not applicable.
Availability of data and materials: The data that support the ndings of this study are available from the
European Union Agency for Fundamental Rights (https://fra.europa.eu/en/about-fra), but restrictions apply to
the availability of these data, which were used under license for the current study, and so are not publicly
available. Data are however available from the authors upon reasonable request and with permission of the
European Union Agency for Fundamental Rights
Competing interest: The authors have no conict of interest to disclose.
Funding: This work was supported by the Swedish Research Council (2018-01876) and the Swedish Research
Council for Health, Working Life, and Welfare (2021-00604). The funding sources had no involvement in the
study design, data collection, analyses, interpretation of data, or the reporting of ndings.
Authors contributions:F.F conceptualized the study and took an active part in its design, performed the
statistical analyses of the descriptive data, interpreted the data and drafted the manuscript; R.B.
conceptualized the study, participated in its design, performed most of the statistical analyses and supervised
the corresponding author in drafting the manuscript. Both authors have read and approved the nal
manuscript.
Acknowledgements:Not applicable.
References
Page 19/26
1. Transgender Europe. Glossary. 2016. https://tgeu.org/glossary. Accessed 7 July 2022.
2. Beek TF, Cohen-Kettenis PT, Kreukels BP. Gender incongruence/gender dysphoria and its classication
history. Int Rev Psychiatry. 2016;28:5–12.
3. Davidson M. Seeking refuge under the umbrella: Inclusion, exclusion, and organizing within the category
transgender. Sexuality Res Social Policy. 2007;4:60–80.
4. Van Caenegem E, Wierckx K, Elaut E, Buysse A, Dewaele A, Van Nieuwerburgh F, et al. Prevalence of
Gender Nonconformity in Flanders, Belgium. Arch Sex Behav. 2015;44:1281–7.
5. Beek TF, Kreukels BP, Cohen-Kettenis PT, Steensma TD. Partial Treatment Requests and Underlying
Motives of Applicants for Gender Arming Interventions. J Sex Med. 2015;12:2201–5.
. Axfors C, Iliadis SI, Rasmusson LL, Beckman U, Fazekas A, Frisén L, et al. Preferences for Gender
Arming Treatment and Associated Factors Among Transgender People in Sweden. Sexuality Res Social
Policy. 2021. doi:10.1007/s13178-021-00650-2.
7. Hage JJ, Karim RB. Ought GIDNOS get nought? Treatment options for nontranssexual gender dysphoria.
Plast Reconstr Surg. 2000;105:1222–7.
. Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, Cuypere G, Feldman J, et al. Standards of Care for
the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. Int J
Transgenderism. 2012;13:165–232.
9. The European Region of the International Lesbian Gay Bisexual Trans and Intersex Association. ILGA-
Europe Rainbow Index. 2012. https://www.ilga-europe.org/sites/default/les/Attachments/ilga-
europe_rainbow_index_side_b.pdf. Accessed 7 June 2021.
10. Global Action for Trans* Equality. English translation of Argentina´s gender identity law as approved by
the Senate of Argentina o May 8. 2012. http://globaltransaction.les.wordpress.com/2012/05/argentina-
gender-identity-law.pdf. Accessed 7 June 2021.
11. Transgender Europe. Norway approves Legal Gender Recognition based on Self Determination. 2016.
https://tgeu.org/norway-lgr. Accessed 7 June 2021.
12. Transgender Europe. Luxembourg adopts self-determination law. 2019 https://tgeu.org/luxembourg-
adopts-self-determination-law. Accessed 7 June 2021.
13. Transgender Equality Newtork Ireland. Gender Recognition. 2015. https://www.teni.ie/gender-recognition.
Accessed 7 June 2021.
14. Transgender Europe. Malta Adopts Ground-breaking Trans and Intersex Law. 2015.
https://tgeu.org/malta-adopts-ground-breaking-trans-intersex-law. Accessed 7 June 2021.
15. Transgender Europe. Historic Danish Gender Recognition Law comes into Force. 2014.
https://tgeu.org/tgeu-statement-historic-danish-gender-recognition-law-comes-into-force. Accessed 7
June 2021.
1. Amnesty International. The State Decides Who I am. Lack of legal gender recognition for transgender
people in Europe. 2014. https://www.amnesty.org/en/documents/eur01/001/2014/en. Accessed 14 July
2022.
17. FRA EUAfFR. Being trans in the EU - comparative analysis of EU LGBT survey data. 2014.
https://fra.europa.eu/sites/default/les/fra-2014-being-trans-eu-comparative-0_en.pdf. Accessed 14 July
Page 20/26
2022.
1. Åhs JW, Dhejne C, Magnusson C, Dal H, Lundin A, Arver S, et al. Proportion of adults in the general
population of Stockholm County who want gender-arming medical treatment. PLoS ONE. 2018.
doi:10.1371/journal.pone.0204606.
19. Scheim AI, Bauer GR. Sex and gender diversity among transgender persons in Ontario, Canada: results
from a respondent-driven sampling survey. J Sex Res. 2015;52:1–14.
20. Kuper LE, Nussbaum R, Mustanski B. Exploring the diversity of gender and sexual orientation identities in
an online sample of transgender individuals. J Sex Res. 2012;49:244–54.
21. Murad MH, Elamin MB, Garcia MZ, Mullan RJ, Murad A, Erwin PJ, et al. Hormonal therapy and sex
reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin
Endocrinol. 2010;72:214–31.
22. Malmquist A, Jonsson L, Wikstrom J, Nieminen K. Minority stress adds an additional layer to fear of
childbirth in lesbian and bisexual women, and transgender people. Midwifery. 2019.
doi:10.1016/j.midw.2019.102551.
23. Zeluf G, Dhejne C, Orre C, Nilunger Mannheimer L, Deogan C, Hoijer J, et al. Health, disability and quality
of life among trans people in Sweden-a web-based survey. BMC Public Health. 2016.
doi:10.1186/s12889-016-3560-5.
24. Bradford J, Reisner SL, Honnold JA, Xavier J. Experiences of transgender-related discrimination and
implications for health: results from the Virginia Transgender Health Initiative Study. Am J Public Health.
2013;103:1820–9.
25. Samuels EA, Tape C, Garber N, Bowman S, Choo EK. "Sometimes You Feel Like the Freak Show": A
Qualitative Assessment of Emergency Care Experiences Among Transgender and Gender-Nonconforming
Patients. Ann Emerg Med. 2018;71:170–82.
2. Sevelius JM, Patouhas E, Keatley JG, Johnson MO. Barriers and facilitators to engagement and retention
in care among transgender women living with human immunodeciency virus. Annals of behavioral
medicine: a publication of the Society of Behavioral Medicine. 2014;47:5–16.
27. Bockting WO, Miner MH, Swinburne Romine RE, Hamilton A, Coleman E. Stigma, mental health, and
resilience in an online sample of the US transgender population. Am J Public Health. 2013;103:943–51.
2. Lombardi EL, Wilchins RA, Priesing D, Malouf D. Gender violence: transgender experiences with violence
and discrimination. J Homosex. 2001;42:89–101.
29. Walters MA, Paterson J, Brown R, McDonnell L. Hate Crimes Against Trans People: Assessing Emotions,
Behaviors, and Attitudes Toward Criminal Justice Agencies. J interpers Violence. 2020;35:4583–613.
30. Link BG, Phelan JC. Stigma and its public health implications. Lancet. 2006;367:528–9.
31. Link BG, Phelan JC. Conceptualizing Stigma. Ann Rev Sociol. 2001;27:363–85.
32. Hebl MR, Dovidio JF. Promoting the "social" in the examination of social stigmas. Personality and social
psychology review: an ocial journal of the Society for Personality and Social Psychology Inc.
2005;9:156–82.
33. White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: A critical review of stigma
determinants, mechanisms, and interventions. Soc Sci Med. 2015;147:222–31.
Page 21/26
34. Hatzenbuehler ML, Link BG. Introduction to the special issue on structural stigma and health. Soc Sci
Med. 2014;103:1–6.
35. Corrigan PW, Sokol KA, Rüsch N. The Impact of Self-Stigma and Mutual Help Programs on the Quality of
Life of People with Serious Mental Illnesses. Commun Ment Health J. 2013;49:1–6.
3. Watson AC, Corrigan P, Larson JE, Sells M. Self-Stigma in People With Mental Illness. Schizophr Bull.
2006;33:1312–8.
37. Pachankis JE. The Psychological Implications of Concealing a Stigma: A Cognitive-Affective-Behavioral
Model. Psychol Bull. 2007;133:328–45.
3. Evans-Lacko S, Brohan E, Mojtabai R, Thornicroft G. Association between public views of mental illness
and self-stigma among individuals with mental illness in 14 European countries. Psychol Med.
2012;42:1741–52.
39. Pachankis JE, Bränström R. Hidden from happiness: Structural stigma, sexual orientation concealment,
and life satisfaction across 28 countries. J Consult Clin Psychol. 2018;86:403–15.
40. Meyer IH. Minority stress and mental health in gay men. J health social Behav. 1995;36:38–56.
41. Nadal KL, Davidoff KC, Davis LS, Wong Y. Emotional, behavioral, and cognitive reactions to
microaggressions: Transgender perspectives. Psychol Sex Orientat Gend Divers. 2014;1:72–81.
42. Hendricks M, Testa R. A Conceptual Framework for Clinical Work With Transgender and Gender
Nonconforming Clients: An Adaptation of the Minority Stress Model. Prof Psychol - Res Pract.
2012;43:460–7.
43. James SA, LaCroix AZ, Kleinbaum DG, Strogatz DS. John Henryism and blood pressure differences
among black men. II. The role of occupational stressors. J Behav Med. 1984;7:259–75.
44. Gump BB, Matthews KA. Vigilance and Cardiovascular Reactivity to Subsequent Stressors in Men: A
Preliminary Study. Health Psychol. 1998;17:93–6.
45. Hatzenbuehler ML, Nolen-Hoeksema S, Erickson SJ. Minority Stress Predictors of HIV Risk Behavior,
Substance Use, and Depressive Symptoms: Results From a Prospective Study of Bereaved Gay Men.
Health Psychol. 2008;27:455–62.
4. Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995;Spec
No:80–94.
47. Link BG, Yang LH, Phelan JC, Collins PY. Measuring mental illness stigma. Schizophr Bull. 2004;30:511–
41.
4. Miller CT, Grover KW, Bunn JY, Solomon SE. Community norms about suppression of AIDS-related
prejudice and perceptions of stigma by people with HIV or AIDS. Psychol Sci. 2011;22:579–83.
49. Gamarel KE, Reisner SL, Laurenceau JP, Nemoto T, Operario D. Gender minority stress, mental health, and
relationship quality: a dyadic investigation of transgender women and their cisgender male partners. J
Fam Psychol. 2014;28:437–47.
50. Perez-Brumer A, Hatzenbuehler ML, Oldenburg CE, Bockting W. Individual- and Structural-Level Risk
Factors for Suicide Attempts Among Transgender Adults. Behav Med. 2015;41:164–71.
51. Reisner SL, Poteat T, Keatley J, Cabral M, Mothopeng T, Dunham E, et al. Global health burden and needs
of transgender populations: a review. Lancet. 2016;388:412–36.
Page 22/26
52. Reisner SL, Hughto JMW, Dunham EE, Hein KJ, Begenyi JBG, Coffey-Esquivel J, et al. Legal Protections
in Public Accommodations Settings: A Critical Public Health Issue for Transgender and Gender-
Nonconforming People. Milbank Q. 2015;93:484–515.
53. McDowell A, Raifman J, Progovac AM, Rose S. Association of Nondiscrimination Policies With Mental
Health Among Gender Minority Individuals. JAMA psychiatry. 2020;77:952–58.
54. Blosnich JR, Marsiglio MC, Gao S, Gordon AJ, Shipherd JC, Kauth M, et al. Mental Health of Transgender
Veterans in US States With and Without Discrimination and Hate Crime Legal Protection. Am J Public
Health. 2016;106:534–40.
55. Bränström R, Pachankis JE. Country-level structural stigma, identity concealment, and day-to-day
discrimination as determinants of transgender peoples life satisfaction. Soc Psychiatry Psychiatr
Epidemiol. 2021;56:1537–45.
5. Berg RC, Ross MW, Weatherburn P, Schmidt AJ. Structural and environmental factors are associated with
internalised homonegativity in men who have sex with men: ndings from the European MSM Internet
Survey (EMIS) in 38 countries. Soc Sci Med. 2013;78:61–9.
57. Pachankis JE, Hatzenbuehler ML, Berg RC, Fernández-Dávila P, Mirandola M, Marcus U, et al. Anti-LGBT
and Anti-immigrant Structural Stigma: An Intersectional Analysis of Sexual Minority Men's HIV Risk When
Migrating to or Within Europe. J Acquir Immune Dec Syndr. 2017;76:356–66.
5. European Commission. Discrimination in the EU in 2012. 2014.
http://data.europa.eu/88u/dataset/S1043_77_4_EBS393. Accessed 7 June 2021.
59. Andersen R, Fetner T. Economic Inequality and Intolerance: Attitudes toward Homosexuality in 35
Democracies. Am J Polit Sci. 2008;52:942–58.
0. Whitehead J, Shaver J, Stephenson R. Outness. Stigma, and Primary Health Care Utilization among Rural
LGBT Populations. PLoS ONE. 2016. doi:10.1271/journal.pone.0146139.
1. Socías ME, Marshall BD, Arístegui I, Romero M, Cahn P, Kerr T, et al. Factors associated with healthcare
avoidance among transgender women in Argentina. Int J Equity Health. 2014. doi:10.1186/s12939-014-
0081-7.
2. Kelley J. Stigma and Human Rights: Transgender Discrimination and Its Inuence on Patient Health. Prof
Case Manag. 2021;26:298–303.
3. Goldenberg T, Jadwin-Cakmak L, Popoff E, Reisner SL, Campbell BA, Harper GW. Stigma, Gender
Armation, and Primary Healthcare Use Among Black Transgender Youth. J Adolesc Health.
2019;65:483–90.
4. Falck F, Frisén L, Dhejne C, Armuand G. Undergoing pregnancy and childbirth as trans masculine in
Sweden: experiencing and dealing with structural discrimination, gender norms and microaggressions in
antenatal care, delivery and gender clinics. Int J Transgender Health. 2021;22:42–53.
5. Gridley SJ, Crouch JM, Evans Y, Eng W, Antoon E, Lyapustina M, et al. Youth and caregiver perspectives
on barriers to gender-arming health care for transgender youth. J Adolesc Health. 2016;59:254–61.
. Poteat T, German D, Kerrigan D. Managing uncertainty: a grounded theory of stigma in transgender health
care encounters. Soc Sci Med. 2013;84:22–9.
Page 23/26
7. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations:
conceptual issues and research evidence. Psychol Bull. 2003;129:674–97.
. Frost DM, Lehavot K, Meyer IH. Minority stress and physical health among sexual minority individuals. J
Behav Med. 2015;38:1–8.
9. Chaudoir SR, Fisher JD. The disclosure processes model: understanding disclosure decision making and
postdisclosure outcomes among people living with a concealable stigmatized identity. Psychol Bull.
2010;136:236–56.
70. Austin EL. Sexual orientation disclosure to health care providers among urban and non-urban southern
lesbians. Women Health. 2013;53:41–55.
71. Cole SW, Kemeny ME, Taylor SE, Visscher BR. Elevated physical health risk among gay men who conceal
their homosexual identity. Health Psychol. 1996;15:243–51.
72. Wirtz AL, Kamba D, Jumbe V, Trapence G, Gubin R, Umar E, et al. A qualitative assessment of health
seeking practices among and provision practices for men who have sex with men in Malawi. BMC Int
Health Hum Rights. 2014. doi:10.1186/1472-698X-14-20.
73. Wanyenze RK, Musinguzi G, Matovu JK, Kiguli J, Nuwaha F, Mujisha G, et al. "If You Tell People That You
Had Sex with a Fellow Man, It Is Hard to Be Helped and Treated": Barriers and Opportunities for
Increasing Access to HIV Services among Men Who Have Sex with Men in Uganda. PLoS ONE. 2016.
doi:10.1371/journal.pone.0147714.
74. Brooks H, Llewellyn CD, Nadarzynski T, Pelloso FC, De Souza Guilherme F, Pollard A, et al. Sexual
orientation disclosure in health care: a systematic review. Br J Gen Pract. 2018.
doi:10.3399/bjgp18X694841.
75. Pachankis JE, Hatzenbuehler ML, Hickson F, Weatherburn P, Berg RC, Marcus U, et al. Hidden from health:
structural stigma, sexual orientation concealment, and HIV across 38 countries in the European MSM
Internet Survey. AIDS. 2015;29:1239–46.
7. Leeman RF, Fischler C, Rozin P. Medical doctors’ attitudes and beliefs about diet and health are more like
those of their lay countrymen (France, Germany, Italy, UK and USA) than those of doctors in other
countries. Appetite. 2011;56:558–63.
77. Karakaş SA, Okanlı A, Yılmaz E. The Effect of Internalized Stigma on the Self Esteem in Patients with
Schizophrenia. Arch Psychiatr Nurs. 2016;30:648–52.
7. Lombardi E. Varieties of transgender/transsexual lives and their relationship with transphobia. J
Homosex. 2009. doi:10.1080/00918360903275393.
79. Seelman KL, Poteat T. Strategies used by transmasculine and non-binary adults assigned female at birth
to resist transgender stigma in healthcare. Int J Transgend Health. 2020;21:350–65.
0. Hatzenbuehler ML, Pachankis JE. Stigma and Minority Stress as Social Determinants of Health Among
Lesbian, Gay, Bisexual, and Transgender Youth: Research Evidence and Clinical Implications. Pediatr Clin
North Am. 2016;63:985–97.
1. Frost DM, Bastone LM. The Role of Stigma Concealment in the Retrospective High School Experiences of
Gay, Lesbian, and Bisexual Individuals. J LGBT Youth. 2008;5:27–36.
Page 24/26
2. Frable DES, Platt L, Hoey S. Concealable Stigmas and Positive Self-Perceptions: Feeling Better Around
Similar Others. J Personal Soc Psychol. 1998;74:909–22.
3. Ragins BR, Singh R, Cornwell JM. Making the Invisible Visible: Fear and Disclosure of Sexual Orientation
at Work. J Appl Psychol. 2007;92:1103–18.
4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: 5:th ed.
Arlington: American Psychiatric Publishing; 2013.
Figures
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Figure 1
1a Mean country-level proportion of having sought psychological or medical help for being transgender
across Europe by country-level structural stigma.
1b Mean country-level proportion of transgender people reporting concealment of their transgender identity in
health care settings, across Europe by country-level structural stigma.
Page 26/26
1c Mean country-level proportion of transgender individuals reporting exposure to discrimination during the
past 12 months by country-level structural stigma and stratied by openness about transgender identity to
health care workers.
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Article
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Introduction Gender affirming surgery of primary and/or secondary sex characteristics has been shown to alleviate gender dysphoria. A descriptive snapshot of current treatment preferences is useful to understand the needs of the transgender population seeking health care. This study aimed to describe preferences for gender affirming treatment, and their correlates, among individuals seeking health care for gender dysphoria in Sweden after major national legislative reforms. Methods Cross-sectional study where transgender patients (n = 232) recruited from all six Gender Dysphoria centers in Sweden 2016–2019, answered a survey on treatment preferences and sociodemographic, health, and gender identity-related information during the same time-period. Factors associated with preferring top surgery (breast augmentation or mastectomy), genital surgery, and other surgery (e.g., facial surgery) were examined in univariable and multivariable regression analyses in the 197 people without prior such treatment. Main study outcomes were preferences for feminizing or masculinizing hormonal and surgical gender affirming treatment. Results The proportion among birth assigned male and assigned female patients preferring top surgery was 55.6% and 88.7%, genital surgery 88.9% and 65.7%, and other surgery (e.g., facial surgery) 85.6% and 22.5%, respectively. Almost all participants (99.1%) wanted or had already received hormonal treatment and most (96.7%) wished for some kind of surgical treatment; 55.0% wanted both top and genital surgery. Preferring a binary pronoun (he/she) and factors indicating more severe gender incongruence were associated with a greater wish for surgical treatment. Participants with somatic comorbidities were less likely to want genital surgery, while aF with lacking social support were less likely to want internal genital surgery, in the multivariable analyses. Conclusions In this sample of Swedish young adults seeking health care for gender dysphoria, preferences for treatment options varied according to perceived gender identity. Policy Implications The study findings underline the need for individualized care and flexible gender affirming treatment options. The role of somatic comorbidities should be further explored, and support should be offered to transgender people in need. There is an unmet need for facial surgery among aM.
Article
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Purpose Discriminatory laws, policies, and population attitudes, surrounding transgender people vary greatly across countries, from equal protection under the law and full acceptance to lack of legal recognition and open bias. The consequences of this substantial between-country variation on transgender people’s health and well-being is poorly understood. We therefore examined the association between structural stigma and transgender people’s life satisfaction across 28 countries. Methods Data from transgender participants ( n = 6771) in the 2012 EU-LGBT-survey regarding identity concealment, day-to-day discrimination, and life satisfaction were assessed. Structural stigma was measured using publicly available data regarding each country’s discriminatory laws, policies, and population attitudes towards transgender people. Results Multilevel models showed that country-level structural stigma was associated with lower life satisfaction, an association largely explained by higher levels of identity concealment in higher-structural-stigma countries. Yet identity concealment was also associated with lower day-to-day discrimination and therefore protected against even lower life satisfaction. Conclusion The results emphasize the importance of changing discriminatory legislation and negative population attitudes to improve transgender people’s life satisfaction, and also highlight targets for intervention at interpersonal and individual levels.
Article
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Background A sterilization requirement to change legal gender was removed from Swedish law in 2013, facilitating pregnancy in trans masculine individuals. The limited number of studies investigating pregnancy and childbirth among trans masculine individuals indicate increased gender dysphoria and negative experiences of pre- and post-natal healthcare, highlighting a need to improve care. Research focusing on Europe or contexts where sterilization to change legal gender was previously required by national law remains minimal. Aims This study aimed to investigate how trans masculine individuals experience healthcare encounters in connection with pregnancy, delivery and nursing, in a setting where mandatory sterilization to change legal gender was recently removed. Methods In-depth face-to-face interviews were conducted with 12 trans masculine individuals who attended Swedish prenatal care and delivered a child after the law on legal gender recognition was amended. Thematic content analysis was used. Results Providers in gender clinics, antenatal care and delivery were perceived to regard a masculine gender identity and pregnancy as incompatible. The main categories encompassed expectations and experiences of pregnancy related care and participant responses to it. Participants took charge of their care to ensure that their needs were fulfilled. The quality of care was inconsistent. Discussion A lack of knowledge, narrow gender norms and the legacy of the former legal sterility requirement limited access to diagnostic evaluation of gender dysphoria, information on reproduction and gender-affirming treatment. Medical safety during pregnancy, childbirth and nursing was impeded, gender dysphoria increased, and participants experienced minority stress. Attempts to avoid microaggressions guided healthcare encounters and birth wishes. Navigating healthcare required considerable attention, personal resources and energy, leaving particularly vulnerable individuals at risk of a lower quality of care. The paper concludes with clinical recommendations.
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The number of patients presenting for care at gender clinics is increasing, yet the proportion of adults in the general population who want gender-affirming medical treatment remains essentially unknown. We measured the wish for cross-sex hormones or gender-affirming surgery, as well as other aspects of gender incongruence, among the general adult population of Stockholm County, Sweden. A population-representative sample of 50,157 Stockholm County residents ages 22 and older comprise the Stockholm Public Health Cohort. They were enrolled in 2002, 2006, and 2010 and followed-up in roughly 4-year intervals, with questions on health, lifestyle and social characteristics. In 2014, participants received the item “I would like hormones or surgery to be more like someone of a different sex.” Two additional items concerned other aspects of gender incongruence: “I feel like someone of a different sex”, and “I would like to live as or be treated as someone of a different sex.” Each item had four answer options (“Not at all correct”, “Somewhat or occasionally correct”, “Quite correct”, and “Absolutely correct”). For each item, any of the three affirmative answer choices were considered as some level of agreement. Calibration weights were used to estimate population-representative rates with 95% confidence intervals. The desire for cross-sex hormones or surgery was reported by 0.5% (95% CI, 0.4%–0.7%) of participants. Feeling like someone of a different sex was reported by 2.3% (95% CI, 2.1%–2.6%). Wanting to live as or be treated as a person of another sex was reported by 2.8% (95% CI, 2.4%–3.1%). These findings greatly exceed estimates of the number of patients receiving gender-affirming medical care. Clinicians must be prepared to recognize and care for patients experiencing discomfort due to gender incongruence and those who would like gender-affirming medical treatment.
Article
Purpose/objectives: Transgender patients encounter barriers to accessing medical treatment. Although the medical field has made strides to improve transgender patients' health care experiences, programs that provide support in navigating existing obstacles are lacking. As integrated care becomes more prevalent, primary care settings have the potential to become medical havens for vulnerable patient populations. Enlisting support of professional case managers to connect transgender patients to services to meet their physical and behavioral health needs could increase health care utilization and decrease disparities. Findings/conclusions: Because of their gender identities, transgender individuals experience high rates of discrimination within health care settings. There are also inequities that limit their access to quality treatment. These, combined with the fear of discrimination, contribute to an avoidance of medical care that negatively impacts the physical and mental health of transgender patients. Implications for case management practice: Transgender discrimination in health care settings is pervasive and has detrimental effects on patients' well-being. Future research should foster collaboration between health care administrators, professional case managers, primary care providers, behavioral health consultants, and transgender patients to remove existing barriers and increase access to care. Until these changes occur, programs need to be designed for case managers to assist transgender patients in navigating the health care system and connecting to affirming providers. Primary practice settings: Health care systems and integrated primary care settings.
Article
Background: Transgender stigma is rampant within healthcare systems in the United States. Transgender adults assigned female at birth – including those identifying as transmasculine or non-binary – face unique barriers, such as stigma when accessing sexual and reproductive healthcare labeled as being for “women.” However, transgender and non-binary people are not passive victims to this stigma, and the medical community would benefit from understanding the actions this population takes to resist and reduce transgender stigma in healthcare. Yet, little research has attempted to understand such actions. Aims: This qualitative study aims to explore how transmasculine and non-binary adults are actively resisting and reducing the impact of transgender stigma in healthcare. Methods: In-depth semi-structured interviews were conducted with 25 transmasculine and non-binary adults assigned female at birth who were living in a metropolitan area in the mid-Atlantic United States. The research team analyzed qualitative interview data using content analysis. Results: The 25 participants ranged in age from 21 to 57, with an average age of 33 years old. Six themes were identified related to resisting and reducing transgender stigma in healthcare: (a) using social support; (b) persistence to meet one’s own needs; (c) avoiding mainstream healthcare; (d) advocacy; (e) doing one’s own research; and (f) strategic disclosure of transgender/non-binary identity. We detail how privilege and intersectionality connect to the use of these strategies. Discussion: Findings indicate there is value in using peer advocates and peer health literacy; in developing and nurturing support groups related to transgender/non-binary health; in developing “allies” employed within the healthcare system; in creating and maintaining lists of culturally responsive health providers and resources about navigating the healthcare system; and in offering trainings related to self-advocacy and health-related activism. These findings can be used to inform future health prevention and intervention efforts with transmasculine and non-binary adults.
Article
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.
Article
Purpose: Healthcare access is important for achieving health equity across vulnerable social groups. However, stigma can be a barrier for accessing healthcare among black transgender and gender diverse youth (TGDY) in the U.S. Using a resilience approach, this article examines the role of gender affirmation within healthcare to determine if it can mitigate the negative relationship between stigma and healthcare use. Methods: Data include responses from 110 black TGDY from 14 U.S. cities. Multiple logistic regression models were fit to determine relationships between stigma in healthcare (anticipated and enacted), gender affirmation in healthcare, and delayed/nonuse of primary care. Interaction terms were included to determine if gender affirmation moderates the relationship between stigma and healthcare nonuse. Results: In the main effects model, gender affirmation was the only variable statistically associated with healthcare nonuse. The interaction between gender affirmation and enacted stigma was not significant, but gender affirmation moderated the relationship between anticipated stigma and healthcare nonuse. For individuals who did not have their gender affirmation needs met, as anticipated stigma increased, healthcare nonuse also increased; however, this did not occur for those who had their gender affirmation needs met. Conclusions: Findings suggest that gender affirmation within healthcare is important for increasing access to care among black TGDY. Interventions should consider how to increase gender affirmation among healthcare providers and within healthcare settings. Additional research using an intersectional approach to understand the experiences of black TGDY is needed to highlight the unique healthcare needs of this population.
Article
Objective: Although structural stigma (i.e., discriminatory laws, policies, and community attitudes) toward sexual minorities predicts adverse health and wellbeing, this association has typically only been examined within a single country and potential mechanisms remain unknown. Consequently, we examined the association between structural stigma and sexual minorities' life satisfaction across 28 countries, identity concealment as a potential mechanism of this association, and, in high-stigma countries, the potential for concealment to protect sexual minorities from discrimination and victimization, and therefore even poorer life satisfaction than they would otherwise experience in those countries. Method: Sexual minority adults (n = 85,582) from 28 European countries responded to questions regarding sexual minority stigma, identity concealment, and life satisfaction. Structural stigma was assessed as national laws, policies, and attitudes affecting sexual minorities in each country. Results: Country-level structural stigma explained 60% of country-level variation in life satisfaction and more than 70% of country-level variation in sexual orientation concealment. Sexual orientation concealment mediated the association between structural stigma and life satisfaction. Especially in high-stigma countries, concealment also protected against even lower life satisfaction than would be experienced if a sexual minority individual did not conceal in those countries because it partially protected against discrimination and victimization. Conclusions: Sexual minorities' life satisfaction varies greatly across countries largely due to the structural stigma of those countries and associated demands to conceal one's sexual orientation. Findings highlight the importance of reducing structural stigma to promote equitable life satisfaction and tailoring affirmative psychotherapies to address the structural context surrounding sexual minorities who seek treatment. (PsycINFO Database Record