State-level nondiscrimination policies may decrease suicidality among gender minority individuals

Nondiscrimination policies appeared associated with a decrease or no change in suicidality among gender minority individuals living in states with these policies, according to results of a cohort study published in JAMA Psychiatry.

“Despite [multiple] medical guidelines, many U.S. insurers categorically exclude coverage of gender-affirming health care services,” Alex McDowell, RN, MSN, MPH, of the department of health care policy at Harvard Medical School, and colleagues wrote. “Such exclusions have health implications for gender minority patients and compound existing barriers to care, including limited availability of clinicians to provide gender-affirming services and frequent experiences of discrimination during interactions with the health care system. These barriers to care are particularly salient given notable mental health disparities: 40% of gender minority individuals have attempted suicide in their lifetime compared with less than 5% in the general population.”

According to the researchers, among Medicare beneficiaries, gender minority individuals are at significantly increased risk for inpatient mental health hospitalization, even after adjusting for mental health conditions and age. Over the past decade, 20 states and the District of Columbia implemented policies that prohibited insurer discrimination based on gender identity. The researchers noted that these policies do not necessarily mandate that private health insurers cover gender-affirming surgery and hormone therapy; however, they do require the removal of these coverage exclusions.

McDowell and colleagues aimed to evaluate whether these state-level policies were linked to suicidality and inpatient mental health hospitalizations among privately insured gender minority individuals. They conducted a difference-in-differences analysis to compare changes in mental health outcomes among gender minority enrollees before and after nondiscrimination policy implementation between 2009 and 2017. Using gender minority-related diagnosis codes obtained from private health insurance claims, they identified a sample of gender minority adults and children. As the exposure, they used living in states with gender identity-based nondiscrimination policies implemented in 2013, 2014, 2015 and 2016. Suicidality served as the primary outcome and inpatient mental health hospitalization as the secondary outcome.

The researchers analyzed data of 28,980 unique gender minority enrollees from 2009 to 2017. Results showed that, relative to comparison states, suicidality decreased in the first year following policy implementation in the 2014 policy cohort (OR = 0.72; 95% CI, 0.58-0.9), the 2015 policy cohort (OR = 0.5; 95% CI, 0.39-0.64) and the 2016 policy cohort (OR = 0.61; 95% CI, 0.44-0.85). For the 2014 policy cohort, the decrease persisted in the second postimplementation year (OR = 0.48; 95% CI, 0.41-0.57); however, it did not persist for the 2015 policy cohort (OR = 0.81; 95% CI, 0.47-1.38). In all four postimplementation years, the 2013 policy cohort experienced no significant change in suicidality after policy implementation. Further, mental health hospitalization rates typically stayed the same or decreased for those living in policy states vs. the comparison group.

“In the setting of rising suicidality among gender minority individuals in the U.S., consideration of health insurance nondiscrimination policies as a mechanism for reducing barriers to care and mitigating discrimination is warranted,” the researchers wrote. – by Joe Gramigna

Disclosures: McDowell and another study author report grants from the Laura and John Arnold Foundation during the conduct of the study. The other authors report no relevant financial disclosures.