Health Disparities
Inequities in access to mental healthcare at intersections of race and ethnicity, gender identity, and gender modality: An application of Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) Arieh Lisitza* Arieh Lisitza Amanda Swarr Katarina Guttmannova Anjum Hajat
Inequities in access to mental healthcare at intersections of race and ethnicity, gender identity, and gender modality: An application of Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA)
Transgender populations, and particularly transgender women of color, are burdened by high rates of both mental illness and healthcare avoidance. Despite this, research examining the patterns of non-use of mental healthcare within this community is lacking, and is further hampered due to the difficulty of collecting large, population-based samples of transgender adults in general, and transgender people of color in particular. We therefore use data from the Census Bureau’s new Household Pulse Study in conjunction with the novel MAIHDA method to assess the prevalence of unmet mental healthcare needs at critical intersections of gender modality, gender identity, and race and ethnicity. Participants were 699,843 U.S. adults who completed the Household Pulse Survey between July 2021 to May 2022. Participants were sorted into intersectional strata by race/ethnicity (Asian, Black, White, Hispanic, and mixed/another race), gender modality (dichotomized as transgender or cisgender) and gender identity (dichotomized as masculine vs feminine). We then fit a multilevel binomial regression model with strata and participant-level random intercepts to assess the main effects, and calculated stratum-level residuals as a measure of intersectional effects. Unmet mental health needs were most prevalent among transgender people (PR=2.57, 95% CI= 2.49, 2.66), women (PR=1.75, 95% CI=1.73, 1.78), and people who self-identified as Black (PR=1.28, 95% CI=1.25, 1.31), Hispanic (PR=1.30, 95% CI=1.27, 1.33) mixed/another race (PR=1.60, 95% CI= 1.55, 1.65). The largest protective intersectional effect was for Black transgender women and the largest detrimental intersectional effect was for Black cisgender women. These preliminary findings suggest that although racism, transphobia, and misogyny might each independently increase the prevalence of unmet mental health needs, there may be an additional resiliency effect associated with experiencing multiple marginalized identities.
