Author ORCID Identifier

Defense Date


Document Type


Degree Name

Doctor of Philosophy



First Advisor

Dr. Kristina Hood

Second Advisor

Dr. Kevin Allison

Third Advisor

Dr. Faye Belgrave

Fourth Advisor

Dr. Ethan Coston

Fifth Advisor

Dr. Paul Perrin


Healthcare inaccessibility through direct exposure (i.e., personal) to myriad forms of gender identity-related discrimination and erasure among the Transgender and Gender Independent (TGI) population has been documented by prior studies. The myriad barriers that individuals who embody TGI identities encounter to accessing healthcare are associated with the underutilization of healthcare, which may further exacerbate the health disparities that exist between this population and cisgender individuals in the United States (U.S.). Although the impacts of the harm that direct exposure to healthcare discrimination and erasure may have on TGI individuals are known, their exposure to such harm vicariously (i.e., through observation or report) is underexplored. Additionally, examinations into the role that mistrust in healthcare may have in the relationship between exposure to healthcare discrimination and healthcare utilization behaviors among this population have been neglected. The present study sought to narrow this gap in empirical analyses by (1) evaluating the relationships between direct and vicarious gender identity-related healthcare discrimination and erasure exposure and past year healthcare utilization, and (2) exploring gender identity-based mistrust in healthcare as a mechanism (i.e., mediator) through which direct and vicarious gender identity-related healthcare discrimination may serve as predictors of healthcare utilization behaviors among a sample (N = 385) of TGI adults in the U.S., aged 18 to 71 recruited online during the summer of 2022. Most participants (81%) reported that they were exposed to at least one of the ten forms of direct exposure to healthcare discrimination in their lifetime. Vicarious exposure to healthcare discrimination was reported by 80% of participants. More than a fourth (29%) of participants reported avoiding healthcare in the year prior to this study in relation to their anticipation of gender identity-related discrimination in healthcare. When controlling for factors that may influence healthcare utilization behaviors (e.g., personal characteristics, socioeconomic positionality, and indicators of perceived or clinical need for care), hierarchical logistic regression analyses indicated that exposure to direct lifetime and vicarious healthcare discrimination and erasure significantly predicted past year healthcare underutilization when participants anticipated encountering gender identity-related healthcare discrimination. Mediational analyses indicated higher levels of exposure to direct lifetime and vicarious healthcare discrimination were related to higher levels of mistrust in healthcare, through which past year underutilization was significantly related. This study’s examination into the multifactorial manner in which healthcare discrimination and erasure influence this population's healthcare utilization behaviors provides evidence that is vital to informing healthcare practice and policy initiatives aimed at ensuring the barriers that deleteriously influence TGI individuals' ability to access health and wholeness in mind and body are ameliorated.


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