Healthcare Avoidance

Evidence Review · ER-004

Ask why a trans person skipped a needed appointment and the answer is often not cost, distance, or forgetfulness, but expectation: a forecast — formed from personal experience or absorbed from others — that the encounter will go badly. This is one of the better-evidenced observational relationships in trans health — the association between anticipating unsafe care and avoiding it is large, consistently observed, and replicated across national datasets. But the strength sits unevenly. The association itself is well-documented in trans populations; the stress mechanism beneath it is borrowed and adapted from research on lesbian, gay, and bisexual people; and the downstream harms — untreated illness and delayed presentation — are largely inferred rather than demonstrated in trans cohorts. This review keeps those three layers visibly apart.

The question

What happens when trans people expect healthcare to be unsafe? More precisely: is the anticipation of mistreatment associated with avoiding or delaying care, what evidence supports the chain from expectation to behaviour to health, and how much of that chain is directly measured versus inferred?

Why it matters

The figures are consistent and substantial, though every one comes from large opt-in (non-probability) US samples of adults, not population-representative data. In the 2015 U.S. Transgender Survey (USTS), a national convenience sample of 27,715 trans adults, 23% did not seek care they needed in the prior year for fear of being mistreated as a trans person; a further 33% went without because they could not afford it; and of those who did see a provider, 33% reported at least one transgender-related negative experience — being refused treatment, verbally harassed, or having to teach the clinician about trans care. The 2022 USTS (92,329 respondents aged 16 and over) found roughly one in four still avoiding needed care for fear of mistreatment, broadly unchanged, while the share reporting a negative experience among those who saw a provider rose to 48%. Serious psychological distress (Kessler-6) was reported by 39% in 2015 and 44% in 2022, against roughly 5% of the US adult population; in 2022, 66% rated their health good or better, compared with 81% of US adults. These are the stakes the question turns on: a large minority foregoing care, against a backdrop of high distress and lower self-rated health.

What the evidence says

The mechanism — minority stress — is well-developed theory, with its foundational evidence drawn substantially from LGB rather than trans populations. Meyer’s minority stress model proposes that stigma, prejudice, and discrimination create a chronically stressful environment, operating through distal stressors (discrete events of discrimination) and proximal ones (expectations of rejection, concealment, internalised stigma) that erode health over time. That model was built and meta-analytically supported in lesbian, gay, and bisexual samples. Hendricks and Testa adapted it explicitly for trans and gender-nonconforming people, adding gender-specific stressors; their 2012 paper is a conceptual framework rather than a primary empirical test. White Hughto, Reisner, and Pachankis later synthesised the trans-specific literature into a social-ecological account in which stigma at individual, interpersonal, and structural levels feeds the anticipation and avoidance of future healthcare encounters. The mechanism is therefore coherent and increasingly trans-grounded — but it should be read as well-supported theory, not as a demonstrated causal pathway.

The core association — anticipated discrimination predicts care avoidance — is directly evidenced in large trans samples, but the data are cross-sectional. Kcomt and colleagues analysed the 2015 USTS (weighted sample of 19,157 adults aged 25–64) and found anticipated discrimination associated with healthcare avoidance after adjustment, with trans men at higher odds than trans women (adjusted odds ratio 1.32, 95% CI 1.21–1.45). Because anticipation and avoidance were measured at the same moment, the analysis establishes a robust association, not temporal order. The replication across the 2015 and 2022 USTS waves, and across independent samples, is what gives this strand its weight.

The fear is not free-floating — it tracks prior enacted discrimination, and prior mistreatment is associated with subsequent or past-year avoidance. Jaffee, Shires, and Stroumsa analysed 3,486 participants in the 2008–2009 National Transgender Discrimination Survey and found, in a multivariable model, the adjusted odds of delaying needed care roughly four times greater among those who had had to teach their provider about trans people, with about one in four respondents having been denied equal treatment in a healthcare setting. In the PRIDE Study (2018 questionnaire), Clark and colleagues found that lifetime healthcare mistreatment among gender-minority participants was associated with past-year avoidance driven by anticipated mistreatment. The expectation of unsafe care, in other words, is a reasonable inference from experience rather than an irrational one.

Trust is the plausible connecting channel, and there is some trans-specific empirical support for it as a mediator. Hughto, Pachankis, and Reisner tested rejection sensitivity — anxious expectation of rejection — as the mechanism linking mistreatment to avoidance in a sample of trans-masculine adults, and found it mediated the relationship; in that sample, roughly 27–29% had avoided preventive, emergency, or sexual healthcare in the prior year. This moves the “trust” strand a step beyond narrative: a measured psychological construct (anticipated rejection) statistically carries part of the path from past harm to present avoidance. It remains observational, in one trans-masculine sample.

Mental health travels alongside avoidance, but the direction of that relationship is not resolved. The distress figures above (39% and 44% serious psychological distress) sit within the same minority-stress account: structural and interpersonal stigma are theorised to drive both poorer mental health and the anticipation that fuels avoidance. What the data cannot settle is causal ordering — whether avoidance worsens mental health, poorer mental health raises avoidance, or both share upstream causes in stigma. The co-occurrence is well-documented; the arrow between them is not.

Structure shapes the pattern, but protective policy on paper did not, in one national study, buffer the association between prior mistreatment and anticipated-mistreatment avoidance. Clark and colleagues tested whether living in a US state with healthcare policy protections buffered the link between past mistreatment and anticipated-mistreatment avoidance. It did not moderate the relationship in any subgroup. The honest reading is that formal protections, absent visible implementation and changed interpersonal behaviour, may not translate into felt safety — a finding that cuts against the assumption that legislation alone resolves avoidance.

Where evidence is uncertain

Correlation is not causation. The strongest avoidance findings (USTS, Kcomt) are cross-sectional, measuring anticipation and avoidance together, so temporal order cannot be established and reverse causation is plausible. Confounding is real and partly visible in the data: Kcomt found poverty, race or ethnicity, insurance status, visual conformity, and disclosure to be significant covariates of avoidance, any of which could drive both the expectation and the behaviour. The mediation evidence for rejection sensitivity (Hughto and colleagues) strengthens the mechanistic story but does not, on its own, license a causal claim.

The link from avoidance to hard health outcomes is largely inferred, not demonstrated in trans cohorts. It is plausible — and consistent with the general-population literature on unmet need — that sustained avoidance produces untreated illness and delayed presentation. But that final step is rarely measured longitudinally in trans samples; statements connecting avoidance directly to elevated cancer, cardiovascular, or mortality risk in trans people typically borrow from general-population data or chain together cross-sectional associations. The behaviour is well-documented; its downstream clinical toll is reasoned, not yet shown. Even so, avoidance and delay are themselves recognised health-services-utilisation outcomes; forgone or deferred care is a clinically meaningful endpoint in its own right, not merely a stand-in for diseases not yet traced to it.

Related constructs are not interchangeable, and precision matters. “Anticipated discrimination,” “anticipated stigma,” “healthcare stereotype threat,” “rejection sensitivity,” and “medical mistrust” are distinct, separately-operationalised constructs; treating them as synonyms overstates how convergent the measurement actually is. “Minority stress” denotes a specific model with defined distal and proximal components, not stress in general. And a patient’s felt sense that care is unsafe is not the same as “psychological safety” in its technical sense — a team-level organisational construct about whether colleagues can speak up without punishment. The topic concerns the former.

What actually reduces avoidance is operationally untested. The evidence describes the problem far better than it validates fixes. Clark and colleagues’ null moderation result suggests that protective state policy alone is not a demonstrated remedy. Provider-training interventions tend to improve clinician knowledge and attitudes in pre-post designs, but their downstream effect on whether patients then avoid care less is largely unmeasured. Specific operational changes — affirming intake forms, navigators, name and pronoun handling at the front desk — are reasonable on the theory but have little controlled outcome evidence behind them.

Key takeaways

• The association between expecting unsafe care and avoiding it is one of the more robustly documented findings in trans health — large, consistently observed, and replicated across the 2015 and 2022 USTS — but it is observational and cross-sectional, not causal proof.
• The fear tracks experience: a third (2015) to nearly half (2022) of trans people who saw a provider reported a transgender-related negative experience, and prior mistreatment is associated with subsequent or past-year avoidance.
• The minority-stress mechanism beneath the pattern is well-developed theory adapted from LGB-derived models; rejection sensitivity has some trans-specific support as a mediator, but the mechanism should not be stated as demonstrated cause.
• The step from avoidance to untreated illness and delayed presentation is plausible and partly inferred from general unmet-need data — not established in trans longitudinal cohorts.
• Structural protections are not an automatic fix: in one national study, state-level policy protections did not buffer the association between prior mistreatment and anticipated-mistreatment avoidance, pointing to implementation and interpersonal conduct as likely operative levers.
• The evidence base is US, adult, and opt-in; extrapolation to other health systems and to minors is not supported by these sources.

References

1. Meyer IH. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. doi:10.1037/0033-2909.129.5.674
2. Hendricks ML, Testa RJ. (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: an adaptation of the Minority Stress Model. Professional Psychology: Research and Practice, 43(5), 460–467. doi:10.1037/a0029597
3. White Hughto JM, Reisner SL, Pachankis JE. (2015). Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. Social Science & Medicine, 147, 222–231. doi:10.1016/j.socscimed.2015.11.010
4. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.
5. James SE, Herman JL, Durso LE, Heng-Lehtinen R. (2024). Early Insights: A Report of the 2022 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.
6. Kcomt L, Gorey KM, Barrett BJ, McCabe SE. (2020). Healthcare avoidance due to anticipated discrimination among transgender people: a call to create trans-affirmative environments. SSM – Population Health, 11, 100608. doi:10.1016/j.ssmph.2020.100608
7. Jaffee KD, Shires DA, Stroumsa D. (2016). Discrimination and delayed health care among transgender women and men: implications for improving medical education and health care delivery. Medical Care, 54(11), 1010–1016. doi:10.1097/MLR.0000000000000583
8. Hughto JMW, Pachankis JE, Reisner SL. (2018). Healthcare mistreatment and avoidance in trans masculine adults: the mediating role of rejection sensitivity. Psychology of Sexual Orientation and Gender Diversity, 5(4), 471–481. doi:10.1037/sgd0000296
9. Clark KD, Luong S, Lunn MR, Flowers E, Bahalkeh E, Lubensky ME, Capriotti MR, Obedin-Maliver J, Flentje A. (2022). Healthcare mistreatment, state-level policy protections, and healthcare avoidance among gender minority people. Sexuality Research and Social Policy, 19(4), 1717–1730. doi:10.1007/s13178-022-00748-1