Delays in Accessing Healthcare Across the Gender Spectrum in the All of Us Research Program

Abstract

Background: Gender minorities and cisgender women face barriers to healthcare access. Prior work suggests cost may represent a particular barrier to accessing care for transgender and gender diverse (TGD) individuals.

Objective: To examine odds of delaying care for any reason and, secondarily, for 7 specific reasons among TGD individuals and cisgender women compared with cisgender men in the All of Us Research Program.

Design: We calculated the odds of delayed care by gender identity relative to cisgender men using multivariable-adjusted logistic regression, with adjustment for age, race, income, education, and Charlson comorbidity index.

Participants: We examined 117,806 All of Us participants who completed the healthcare access and utilization survey.

Main measures: The primary outcome was self-reported delayed care in the past 12 months for any of 7 potential reasons: cost (out-of-pocket cost, co-payment costs, and/or high deductible), lack of childcare, lack of eldercare, nervousness associated with visiting the healthcare provider, rurality, inability to take time off work, and lack of transportation.

Key results: Compared with cisgender men, the multivariable-adjusted odds ratio (OR) for delaying care for any reason was 1.48 (95% CI, 1.44-1.53; P < 0.001) among cisgender women, 1.65 (95% CI, 1.24-2.21; P < 0.001) among TGD individuals assigned male at birth, and 2.76 (95% CI, 2.26-3.39; P < 0.001) among TGD individuals assigned female at birth. Results were consistent across multiple sensitivity analyses. TGD individuals were substantially more likely to cite nervousness with visiting a healthcare provider as a barrier, whereas cisgender women were more likely to delay care due to lack of childcare coverage.

Conclusions: Cisgender women and TGD individuals were more likely to delay seeking heath care compared with cisgender men, and for partially different reasons. These findings highlight the need to address common and distinct barriers to care access among marginalized groups.

Keywords: disparities; gender diverse; healthcare access; transgender.

Figure 1

Creation of the study cohort. The asterisk denotes that answers excluded for reported sex at birth were skipped, prefer not to answer, intersex, no matching concept, or none.

Figure 2

Odds of delayed healthcare by sex/gender category in the All of Us Research Program. Odds ratios are displayed for delays in accessing care during the previous 12 months due to any reason, cost-related (out-of-pocket costs, co-payment costs, high deductible), lack of childcare coverage, lack of eldercare coverage, nervousness associated with visiting the healthcare provider, living in a rural area, inability to take time off work, and inability to obtain transportation. Covariates included age, race, income, educational attainment, and a modified Charlson comorbidity index. Estimates with P < 0.05 are displayed in red. TGD, transgender and gender diverse; AMAB, assigned male at birth; AFAB, assigned female at birth.