Anti-transgender state policies and mental health outcomes among sexual and gender minority adults: A difference-in-differences analysis

Importance: There has been a recent rise in anti-transgender state policies targeting gender minority (GM) — transgender and gender diverse — people, likely impacting the mental health of sexual and gender minority (SGM) people and GM people. Objective: To estimate changes in mental health symptoms associated with recent enactment of anti-transgender state policies among SGM people and GM people specifically. Design: A staggered difference-in-differences analysis to examine the associations between anti-transgender policies and mean changes in mental health outcomes.Setting: United StatesParticipants: SGM adults who completed annual questionnaires between April 1, 2020 and May 2023 for The Population Research in Identity and Disparities for Equality (PRIDE) Study, a national, prospective, continuously enrolling, online, cohort study of SGM adults.Exposures: Living in a state with one or more of the following enacted policies: (1) restrictions on GM people using bathrooms congruent with their gender identity; (2) bans on GM young people participating in sports; (3) bans on gender-affirming care. Main Outcomes: Mean levels of anxiety (7-item Generalized Anxiety Disorder scale), depression (9-item Patient Health Questionnaire), and posttraumatic stress disorder (PTSD) symptoms (6-item PTSD Checklist).Results: Of the 8,733 SGM participants in the sample, 4,354 (49.9%) were GM, 7,884 (78.6%) identified as White only, and the median age of participants was 32.5 years old. Among all SGM participants, anti-transgender policy enactment was associated with increases in anxiety (1.01 points, 95% CI=[0.01, 2.03]) and PTSD (0.97 points, 95% CI=[0.07, 1.87]) symptoms, but smaller and non-significant increases in depression symptoms (0.75 points, 95% CI=[-0.36, 1.85]). In the GM subsample, smaller, non-significant increases in anxiety (0.86 points, 95% CI=[-0.50, 2.22]), depression (0.29 points, 95%CI=[-1.27, 1.85]), and PTSD (0.89 points, 95% CI=[-0.49, 2.26]) were observed after policy enactment. GM adults had high mental health symptoms across the study period, which may account for the smaller increases in GM adults’ symptoms in states that enacted policies. Conclusions: Anti-transgender policies are likely negatively impacting SGM people’s mental health. Given the already high levels of mental health symptoms observed, multi-level interventions are necessary to support SGM people’s mental health amid this recent wave of anti-transgender policies.