The implementation of state-level nondiscrimination policies decreased or did not change suicidality among gender minorities, according to the results of a cohort study published in JAMA Psychiatry. States that implemented such policies in 2014 through 2016 saw a decrease in suicidality among this population, whereas those states that did so in 2013 experienced no change.

Gender dysphoria is common among gender minorities, and medical guidelines have recommended gender-affirming healthcare services such as hormone therapy, reconstructive surgery, and mental health services. Nonetheless, many US insurers exclude coverage of these healthcare services. Given that 40% of gender minority individuals attempt suicide in their lifetime, it is essential to address barriers to care and discriminatory practices.

Alex McDowell, RN, MSN, MPH, of the department of health care policy, Harvard Medical School, Boston, Massachusetts, and colleagues conducted a difference-in-differences analysis comparing mental health outcomes among gender minorities before and after implementation of nondiscrimination policies between 2009 and 2017. They identified gender minority participants, both children and adults, using diagnosis codes obtained from private health insurance claims in states that had implemented the new policies.

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The study population included 28,980 individuals (mean age, 26.5±15 years). Overall, suicidality declined in the first year after the implementation of nondiscriminatory policies. For the 2014 policy cohort, the odds ratio (OR) for suicidality was 0.72 (P =.005); for the 2015 cohort it was 0.50 (P <.001), and for the 2016 cohort the OR was 0.61 (P =.004). Although the decrease persisted for the second postimplementation year in the 2014 cohort (OR, 0.48; P <.001), it did not decrease for the 2015 cohort (OR, 0.81; P =.43).

For the 2013 cohort, there was no significant change in suicidality following the implementation of a nondiscrimination policy for any of the 4 subsequent years. In terms of the secondary outcome, mental health-related hospitalization, rates declined or remained the same for patients in policy states.

The difference-in-differences design of the study may assume that outcome trends are parallel in exposure and comparison groups, which may not have been the case. Potential confounders, such as health plan generosity, socioeconomic factors, and coding practices, may have impacted the outcomes as well, and data capture based on insurance claims may have underestimated the level of suicidality. Finally, the sample includes individuals enrolled in plans that may not be regulated by state insurance policies.

The researchers concluded, “In the setting of rising suicidality among gender minority individuals in the US, consideration of health insurance nondiscrimination policies as a mechanism for reducing barriers to care and mitigating discrimination is warranted.”


McDowell A, Raifman J, Progovac AM, Rose S. Association of nondiscrimination policies with mental health among gender minority individuals. JAMA Psychiatry. 2020. doi:10.1001/jamapsychiatry.2020.0770.