Transgender-inclusive health policies: A systematic review of effects on trans health and trans people’s values and preferences

Abstract Background Gender-inclusive health policies include laws, policies, and regulations that provide insurance coverage for gender-affirming care, promote stigma reduction and inclusion in healthcare settings, and mandate non-discriminatory treatment for transgender, nonbinary, and gender diverse (“trans”) people. Methods We conducted a systematic review (PROSPERO CRD42023465905) on the health effects of gender-inclusive health policies among trans people. We searched six databases and grey literature from January 1, 2013, through April 1, 2024, with no language restrictions. The effectiveness review included quantitative studies assessing the effects of gender-inclusive health policies compared to policies that do not promote inclusion or that restrict access to gender-affirming or inclusive care. Data were narratively synthesized. ROBINS-E and GRADE were used to assess study risk of bias and certainty. Using the same search, we reviewed data on trans people’s values and preferences related to health policies and evaluated confidence in the cumulative evidence using GRADE-CERQual. Results Of the 2399 articles we screened, we included six studies, all from the United States, in the effectiveness review. Outcome data were available in three categories: access and utilization of health services, mental health, and experiences of stigma and discrimination. Evidence indicated that gender-inclusive health policies improve access to gender-affirming health care (e.g., surgery, prescribed versus unprescribed hormone therapy) and health insurance while reducing health care avoidance. Limited evidence indicated that policies prohibiting gender identity discrimination in health insurance reduced suicidality and psychological distress. The evidence was rated as very low certainty due to observational study designs and the likelihood of residual confounding in some studies. We included 19 studies from nine countries in the review of values and preferences, finding that trans people were less likely to report healthcare avoidance in the presence of inclusive health policies. Implementation gaps limited the perceived impact of such policies and may reduce their effectiveness. We had moderate-to-high confidence in the qualitative findings. Conclusions Gender-inclusive health policies may improve trans health, particularly by increasing access to gender-affirming medical care and reducing avoidance of general health care. To inform policy development, research should evaluate specific policy provisions, assess the extent of policy implementation, use quasi-experimental designs, and examine policies beyond the United States.