Unmet need for gender-affirming care as a social determinant of mental health inequities for transgender youth in Aotearoa/New Zealand.

BACKGROUND: Past studies have demonstrated better mental health and well-being among transgender youth who had accessed gender-affirming care. However, few existing studies have assessed unmet need for gender-affirming care as a social determinant of mental health inequities. METHODS: Data on unmet need for gender-affirming care, distress and suicidality were analysed from the 2018 Counting Ourselves nationwide community-based survey of transgender people in Aotearoa/New Zealand. Associations between unmet need for gender-affirming care and mental health indicators were tested for transgender youth within the sample (aged 14-26 years; n = 608; Mage = 20.5). RESULTS: Transgender youth reported unmet needs ranging from 42% for gender-affirming hormone to 100% for feminizing surgeries and voice surgeries. Overall unmet need for gender-affirming care was associated with worse mental health. Trans men with an unmet need for chest reconstruction (84%) scored an average of 7.13 points higher on the K10 Psychological Distress Scale relative to those whose need had been met. Participants reporting unmet need for hormones (42%) had twice the odds (adjusted odds ratios = 2.01; CI = 1.02-3.98) of having attempted suicide in the last 12 months. CONCLUSIONS: Dismantling barriers to accessing gender-affirming care could play a crucial role in reducing mental health inequities faced by transgender youth.

Uptake, experiences and barriers to cervical screening for trans and non-binary people in Aotearoa New Zealand.

Little is known about experiences and barriers for trans and non-binary (TGNB) people eligible for cervical screening in Aotearoa New Zealand. AIMS: To identify uptake, barriers and reasons for delaying cervical cancer screening among TGNB people in Aotearoa. MATERIALS AND METHODS: The 2018 Counting Ourselves data on TGNB people assigned female at birth aged 20-69 years who had ever had sex, were analysed to report on experiences of those who were eligible for cervical screening (n = 318). Participants answered questions about whether they had taken part in cervical screening and reasons behind any delays in receiving the test. RESULTS: Trans men were more likely than non-binary participants to report that they did not require cervical screening or were unsure if they needed it. For those who had delayed cervical screening, 30% did so due to feeling worried about how they would be treated as a trans or non-binary person and 35% due to another reason. Other reasons for delay related to general and gender-related discomfort, previous traumatic experiences, anxiety or fear of the test and pain. Material barriers to access included cost and lack of information. CONCLUSIONS: The current cervical screening program in Aotearoa does not consider the needs of TGNB people, leading to delayed and reduced uptake of cervical screening. Health providers require education on the reasons TGNB people delay or avoid cervical screening in order to provide appropriate information and affirmative healthcare environments. The human papillomavirus self-swab may address some of the existing barriers.

Supportive interactions with primary care doctors are associated with better mental health among transgender people: results of a nationwide survey in Aotearoa/New Zealand.

BACKGROUND: Past research has established that transgender people experience significant disparities in mental health outcomes and healthcare dissatisfaction compared with cisgender people, but more research is needed on how supportive healthcare interactions relate to the mental health of transgender people. OBJECTIVES: The 2 main aims of our analyses were: (i) to establish the most common negative experiences in healthcare and the most common supportive experiences specifically with primary care doctors for transgender people; and (ii) to examine the association of supportive experiences with mental health variables after controlling for demographic factors. METHODS: Data from the 2018 Counting Ourselves nationwide survey of transgender people were analysed using regression modelling. The 948 participants with a primary care doctor or general practitioner were included in analyses. Participants were aged 14-83 years old (mean 30.20). RESULTS: The most common supportive experiences involved primary care doctors treating transgender people equitably, with competence, and with respect. Participants with more negative healthcare experiences had higher psychological distress as well as higher likelihood of reporting nonsuicidal self-injury and suicidality. Conversely, participants with more experiences of supportive primary care doctors had lower psychological distress and were less likely to have attempted suicide in the past 12 months. CONCLUSION: When transgender people receive supportive care from their primary care providers they experience better mental health, despite ongoing negative healthcare experiences. Future research is needed to confirm ways of supporting positive trajectories of mental health for transgender people but these findings demonstrate the importance of positive aspects of care.

Mental health of people of diverse genders and sexualities in Aotearoa/New Zealand: Findings from the New Zealand Mental Health Monitor.

ISSUES ADDRESSED: To examine the mental health inequities, and social exclusion and isolation and protective factor differences between people of diverse genders and sexualities (lesbian/gay, bisexual, gender diverse and takatapui) and cisgender and heterosexual people in Aotearoa/New Zealand. METHODS: We employed data from the pooled probability sample of 2016 and 2018 New Zealand Mental Health Monitor. The sample comprised of 2938 people at least 15 years old, of which 93 had diverse gender and sexuality identities. Generalised linear models were used to test for differences in mental health (current and lifetime mental distress, depression, anxiety, self-harm and suicide), social exclusion and isolation, and friend and family support for people of diverse genders and sexualities. We also conducted exploratory linear regression analyses to examine whether mental health difficulties were associated with social exclusion and isolation and friend/family support. RESULTS: People of diverse genders and sexualities had high rates of mental health difficulties across all variables we examined. For example, people identifying as diverse genders and sexualities had three times the risk of considering self-harm and suicide than their cisgender and heterosexual counterparts (22% vs 5%; RR = 3.12). People of diverse genders and sexualities also scored an average of 6.08 points higher on the 27-point PHQ-9 depression scale when they had experienced social isolation, and 4.01 points higher when they experienced social exclusion. CONCLUSION: Our results are consistent with current literature on the large mental health inequities faced by people of diverse genders and sexualities. SO WHAT?: Policy makers and health care providers in Aotearoa/New Zealand should consider the negative mental health consequences of social exclusion and isolation for people of diverse genders and sexualities.

Primary care access and foregone care: a survey of transgender adolescents and young adults.

Objective: To examine the issues of primary care access and foregone health care among transgender adolescents and young adults. Methods: This cross-sectional analysis of data from the Canadian Trans Youth Health Survey was conducted online during 2013-2014. Participants included 923 youth aged 14-25 (323 adolescents aged 14-18 and 600 young adults aged 19-25). Main outcome measures were self-reported general and mental health status, comfort discussing transgender identity and health care needs with general practitioners, and types of and reasons for self-identified foregone health care. Results: Most youth reported poor/fair general and mental health status. Comfort with a family doctor was positively correlated with both general health (r(528) = 21, P < 0.001) and mental health (r(450) = 26, P < 0.001) status, as was having a doctor who was aware of one's transgender status. 47.2% (n = 219) of young adults reported foregoing needed health care. Among adolescents, levels of comfort with family doctor were negatively correlated with foregone mental health care in the previous 12 months (F3,166 = 3.829, P = 0.011), but not correlated with foregone physical health care (F3,165 = 0.506, P = 0.679). Reasons for missing needed care spanned the dimensions of health care access, ranging from cost barriers to previous negative experiences with health care providers, and concerns that a doctor would be uneducated about transgender people. Conclusion: General practitioners can play a key role in improving the health of transgender youth by demonstrating understanding of the health care needs of transgender youth and competence in gender-affirming care, and by ensuring that their practices are accessible to all transgender youth in need of care.

Transgender Health: New Zealand's Innovative Statistical Standard for Gender Identity.

The implementation of the New Zealand government's recently developed statistical standard for gender identity has led to, and will stimulate further, collection of gender identity data in administrative records, population surveys, and perhaps the census. This will provide important information about the demographics, health service use, and health outcomes of transgender populations to allow evidence-based policy development and service planning. However, the standard does not promote the two-question method, risking misclassification and undercounts; does promote the use of the ambiguous response category "gender diverse" in standard questions; and is not intersex inclusive. Nevertheless, the statistical standard provides a first model for other countries and international organizations, including United Nations agencies, interested in policy tools for improving transgender people's health.

Disordered eating behaviors among transgender youth: Probability profiles from risk and protective factors.

PURPOSE: Research has documented high rates of disordered eating for lesbian, gay, and bisexual youth, but prevalence and patterns of disordered eating among transgender youth remain unexplored. This is despite unique challenges faced by this group, including gender-related body image and the use of hormones. We explore the relationship between disordered eating and risk and protective factors for transgender youth. METHODS: An online survey of 923 transgender youth (aged 14-25) across Canada was conducted, primarily using measures from existing youth health surveys. Analyses were stratified by gender identity and included logistic regressions with probability profiles to illustrate combinations of risk and protective factors for eating disordered behaviors. RESULTS: Enacted stigma (the higher rates of harassment and discrimination sexual minority youth experience) was linked to higher odds of reported past year binge eating and fasting or vomiting to lose weight, while protective factors, including family connectedness, school connectedness, caring friends, and social support, were linked to lower odds of past year disordered eating. Youth with the highest levels of enacted stigma and no protective factors had high probabilities of past year eating disordered behaviors. DISCUSSION: Our study found high prevalence of disorders. Risk for these behaviors was linked to stigma and violence exposure, but offset by social supports. Health professionals should assess transgender youth for disordered eating behaviors and supportive resources. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:515-522).

Factorial Validity and Invariance Assessment of a Short Version of the Recalled Childhood Gender Identity/Role Questionnaire.

Recalled childhood gender role/identity is a construct that is related to sexual orientation, abuse, and psychological health. The purpose of this study was to assess the factorial validity of a short version of Zucker et al.'s (2006) "Recalled Childhood Gender Identity/Gender Role Questionnaire" using confirmatory factor analysis and to test the stability of the factor structure across groups (measurement invariance). Six items of the questionnaire were completed online by 1929 participants from a variety of gender identity and sexual orientation groups. Models of the six items loading onto one factor had poor fit for the data. Items were removed for having a large proportion of error variance. Among birth-assigned females, a five-item model had good fit for the data, but there was evidence for differences in scale's factor structure across gender identity, age, level of education, and country groups. Among birth-assigned males, the resulting four-item model did not account for all of the relationship between variables, and modeling for this resulted in a model that was almost saturated. This model also had evidence of measurement variance across gender identity and sexual orientation groups. The models had good reliability and factor score determinacy. These findings suggest that results of previous studies that have assessed recalled childhood gender role/identity may have been susceptible to construct bias due to measurement variance across these groups. Future studies should assess measurement invariance between groups they are comparing, and if it is not found the issue can be addressed by removing variant indicators and/or applying a partial invariance model.

The case for the World Health Organization's Commission on Social Determinants of Health to address gender identity.

We analyzed the case of the World Health Organization's Commission on Social Determinants of Health, which did not address gender identity in their final report. We argue that gender identity is increasingly being recognized as an important social determinant of health (SDH) that results in health inequities. We identify right to health mechanisms, such as established human rights instruments, as suitable policy tools for addressing gender identity as an SDH to improve health equity. We urge the World Health Organization to add gender identity as an SDH in its conceptual framework for action on the SDHs and to develop and implement specific recommendations for addressing gender identity as an SDH.

Evidence against a typology: a taxometric analysis of the sexuality of male-to-female transsexuals.

Previous theories and research have suggested there are two distinct types of male-to-female (MF) transsexuals and these types can be distinguished by their sexuality. Using the scales Attraction to Femininity in Males, Core Autogynephilia, Autogynephilic Interpersonal Fanasy, and Attraction to Transgender Fiction as indicator variables, taxometric analysis was applied to an online-recruited sample of 308 MF transsexuals to investigate whether such a distinction is justified. In accordance with previous research findings, MF transsexuals categorized as "nonandrophilic" scored significantly higher on Core Autogynephilia than did those categorized as "androphilic"; they also scored significantly higher on Attraction to Femininity in Males and Attraction to Transgender Fiction. Results of one of the taxometric procedures, L-Mode, gave slightly more support for a dimensional, rather than taxonic (two-type), latent structure. Results of the two other taxometric procedures, MAMBAC and MAXCOV, showed greater support for a dimensional latent structure. Although these results require replication with a more representative sample, they show little support for a taxonomy, which contradicts previous theory that has suggested MF transsexuals' sexuality is typological.

Edinburgh Handedness Inventory - Short Form: a revised version based on confirmatory factor analysis.

While the Edinburgh Handedness Inventory has been widely used, there have been few studies assessing its factorial validity. There is evidence that the original instructions and response options are difficult to understand. Using simplified instructions and response options, the Edinburgh Handedness Inventory was administered on a sample of 1514 participants using an online questionnaire. In accordance with previous research, a model of the 10-item inventory had poor fit for the data. This study also detected model misspecification in the previously-proposed 7-item modification. A 4-item Edinburgh Handedness Inventory - Short Form had good model fit with items modelled as both continuous and ordinal. Despite its brevity, it showed very good reliability, factor score determinacy, and correlation with scores on the 10-item inventory. By eliminating items that were modelled with considerable measurement error, the short form alleviates the concern of the 10-item inventory over-categorising mixed handers. Evidence was found for factorial invariance across level of education, age groups, and regions (USA and Australia/New Zealand). There generally appeared to be invariance across genders for the 4-item inventory. The proposed Edinburgh Handedness Inventory - Short Form measures a single handedness factor with an inventory that has brief and simple instructions and a small number of items.

Transgender-related stigma and gender minority stress-related health disparities in Aotearoa New Zealand: hypercholesterolemia, hypertension, myocardial infarction, stroke, diabetes, and general health.

Background: Research has found that transgender-related enacted stigma-including discrimination, harassment, violence, cyberbullying, community rejection, and conversion efforts-is associated with negative mental health among transgender people. Transgender people also experience physical health disparities that could be due to chronic gender minority stress caused by stigma and prejudice. Methods: We compared a large New Zealand national survey of transgender participants with the New Zealand Health Survey (NZHS) with age and ethnicity weightings on stress-related health conditions and indicators. We conducted multivariate logistic regression to test associations between transgender-related enacted stigma and physical health conditions and indicators, controlling for age, gender, ethnicity, gender affirming hormone use, and alcohol and tobacco use. Findings: Transgender participants had a greater likelihood of ever having hypertension (63%, 95% CI 41%-89%), a myocardial infarction (98%, 6%-271%), a stroke (104%, 2%-311%), hypercholesteremia 148% (114%-188%), and current poor or fair general health (128%, 107%-151%). There were no significant differences for diabetes. Compared with those scoring at the 10th percentile on transgender-related enacted stigma, those at the 90th percentile were more likely to have had hypertension (81%, 36%-140%), hypercholesteremia (54%, 20%-98), and poor/fair health (75%, 45%-110%). Interpretation: We found large disparities for stress-related physical health conditions and indicators, and transgender people who experienced higher transgender-related enacted stigma had a significantly increased prevalence of these negative outcomes. Our findings highlight the need for health professionals to consider gender minority stress and for interventions and policy/law reforms to address transgender-related stigma. Funding: The Health Research Council of New Zealand and Rule Foundation.

PATHA's vision for transgender healthcare under the current health reforms.

AIM: The Aotearoa New Zealand healthcare system does not adequately meet the needs of transgender people. Due to healthcare reforms and increases in funding and awareness of transgender health, the Ministry of Health has met with the Professional Association for Transgender Health Aotearoa (PATHA) to discuss ways to improve the healthcare system. We developed a vision for a transgender healthcare document to enable a process for our members to collaborate and to increase transparency about what advice PATHA has provided to the Ministry. METHOD: Feedback from PATHA's committees was incorporated into a draft document, which was then sent to all PATHA members for further feedback and collaboration. RESULTS: PATHA proposes improvements to transgender healthcare that are centred around a new transgender health resourcing hub, which should operate according to a Te Tiriti o Waitangi framework, provide national coordination of a distributed model of care, provide resourcing (including education) for primary care and actively work to increase provision and equity of gender-affirming surgeries. In order to be effective, the new resourcing hub would utilise peer health navigators, provide education and professional development, promote healing-focussed care and incorporate transgender community leadership and accountability. CONCLUSIONS: These improvements would allow for the best practices from existing regional programmes to be implemented throughout the healthcare system. The proposed changes align with the goals of the healthcare reforms to make healthcare for transgender people more equitable, accessible and cohesive.

"Being Trans Intersects with My Cultural Identity": Social Determinants of Mental Health Among Asian Transgender People.

Purpose: While studies on the relationship between social determinants and mental health among transgender people in Asia are increasing, there is a paucity of research on Asian transgender people living in Western countries. This study aimed to examine how social positions (gender, ethnicity, and migrant status) and social determinants of mental health were inter-related for Asian transgender people in Aotearoa/New Zealand. Methods: We analyzed both quantitative and qualitative data from Asian participants (n=49) who responded to the 2018 Counting Ourselves: Aotearoa New Zealand Trans and Non-Binary Health Survey. Results: Overall, 35% reported a very high psychological distress level. There were high levels of unmet needs for gender-affirming care, and participants reported a range of negative experiences at health care settings. About two-fifths had been discriminated because of their transgender (42%) or Asian (39%) identities. Fewer than half of participants felt that their family members were supportive of them being transgender (44%), and most reported they had supportive friends (73%). More than two-thirds of participants (68%) had a strong sense of belongingness to the transgender community and 35% reported this for the Asian community. Qualitative findings revealed specific challenges that participants experienced; these included barriers to accessing health care due to their migrant status and language barriers, influences of Asian cultures on mental health experiences, and rejection by family and people in Asian communities. Conclusion: Our study provides evidence for health care providers, researchers, and policy makers to employ a culturally appropriate lens to improve knowledge about the intersectional experiences of being Asian and transgender.

Barriers to Possessing Gender-Concordant Identity Documents are Associated with Transgender and Nonbinary People's Mental Health in Aotearoa/New Zealand.

Purpose: This study sought to expand on previous scholarship focused on gender-concordant identity documents (IDs) as a social determinant of health. We examined the association between barriers to legal gender recognition and the mental health of transgender and nonbinary people in Aotearoa/New Zealand. Methods: We used data from a 2018 nationwide community-based survey of trans and nonbinary people in Aotearoa (N = 818). Variables of investigation included: gender-concordant IDs, mental health (past-month psychological distress, past-year nonsuicidal self-injury, past-year suicidality) and barriers to changing gender markers on a birth certificate or passport. Associations between gender-concordant IDs and mental health were determined using generalized linear regression models. Results: In total, 34.8% reported the correct name on all of their IDs. The proportion with the correct gender marker on both birth certificates and passports was 16.0%. Participants with gender-concordant IDs were more likely to be older, have higher levels of income and education, and have had genital reconstruction. In addition, 68.7% of participants reported experiencing at least one barrier to changing gender markers on their IDs, and these participants had significantly higher average points of psychological distress scores (b = 2.39) and greater odds of suicidal ideation (odds ratio = 2.02) than those with gender-concordant IDs, after adjusting for sociodemographic variables. Conclusion: We present novel findings on higher levels of mental health problems among trans and nonbinary people who faced barriers in trying to obtain gender-concordant IDs compared with those with gender-concordant IDs. Removing barriers to legal gender recognition may be an effective way to improve mental health.

PrEP awareness and protective barrier negotiation among transgender people attracted to men in Aotearoa New Zealand.

INTRODUCTION: Internationally, trans women are disproportionately impacted by HIV, encounter specific barriers navigating safer sex and face inequities accessing HIV prevention, including pre-exposure prophylaxis (PrEP). Aotearoa/New Zealand (hereafter Aotearoa) was one of the first countries internationally to publicly fund PrEP in 2018, including for trans people. However, few data exist on PrEP awareness or sexual negotiation among trans populations to guide implementation. We present the first Aotearoa data on trans people's ability to negotiate barrier protection and awareness of PrEP efficacy and availability. METHODS: We used data from a large, diverse community-based nationwide survey of trans (including non-binary) people in Aotearoa: Counting Ourselves (N = 1178) conducted from 21 June to 30 September 2018. Generalized regression analyses were carried out among participants who have had sex (n = 704; Mage = 32.5) to identify associations between demographic factors (age, gender and sexual attraction, ethnicity, income, education qualification and current sex work involvement) and the Trans-Specific Barrier Negotiation Self-Efficacy (T-Barrier) Scale and PrEP awareness. RESULTS: The mean value of a 40-point T-Barrier Scale was 33.45 (SD: 6.89), suggesting a relatively high perceived ability among our participants to negotiate protective barrier usages in different situations. Asian participants scored 3.46 points lower compared to Pakeha (White) participants, and trans women attracted to men (cisgender and/or trans men) scored 2.40 points higher than trans women not attracted to men. Three-fifths (59.7%) were aware that PrEP reduced HIV risks and did not prevent sexually transmitted infections (STI) transmission, and only two-fifths (40.2%) knew PrEP was publicly funded for trans people. In multivariate models, we found participants who were older, trans women or those with lower education qualifications were less likely to have increased levels of PrEP awareness. CONCLUSIONS: Participants attracted to men have a higher potential need for PrEP and were more likely to report PrEP awareness and that they could negotiate protective barrier usage. However, trans women and those with lower educational qualifications reported lower levels of PrEP awareness. More trans-competent sexual health education, drawing on the newly released PrEP guidelines, is needed to promote the benefits of PrEP in the Aotearoa HIV epidemic context, particularly for trans women.

"I teach them. I have no choice": experiences of primary care among transgender people in Aotearoa New Zealand.

AIM: This study aims to report primary care experiences among transgender people in Aotearoa New Zealand based on quantitative and qualitative data from a nationwide community-based survey of transgender people. METHODS: Subsamples with a usual general practitioner were employed from the 2018 Counting Ourselves Survey (n=871) and the 2018/19 New Zealand Health Survey to assess inequities between these samples in primary care experiences and barriers. Guided by Andersen's Behavioural Model of healthcare access, we conducted a content analysis on comments from Counting Ourselves participants (n=153) to identify themes about issues of concern for transgender people when accessing primary care. RESULTS: Transgender participants had greater risk of feeling no confidence in their GPs (Mdifference=0.22; Cohen's d=0.39), reporting barriers accessing primary care due to cost (38.4% vs 17.4%; RR=2.21), and transport issues (13.5% vs 3.0%; RR=4.58) compared to the general population. Content analysis uncovered how transgender people's primary care experiences are shaped by healthcare environments, predisposing characteristics, and enabling resources. CONCLUSION: Our findings indicate ways to ensure primary care services are inclusive so that all transgender people feel welcome. This requires all primary healthcare professionals to demonstrate core trans-specific cultural safety when providing healthcare to transgender patients.

Setting a research agenda in trans health: An expert assessment of priorities and issues by trans and nonbinary researchers.

Background: This article is by a group of trans and nonbinary researchers and experts in the field of trans health who have conducted an analysis of trans health research needs. Aims: To highlight topics that need further research and to outline key considerations for those conducting research in our field. Methods: The first author conducted semi-structured interviews with all coauthors, and these were used to create a first draft of this manuscript. This draft was circulated to all authors, with edits made until consensus was reached among the authors. Results: More comprehensive long-term research that centers trans people's experiences is needed on the risks and benefits of gender affirming hormones and surgeries. The trans health research field also needs to have a broader focus beyond medical transition or gender affirmation, including general health and routine healthcare; trans people's lives without, before, and after medical gender affirmation; and sexuality, fertility, and reproductive healthcare needs. More research is also needed on social determinants of health, including ways to make healthcare settings and other environments safer and more supportive; social and legal gender recognition; the needs of trans people who are most marginalized; and the ways in which healing happens within trans communities. The second part of this article highlights key considerations for researchers, the foremost being acknowledging trans community expertise and centering trans community members' input into research design and interpretation of findings, in advisory and/or researcher roles. Ethical considerations include maximizing benefits and minimizing harms (beneficence) and transparency and accountability to trans communities. Finally, we note the importance of conferences, grant funding, working with students, and multidisciplinary teams. Discussion: This article outlines topics and issues needing further consideration to make the field of trans health research more responsive to the needs of trans people. This work is limited by our authorship group being mostly White, all being Anglophone, and residing in the Global North.

Enacted stigma experiences and protective factors are strongly associated with mental health outcomes of transgender people in Aotearoa/New Zealand.

INTRODUCTION: International evidence has found large mental health inequities among transgender people and demonstrates that mental health outcomes are associated with enacted stigma experiences and protective factors. This study aimed to examine the extent of associations of enacted stigma experiences specific to transgender people alongside protective factors with mental health of transgender people in Aotearoa/New Zealand. METHODS: The 2018 Counting Ourselves survey was a nationwide community-based study of transgender people (N = 1178, Mage = 29.5) living in Aotearoa/New Zealand. The survey assessed a wide range of gender minority stress experiences and protective factors that comprised primary (support from friends and family) and secondary social ties (neighborhood and transgender community belongingness). We calculated the predicted probabilities that transgender people exhibit very high psychological distress level, non-suicidal self-injury, and suicidal risks with different combinations and exposure profiles of enacted stigma and protective factors. RESULTS: Our findings demonstrated that enacted stigma was associated with negative mental health, and support of friends and family was linked to better outcomes across all mental health measures. Beyond primary social ties, sense of belongingness to neighborhood and transgender communities were linked to reduced odds of psychological distress and suicidal ideation. For those scoring high on enacted stigma and low on protective factors, our model revealed a 25% probability of attempting suicide in the last year compared to 3% for those scoring low on enacted stigma and high on protective factors. CONCLUSIONS: Echoing previous findings, this study demonstrates that transgender people across Aotearoa/New Zealand are less likely to manifest life-threatening mental health outcomes if they experience low levels of enacted stigma and high levels of access to protective factors. Our findings suggest a need to address the enacted stigma that transgender people face across interpersonal and structural settings, and also to enhance social supports that are gender affirmative for this population.