Last spring, SPA Assistant Professor David Schwegman and coauthors provided the first experimental evidence, from a correspondence audit field experiment (“simulated patients” study), of the extent of racial and gender identity discrimination in securing mental health-care appointments. The study found significant discrimination against transgender or non-binary African Americans and Hispanics, as well as that against cisgender African American women.
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Mental Health Disparities Among Gender, Racial, and Ethnic Minorities
Transgender and non-binary (TNB) individuals experience worse outcomes for income, employment, and food security compared with cisgender individuals, and are more likely to face mental illness and severe psychological stress, with higher rates for anxiety, depression, substance misuse, and suicidality. In one sample of 1,053 transgender persons, 41% reported attempting suicide— 26 times higher than the general population. Around one-fourth of transgender individuals opt not to seek needed health care for fear of mistreatment due to their gender identity, and one-third report a related negative experience.

Racial and ethnic minorities face similar discrimination and disparities, especially TNB African Americans and Hispanics. The complex relationship between race, ethnicity, gender identity, and mental health has yielded conflicting evidence on the direction of mental health disparities. Transgender people, African Americans, and Hispanics are more likely to be unemployed, uninsured, exposed to neighborhood violence, and involved in the criminal justice system, creating a special category often referred to as “minority stress,” which correlates with worse mental health outcomes.

For transgender, African American, and Hispanic people facing psychological stressors, counseling and therapy can help address numerous mental health concerns, such as stress, anxiety, depression, and substance misuse. However, discrimination against minoritized groups, in the form of restricted access, may cause or worsen underlying race-, ethnicity-, and gender identity–related mental health disparities.

The Discretion of Mental Health Care Providers in the United States
Mental health-care providers (MHPs)––primary care physicians, psychologists, psychiatrists, nurses, mental health and substance abuse counselors, family and marriage counselors, and social workers–– supply and regulate access to mental health-care services in the U.S. Regardless of professional training and qualifications, MHPs have a significant degree of professional autonomy, specifically over which clients to accept (especially during high-demand periods). They are more likely to practice solo than other health-care providers, with fewer institutional constraints checking their explicit or implicit biases.

Previous studies establish that health-care providers, including MHPs, make decisions about patients that are shaped by their perceptions of a patient’s race, social class, and gender. For example, MHPs have been found to cultivate a group of desirable patients by “creamskimming,” or choosing to provide services to a specific group of patients, based on gender or race homophily, type of service requested, or insurance status, which can also proxy for education, the likelihood and- amount of payment, and so on.

If MHP behaviors limit access to mental health services for gender, racial, and ethnic minorities, or discourage them from seeking treatment, it will worsen mental health disparities by 1) adding stress, 2) delaying treatment, which negatively impacts health and increases treatment costs, and 3) discouraging many from seeking treatment at all. Discrimination may also reduce provider-patient match quality (crucial for effective care) by forcing the patient to select a therapist who is trans-friendly but is otherwise less suitable.

The Study
Using a popular website, researchers requested appointments for common mental health concerns (anxiety, depression, and stress) from U.S. mental health providers—psychologists, counselors, social workers, and psychiatrists, including transgender and non-binary individuals. Appointment request emails included randomly-assigned names to signal race or ethnicity (African American, Hispanic, or White). Each MHP received one inquiry from one prospective patient who disclosed that they are transgender (25% of the time), non-binary (25%), or undisclosed—presumed cisgender (50%). Discrimination was quantified by comparing the MHP positive response rates (appointment, consultation, or phone call offer) by patient gender identity, race, and ethnicity. MHPs had the options of responding via email, phone (or voicemail), or text message; their response was coded to one of seven mutually exclusive outcome categories: appointment offered, call or consultation offer, screening question(s) (e.g., can you pay out of pocket?), referral, waitlist, rejection, and no response.

Results
They received nonautomated responses to 75.5% of inquiries, and a positive response—either an appointment offer (33.3%) or a call or consultation (23.3%)—for 56.6% of inquiries. They received no response 24.5% of the time, by far the most common negative response.

The study found that African American and Hispanic transgender and non-binary people face discrimination when attempting to access mental health-care services, though White transgender and non-binary prospective patients do not. It could not determine whether cisgender African American or Hispanic prospective patients face discrimination. There was no evidence of discrimination against White transgender and nonbinary individuals, and it is unclear whether (presumed) cisgender African American or Hispanic patients face discrimination in access to appointments relative to their White and cisgender counterparts. Further, cisgender African American women face discrimination relative to cisgender White women and cisgender African American men.

Policy Implications and Recommendations
These findings inform discussions around oversight and regulation of the mental health-care markets, which occurs through federal and state anti-discrimination laws, state licensing regulations, and professional association policies. Second, they speak to the undersupply of LGBTQ1-competent MHPs and African American and Hispanic MHPs, and can guide conversations around diversifying the profession and improving training. Third, research on discriminatory barriers faced by transgender and racially diverse people in access to mental health care is increasingly relevant, as many governments, particularly those in the United States, are aggressively proposing and passing anti-LGBTQ1 legislation that could negatively affect mental health and reduce access to health care.

Conclusion
MHPs are less likely to offer appointments or respond to African American or Hispanic transgender and non-binary (TNB) prospective patients, a big problem given the mental health disparities faced by TNB individuals, African Americans, and Hispanics, and particularly, TNB African Americans and Hispanics. Given that these minoritized groups are, on average, in greater need for mental health services, discrimination by MHPs can have profound mental and physical health consequences.