Abstract
IMPORTANCE: A recent increase in state policies targeting gender minority (GM; transgender and gender-diverse) people may affect the mental health of sexual and gender minority (SGM; nonheterosexual and/or GM) people and GM people specifically. OBJECTIVE: To estimate changes in mental health symptoms associated with enactment of anti-GM state policies among SGM people and GM people specifically. DESIGN, SETTING, AND PARTICIPANTS: This repeated cross-sectional study used a staggered difference-in-differences analysis to examine the associations between anti-GM policies in the US and mean changes in mental health symptoms among 8733 SGM adults who completed annual questionnaires between April 1, 2020, and June 1, 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 1 or more of the following enacted policies: (1) bathroom restrictions for GM people, (2) sports bans for GM young people participating in school sports, and (3) bans on gender-affirming care for young people. MAIN OUTCOMES AND MEASURES: Mean levels of anxiety (measured using the 7-item Generalized Anxiety Disorder scale [GAD-7]; total score range, 0-21), depression (measured using the 9-item Patient Health Questionnaire scale [PHQ-9]; total score range, 0-27), and posttraumatic stress disorder (PTSD) symptoms (measured using the 6-item PTSD Checklist scale [PCL-6]; total score range, 6-30). For all 3 scales, higher scores indicate more severe symptoms. RESULTS: Among all 8733 SGM participants in the sample (median age, 32.5 years [IQR, 26.0-45.0 years]; 2024 cisgender men [23.2%], 2355 cisgender women [27.0%], 2198 gender-diverse adults assigned female at birth [25.2%], 321 gender-diverse adults assigned male at birth [3.7%], 1294 transgender men [14.8%], and 541 transgender women [6.2%]), anti-GM policy enactment was associated with significant increases in anxiety (GAD-7 score, 0.8 points [95% CI, 0.2-1.4 points]) and PTSD (PCL-6 score, 0.8 points [95% CI, 0.1-1.4 points]) symptoms in states that enacted anti-GM policies compared with states that did not but was not associated with significant increases in depression symptoms (PHQ-9 score, 0.6 points [95% CI, -0.1 to 1.4 points]). In the GM subsample (n = 4354), nonsignificant changes in anxiety (GAD-7 score, 0.6 points [95% CI, -0.2 to 1.4 points]), depression (PHQ-9 score, 0.1 points [95% CI, -0.9 to 1.1 points]), and PTSD (PCL-6 score, 0.7 points [95% CI, -0.2 to 1.6 points]) symptoms were observed after policy enactment in states that enacted anti-GM policies compared with states that did not. Gender minority adults had high mental health symptoms across the study period. CONCLUSIONS AND RELEVANCE: In this study of 8733 SGM adults using difference-in-differences analysis, anti-GM policies were associated with worse mental health symptoms among SGM adults but no changes in mental health symptoms among GM adults. As these policies proliferate, it is important to consider how they may affect mental health.