{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,12]],"date-time":"2026-09-12T21:39:27Z","timestamp":1789249167837,"version":"build-2803163510"},"reference-count":50,"publisher":"Springer Science and Business Media LLC","issue":"6","license":[{"start":{"date-parts":[[2020,3,3]],"date-time":"2020-03-03T00:00:00Z","timestamp":1583193600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/www.springer.com\/tdm"},{"start":{"date-parts":[[2020,3,3]],"date-time":"2020-03-03T00:00:00Z","timestamp":1583193600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/www.springer.com\/tdm"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["J GEN INTERN MED"],"published-print":{"date-parts":[[2020,6]]},"DOI":"10.1007\/s11606-020-05724-2","type":"journal-article","created":{"date-parts":[[2020,3,4]],"date-time":"2020-03-04T00:05:10Z","timestamp":1583280310000},"page":"1693-1700","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":95,"title":["Transgender-Related Insurance Denials as Barriers to Transgender Healthcare: Differences in Experience by Insurance Type"],"prefix":"10.1007","volume":"35","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1302-9959","authenticated-orcid":false,"given":"Matthew","family":"Bakko","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shanna K.","family":"Kattari","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2020,3,3]]},"reference":[{"issue":"2","key":"5724_CR1","doi-asserted-by":"publisher","first-page":"139","DOI":"10.1007\/s40124-018-0173-8","volume":"6","author":"LAE Conard","year":"2018","unstructured":"Conard LAE, Corathers SD, Trotman G. Caring for transgender and gender-nonconforming youth. Curr Pediatr Rep 2018;6(2):139\u2013146.","journal-title":"Curr Pediatr Rep"},{"issue":"4","key":"5724_CR2","doi-asserted-by":"publisher","first-page":"60","DOI":"10.1525\/srsp.2007.4.4.60","volume":"4","author":"M Davidson","year":"2007","unstructured":"Davidson M. Seeking refuge under the umbrella: Inclusion, exclusion, and organizing within the category transgender. Sex Res Soc Policy 2007;4(4):60\u201380.","journal-title":"Sex Res Soc Policy"},{"issue":"3","key":"5724_CR3","doi-asserted-by":"publisher","first-page":"336","DOI":"10.1016\/j.amepre.2018.04.045","volume":"55","author":"JM Downing","year":"2018","unstructured":"Downing JM, Przedworski JM. Health of Transgender Adults in the US, 2014\u20132016. Am J Prev Med 2018;55(3):336\u2013344.","journal-title":"Am J Prev Med"},{"issue":"4","key":"5724_CR4","doi-asserted-by":"publisher","first-page":"244","DOI":"10.1089\/lgbt.2016.0099","volume":"4","author":"WV Padula","year":"2017","unstructured":"Padula WV, Baker K. Coverage for gender-affirming care: Making health insurance work for transgender Americans. LGBT Health 2017;4(4):244\u2013247.","journal-title":"LGBT Health"},{"key":"5724_CR5","unstructured":"World Professional Association for Transgender Health (WPATH). Position statement on medical necessity of treatment, sex reassignment, and insurance coverage in the USA; 2016."},{"issue":"4","key":"5724_CR6","doi-asserted-by":"publisher","first-page":"696","DOI":"10.1542\/peds.2013-2958","volume":"134","author":"AL De Vries","year":"2014","unstructured":"De Vries AL, McGuire JK, Steensma TD, et al. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014;134(4):696\u2013704.","journal-title":"Pediatrics."},{"issue":"11\u201312","key":"5724_CR7","doi-asserted-by":"publisher","first-page":"675","DOI":"10.1007\/s11199-012-0216-5","volume":"68","author":"JM Sevelius","year":"2013","unstructured":"Sevelius JM. Gender affirmation: A framework for conceptualizing risk behavior among transgender women of color. Sex Roles 2013;68(11\u201312):675\u2013689.","journal-title":"Sex Roles"},{"issue":"4","key":"5724_CR8","doi-asserted-by":"publisher","first-page":"394","DOI":"10.1007\/s11606-015-3529-6","volume":"31","author":"WV Padula","year":"2016","unstructured":"Padula WV, Heru S, Campbell JD. Societal implications of health insurance coverage for medically necessary services in the U.S. transgender population: A cost-effectiveness analysis. J Gen Intern Med 2016;31(4):394\u2013401.","journal-title":"J Gen Intern Med"},{"key":"5724_CR9","volume-title":"The aging and health report: Disparities and resilience among lesbian, gay, bisexual, and transgender older adults","author":"KI Fredriksen-Goldsen","year":"2011","unstructured":"Fredriksen-Goldsen KI, Kim HJ, Emlet CA, et al. The aging and health report: Disparities and resilience among lesbian, gay, bisexual, and transgender older adults. 2011. Seattle: Institute for Multigenerational Health."},{"key":"5724_CR10","volume-title":"Injustice at every turn: A report of the national transgender discrimination survey","author":"J Grant","year":"2011","unstructured":"Grant J, Mottet L, Tanis J, et al. Injustice at every turn: A report of the national transgender discrimination survey. 2011. Washington, DC, National Center for Transgender Equality and National Gay and Lesbian Task Force."},{"issue":"4","key":"5724_CR11","doi-asserted-by":"publisher","first-page":"726","DOI":"10.1111\/1468-0009.12297","volume":"95","author":"G Gonzales","year":"2017","unstructured":"Gonzales G, Henning-Smith C. Barriers to care among transgender and gender nonconforming adults. Milbank Q 2017;95(4):726\u2013748.","journal-title":"Milbank Q"},{"key":"5724_CR12","volume-title":"The report of the 2015 U.S. transgender survey","author":"SE James","year":"2016","unstructured":"James SE, Herman JL, Rankin S, et al. The report of the 2015 U.S. transgender survey. 2016. Washington, DC, National Center for Transgender Equality."},{"issue":"3","key":"5724_CR13","doi-asserted-by":"publisher","first-page":"e20171683","DOI":"10.1542\/peds.2017-1683","volume":"141","author":"GN Rider","year":"2018","unstructured":"Rider GN, McMorris BJ, Gower AL, et al. Health and care utilization of transgender and gender nonconforming youth: A population-based study. Pediatrics. 2018;141(3):e20171683.","journal-title":"Pediatrics."},{"key":"5724_CR14","volume-title":"Improving the lives of transgender adults","author":"A Auldridge","year":"2012","unstructured":"Services and Advocacy for GLBT Elders (SAGE), National Center for Transgender Equality (NCTE), Auldridge A, et al. Improving the lives of transgender adults. New York and Washington, DC, SAGE and NCTE; 2012."},{"issue":"8","key":"5724_CR15","doi-asserted-by":"publisher","first-page":"1210","DOI":"10.1001\/jamainternmed.2017.1460","volume":"177","author":"CG Streed","year":"2017","unstructured":"Streed CG, McCarthy EP, Haas JS. Association between gender minority status and self-reported physical and mental health in the United States. JAMA Intern Med 2017;177(8):1210\u20131212.","journal-title":"JAMA Intern Med"},{"issue":"1","key":"5724_CR16","doi-asserted-by":"publisher","first-page":"44","DOI":"10.1016\/j.jadohealth.2016.09.014","volume":"60","author":"JF Veale","year":"2017","unstructured":"Veale JF, Watson RJ, Peter T, Saewyc EM. The mental health of Canadian transgender youth compared with the Canadian population. J Adolesc Health 2017;60(1):44\u201349.","journal-title":"J Adolesc Health"},{"issue":"8","key":"5724_CR17","doi-asserted-by":"publisher","first-page":"2129","DOI":"10.1007\/s11136-017-1545-1","volume":"26","author":"AR Gordon","year":"2017","unstructured":"Gordon AR, Krieger N, Okechukwu CA, et al. Decrements in health-related quality of life associated with gender nonconformity among US adolescents and young adults. Qual Life Res 2017;26(8):2129\u20132138.","journal-title":"Qual Life Res"},{"issue":"2","key":"5724_CR18","doi-asserted-by":"publisher","first-page":"146","DOI":"10.1037\/sgd0000029","volume":"1","author":"L Mizock","year":"2014","unstructured":"Mizock L, Mueser KT. Employment, mental health, internalized stigma, and coping with transphobia among transgender individuals. Psychol Sex Orientat Gend Divers 2014;1(2):146\u2013158.","journal-title":"Psychol Sex Orientat Gend Divers"},{"issue":"6","key":"5724_CR19","doi-asserted-by":"publisher","first-page":"424","DOI":"10.1089\/lgbt.2016.0044","volume":"3","author":"JM White Hughto","year":"2016","unstructured":"White Hughto JM, Murchison GR, Clark K, et al. Geographic and individual differences in healthcare access for US transgender adults: A multilevel analysis. LGBT Health 2016;3(6):424\u2013433.","journal-title":"LGBT Health"},{"key":"5724_CR20","doi-asserted-by":"publisher","first-page":"222","DOI":"10.1016\/j.socscimed.2015.11.010","volume":"147","author":"JM White Hughto","year":"2015","unstructured":"White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med 2015;147:222\u2013231.","journal-title":"Soc Sci Med"},{"issue":"2\u20133","key":"5724_CR21","doi-asserted-by":"publisher","first-page":"57","DOI":"10.1300\/J485v08n02_06","volume":"8","author":"GP Kenagy","year":"2005","unstructured":"Kenagy GP, Bostwick WB. Health and social service needs of transgender people in Chicago. Int J Transgend 2005;8(2\u20133):57\u201366.","journal-title":"Int J Transgend"},{"issue":"1","key":"5724_CR22","doi-asserted-by":"publisher","first-page":"127","DOI":"10.1353\/hpu.2017.0014","volume":"28","author":"JE Lerner","year":"2017","unstructured":"Lerner JE, Robles G. Perceived barriers and facilitators to health care utilization in the United States for transgender people: A review of recent literature. J Health Care Poor Underserved 2017;28(1):127\u2013152.","journal-title":"J Health Care Poor Underserved"},{"issue":"1","key":"5724_CR23","doi-asserted-by":"publisher","first-page":"63","DOI":"10.1080\/01488376.2011.637858","volume":"39","author":"RL Stotzer","year":"2013","unstructured":"Stotzer RL, Silverschanz P, Wilson A. Gender identity and social services: Barriers to care. J Soc Serv Res 2013;39(1):63\u201377.","journal-title":"J Soc Serv Res"},{"issue":"2","key":"5724_CR24","doi-asserted-by":"publisher","first-page":"116","DOI":"10.1080\/1536710X.2017.1299661","volume":"16","author":"SK Kattari","year":"2017","unstructured":"Kattari SK, Walls NE, Speer SR. Differences in experiences of discrimination in accessing social services among transgender\/gender nonconforming individuals by (Dis) ability. J Soc Work Disabil Rehabil 2017;16(2):116\u2013140.","journal-title":"J Soc Work Disabil Rehabil"},{"issue":"2","key":"5724_CR25","doi-asserted-by":"publisher","first-page":"68","DOI":"10.1080\/15532739.2015.1064336","volume":"16","author":"SK Kattari","year":"2015","unstructured":"Kattari SK, Walls NE, Whitfield DL, Langenderfer-Magruder L. Racial and ethnic differences in experiences of discrimination in accessing health services among transgender people in the United States. Int J Transgend 2015;16(2):68\u201379.","journal-title":"Int J Transgend"},{"issue":"2","key":"5724_CR26","doi-asserted-by":"publisher","first-page":"285","DOI":"10.1177\/0898264315590228","volume":"28","author":"SK Kattari","year":"2016","unstructured":"Kattari SK, Hasche L. Differences across age groups in transgender and gender non-conforming people\u2019s experiences of health care discrimination, harassment, and victimization. J Aging Health 2016;28(2):285\u2013306.","journal-title":"J Aging Health"},{"issue":"1","key":"5724_CR27","first-page":"13","volume":"2","author":"J Harrison","year":"2012","unstructured":"Harrison J, Grant J, Herman, JL. A gender not listed here: Genderqueers, gender rebels, and otherwise in the National Transgender Discrimination Survey. LGBTQ Public Policy J Harv Kennedy Sch 2012;2(1):13.","journal-title":"LGBTQ Public Policy J Harv Kennedy Sch"},{"issue":"3","key":"5724_CR28","doi-asserted-by":"publisher","first-page":"809","DOI":"10.1111\/socf.12193","volume":"30","author":"LR Miller","year":"2015","unstructured":"Miller LR, Grollman, EA. The social costs of gender nonconformity for transgender adults: Implications for discrimination and health. Sociol Forum 2015;30(3):809\u2013831.","journal-title":"Sociol Forum"},{"key":"5724_CR29","unstructured":"Doctor-Patient Rights Project. Not what the doctor ordered: Barriers to healthcare access for patients. Washington, DC; 2017"},{"issue":"3","key":"5724_CR30","doi-asserted-by":"publisher","first-page":"275","DOI":"10.1037\/sgd0000169","volume":"3","author":"LM Dickey","year":"2016","unstructured":"Dickey LM, Budge SL, Katz-Wise SL, Garza MV. Health disparities in the transgender community: Exploring differences in insurance coverage. Psychol Sex Orientat Gend Divers 2016;3(3):275\u2013282.","journal-title":"Psychol Sex Orientat Gend Divers"},{"key":"5724_CR31","doi-asserted-by":"publisher","first-page":"65","DOI":"10.1016\/j.socscimed.2014.03.032","volume":"110","author":"TM Cruz","year":"2014","unstructured":"Cruz TM. Assessing access to care for transgender and gender nonconforming people: A consideration of diversity in combating discrimination. Soc Sci Med 2014;110:65\u201373.","journal-title":"Soc Sci Med"},{"issue":"19","key":"5724_CR32","doi-asserted-by":"publisher","first-page":"1801","DOI":"10.1056\/NEJMp1702427","volume":"376","author":"KE Baker","year":"2017","unstructured":"Baker KE. The future of transgender coverage. N Engl J Med 2017;376(19):1801\u20131804.","journal-title":"N Engl J Med"},{"issue":"3","key":"5724_CR33","doi-asserted-by":"publisher","first-page":"e31","DOI":"10.2105\/AJPH.2013.301789","volume":"104","author":"D Stroumsa","year":"2014","unstructured":"Stroumsa D. The state of transgender health care: policy, law, and medical frameworks. Am J Public Health Res 2014;104(3):e31-e38.","journal-title":"Am J Public Health Res"},{"issue":"1","key":"5724_CR34","doi-asserted-by":"publisher","first-page":"8","DOI":"10.1002\/hast.805","volume":"48","author":"K Underhill","year":"2018","unstructured":"Underhill K. Raising the Stakes for Nondiscrimination Protections in the ACA. Hast Cent Rep 2018;48(1):8\u20139.","journal-title":"Hast Cent Rep"},{"key":"5724_CR35","first-page":"375","volume":"11","author":"L Khan","year":"2011","unstructured":"Khan, L. Transgender health at the crossroads: Legal norms, insurance markets, and the threat of healthcare reform. Yale J Health Policy Law Ethics 2011;11:375\u2013418.","journal-title":"Yale J Health Policy Law Ethics"},{"key":"5724_CR36","first-page":"1","volume":"51","author":"S Rosh","year":"2017","unstructured":"Rosh S. Beyond categorical exclusions: Access to transgender healthcare in state Medicaid programs. Columbia J Law Soc Probl 2017;51:1\u201337.","journal-title":"Columbia J Law Soc Probl"},{"key":"5724_CR37","unstructured":"Movement Advancement Project (MAP). Healthcare laws and policies; 2019 [cited 2019 April 15th]; Available from http:\/\/www.lgbtmap.org\/equality-maps\/healthcare_laws_and_policies."},{"key":"5724_CR38","unstructured":"National Center for Transgender Equality (NCTE). Medicare and Transgender People; 2014 [cited 2019 April 15th]; Available from https:\/\/transequality.org\/sites\/default\/files\/docs\/kyr\/MedicareAndTransPeople.pdf."},{"issue":"2","key":"5724_CR39","doi-asserted-by":"publisher","first-page":"122","DOI":"10.1089\/lgbt.2015.0058","volume":"3","author":"GR Brown","year":"2016","unstructured":"Brown GR, Jones KT. Mental health and medical health disparities in 5135 transgender veterans receiving healthcare in the Veterans Health Administration: A case\u2013control study. LGBT Health 2016;3(2):122\u2013131.","journal-title":"LGBT Health"},{"key":"5724_CR40","unstructured":"Department of Veterans Affairs, Veterans Health Administration. VHA Directive 2013\u2013003: Providing health care for transgender and intersex veterans; 2013 [cited 2019 April 15th]; Available from www. va.gov\/vhapublications\/ViewPublication.asp?pub_ID=2863."},{"key":"5724_CR41","unstructured":"National Center for Transgender Equality (NCTE). Veterans Health Administrations Transgender Healthcare Directive; 2011 [cited 2019 April 15th]; Available from https:\/\/transequality.org\/sites\/ default\/files\/docs\/resources\/VHA_Trans_Health.pdf."},{"key":"5724_CR42","unstructured":"Bushatz A. Defense Department Releases New Tricare Transgender Policy; 2016 [cited 2019 April 15th]; Available from https:\/\/www.military.com\/daily-news\/2016\/09\/06\/defense-department-releases-new-tricare-transgender-policy.html."},{"issue":"1","key":"5724_CR43","doi-asserted-by":"publisher","first-page":"43","DOI":"10.1097\/00001648-199001000-00010","volume":"1","author":"KJ Rothman","year":"1990","unstructured":"Rothman KJ. No adjustments are needed for multiple comparisons. Epidemiology. 1990;1(1):43\u201346.","journal-title":"Epidemiology."},{"issue":"7139","key":"5724_CR44","doi-asserted-by":"publisher","first-page":"1236","DOI":"10.1136\/bmj.316.7139.1236","volume":"316","author":"TV Perneger","year":"1998","unstructured":"Perneger TV. What\u2019s wrong with Bonferroni adjustments. BMJ. 1998;316(7139): 1236\u20131238.","journal-title":"BMJ."},{"issue":"3","key":"5724_CR45","doi-asserted-by":"publisher","first-page":"492","DOI":"10.1177\/1536867X1301300304","volume":"13","author":"EC Norton","year":"2013","unstructured":"Norton EC, Miller MM, Kleinman LC. Computing adjusted risk ratios and risk differences in Stata. Stata J 2013;13(3):492\u2013509.","journal-title":"Stata J"},{"key":"5724_CR46","unstructured":"Center of Excellence for Transgender Health, Wilson AA, Green J. Health insurance coverage issues for transgender people in the United States. 2016. Available from https:\/\/transcare.ucsf.edu\/guidelines\/insurance."},{"key":"5724_CR47","unstructured":"Centers for Medicare and Medicaid Services. Decision memo for gender dysphoria and gender reassignment surgery (CAG-00446N); 2016 [cited 2019 April 15th]; Available from https:\/\/www.cms.gov\/medicare-coverage-database\/details\/nca-decision-memo.aspx?NCAId=282."},{"key":"5724_CR48","unstructured":"National Academy for State Health Policy. Medical Necessity; 2013 [cited 2019 April 15th]; Available from https:\/\/nashp.org\/medical-necessity."},{"issue":"1","key":"5724_CR49","doi-asserted-by":"publisher","first-page":"250","DOI":"10.1089\/trgh.2016.0031","volume":"1","author":"K Proctor","year":"2016","unstructured":"Proctor K, Haffer SC, Ewald E, et al. Identifying the transgender population in the Medicare Program. Transgend Health 2016;1(1):250\u2013265.","journal-title":"Transgend Health"},{"issue":"1","key":"5724_CR50","doi-asserted-by":"publisher","first-page":"84","DOI":"10.1001\/jama.2018.6971","volume":"320","author":"EC Norton","year":"2018","unstructured":"Norton EC, Dowd BE, Maciejewski ML. Odds ratios\u2014current best practice and use. JAMA. 2018;320(1):84\u201385.","journal-title":"JAMA."}],"container-title":["Journal of General Internal Medicine"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1007\/s11606-020-05724-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/link.springer.com\/article\/10.1007\/s11606-020-05724-2\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1007\/s11606-020-05724-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,3,3]],"date-time":"2021-03-03T01:11:51Z","timestamp":1614733911000},"score":1,"resource":{"primary":{"URL":"http:\/\/link.springer.com\/10.1007\/s11606-020-05724-2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,3,3]]},"references-count":50,"journal-issue":{"issue":"6","published-print":{"date-parts":[[2020,6]]}},"alternative-id":["5724"],"URL":"https:\/\/doi.org\/10.1007\/s11606-020-05724-2","relation":{},"ISSN":["0884-8734","1525-1497"],"issn-type":[{"value":"0884-8734","type":"print"},{"value":"1525-1497","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,3,3]]},"assertion":[{"value":"23 July 2019","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"25 December 2019","order":2,"name":"revised","label":"Revised","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"5 February 2020","order":3,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"3 March 2020","order":4,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"As anonymized secondary data, this study received exempt approval from the University of Michigan IRB.","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Compliance with Ethical Standards"}},{"value":"No conflict of interest exists for any of the authors.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of Interest"}},{"value":"This content has been made available to all.","name":"free","label":"Free to read"}]}}