The trans care paradox: Mental health disparities among transgender and nonbinary patients in a trans-protective environment.

This study examines mental health disparities among transgender, nonbinary, and gender-expansive (hereinafter "trans") patients within a large urban health care system in the Bronx, New York-a relatively trans-protective legislative environment-amid escalating federal anti-trans legislation. Using electronic health record data (2015-2023) from a large safety-net health care system, we conducted a retrospective cohort study comparing mental health outcomes and services among trans (n = 2,898) and cisgender (n = 29,818) adult patients. We applied the Institute of Medicine rank-and-replace method to isolate disparities attributable to systemic inequities independent of clinical need. Despite greater engagement, trans patients faced disproportionately poor outcomes. Trans patients had more than twice the prevalence of mental health concerns compared with cisgender patients (all ps < .001), including higher rates of mood disorders (10.9% vs. 2.6%) and anxiety disorders (9.7% vs. 3.1%). Trans patients had higher predicted means of primary care utilization (40.92% vs. 38.45%, disparity: 2.48 percentage points, p < .001), minimally recommended mental health treatment (21.18% vs. 19.44%, disparity: 1.74 percentage points, p < .001), suicide-related visits (2.3% vs. 1.2%, disparity: 1.1 percentage points, p < .001), emergency department mental health visits (8.6% vs. 6.4%, disparity: 2.2 percentage points, p < .001), and inpatient mental health stays (0.13 vs. 0.09 stays per year, p < .001). Intersectional analyses revealed compounded disparities for Black and Hispanic patients. These findings highlight a persistent "care paradox," wherein greater health care utilization fails to mitigate adverse outcomes. Results underscore the need for integrated, trans-affirming interventions at the health care system level, broader structural reforms, and community-driven efforts to bolster trans mental health. (PsycInfo Database Record (c) 2026 APA, all rights reserved).