Intersectional discrimination, mental health, and health care access among transgender women in Brazil.

Abstract

Objectives: Intersectional discrimination leads to negative health outcomes among transgender (trans) women. To address the need for validated tools to measure experiences of intersectional discrimination, we evaluated the performance of the Intersectional Discrimination Index (InDI) and measured associations with mental health and health care engagement among trans women in São Paulo, Brazil.

Method: Using baseline data from the Manas por Manas randomized controlled trial (n = 392), we characterized participant experiences of intersectional discrimination using the InDI-anticipated (InDI-A), day-to-day (InDI-D), and major (InDI-M) discrimination subscales. We evaluated the validity of the InDI-A using confirmatory factor analysis, and reliability using Cronbach's coefficient alpha (Cα) and explored relationships between each subscale, mental health, and health care engagement.

Results: A single-factor solution yielded excellent for InDI-A. All subscales demonstrated good reliability: InDI-A (Cα = .85); InDI-D (lifetime Cα = .84, past-year Cα = .87), InDI-M (lifetime Cα = .78, past-year Cα = .76). A one-unit increase in anticipated discrimination was associated with severe psychological distress, adjusted odds ratio (AOR) = 2.13, 95% confidence interval (CI) [1.57, 2.89], p < .0001, and suicidality (AOR = 1.44, 95% CI [1.08, 1.93], p < .05). Similar patterns emerged for major and day-to-day discrimination. We observed important differences by race. Anticipated discrimination was associated with higher odds of HIV testing (AOR = 1.46, 95% CI [1.08, 1.97], p = .013). Discrimination was not associated with accessing primary care.

Conclusion: The InDI is a valid and reliable tool for measuring intersectional discrimination among Brazilian trans women; InDI scores are strongly associated with negative mental health sequelae. Interventions are needed to mitigate structural barriers to care in Brazil, where poor mental health and HIV prevalence are high among trans women. (PsycInfo Database Record (c) 2025 APA, all rights reserved).