Structural drivers of health (SDOH) have been defined as “the written and unwritten rules that create, maintain, or eliminate durable and hierarchical patterns of advantage among socially constructed groups in the conditions that affect health (Heller et al., 2024).” When providing this definition, Heller and colleagues emphasize that groups with more power in the existing social structures reinforce or modify the rules to maintain their advantage. Residential segregation is a term that refers to the physical separation of different groups of people, often based on race, ethnicity, and/or socioeconomic status (Timberlake and Ignatov, 2014). In the United States (U.S.), residential segregation is a key structural determinant of health (Arcaya et al., 2024; Steil and Arcaya, 2023). The creation and maintenance of economically and racially unequal neighborhoods, i.e. residential segregation, allows advantaged groups to control access to place-based resources and is key to social stratification and racial inequality in the U.S. (Steil and Arcaya, 2023). Residential segregation plays an important role in determining access to education, income, employment, and housing - all key drivers of health (Carter and Zimmerman, 2022).

Residential segregation has been associated with a wide range of negative health outcomes and health inequities for ethnoracial groups living in disadvantaged neighborhoods (Larrabee Sonderlund et al., 2022; Yang et al., 2020). However, some studies have shown null or even protective associations between neighborhood disadvantage and health, positing potential benefits of ethnoracial residential density for social support and mental health among minoritized groups (Steil and Arcaya, 2023). While few studies have explored relationships between residential segregation and mental health (Steil and Arcaya, 2023), a recent study found no significant association between residential segregation and anxiety and depression symptoms nor between residential segregation and self-rated health in a large national sample of community-dwelling older adults (Smith et al., 2022). Another study found that residing in disdavantaged neighborhoods was associated with negative physical health outcomes but positive mental health outcomes for Black participants (Smith, 2024). We were unable to identify any quantitative studies that addressed the effects of racialized economic residential segregation on the health of transgender people.

Racialized economically disadvantaged neighborhoods are often targets for urban redevelopment strategies aimed at improving economic conditions and the built environment. Such reinvestment often leads to gentrification, a process by which wealthier people move into low-income neighborhoods, drive up housing prices and other costs, and displace long-time, lower income residents; thereby ultimately sustaining or increasing residential segregation (Schnake-Mahl et al., 2020). A recent systematic review on the effects of gentrification on population health found contradicting results across studies with some beneficial and some detrimental effects on health (Schnake-Mahl et al., 2020).

While most studies on the health effects of residential segregation and gentrification have focused on ethnoracial health inequities (Larrabee Sonderlund et al., 2022; Schnake-Mahl et al., 2020; Yang et al., 2020), a few have also examined inequities among (presumably cisgender) men versus women (D'Agostino et al., 2018; Frankenfeld et al., 2022). However, we were unable to identify any quantitative studies that examined the health effects of residential segregation or gentrification among transgender populations. Transgender women experience marginalization at the intersection of both sexism and transphobia (Matsuzaka and Koch, 2018), resulting in a number of well-documented mental and physical health inequities (Scheim et al., 2022).

Health inequities were exacerbated by the onset of the COVID-19 pandemic, which disproportionately impacted transgender populations (Philip, 2021; Zubizarreta et al., 2022). A number of studies have examined the effects of the pandemic on health outcomes among transgender people and found that pandemic-associated stress, social isolation, and facility closures were associated with reduced quality of life, poorer mental health, and decreased access to care (Koehler et al., 2023; O'Handley and Courtice, 2022; Zubizarreta et al., 2022). However, these studies have not examined early pandemic health outcomes in the context of neighborhood-level structural factors. Few studies, overall, have used multi-wave, multilevel data to examine the effects of neighborhood-level structural factors on transgender health.

This study addressed these knowledge gaps by examining associations between neighborhood structures (racialized economic residential segregation and gentrification, respectively) and psychological distress and self-rated health, among a national sample of transgender women during the early COVID-19 pandemic in the U.S, across two waves of data collection. We hypothesized that living in racialized economically disadvantaged neighborhoods, or living in gentrified neighborhoods, would be associated with greater relative risk of psychological distress and poor self-rated health, even when adjusting for individual-level factors known to affect mental health and wellbeing.