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The Journals of Gerontology Series B: Psychological Sciences and Social Sciences logoLink to The Journals of Gerontology Series B: Psychological Sciences and Social Sciences
. 2023 Jan 23;78(6):1051–1059. doi: 10.1093/geronb/gbad012

Transgender Adults From Minoritized Ethnoracial Groups in the U.S. Report Greater Subjective Cognitive Decline

Ethan C Cicero 1,✉, Elle Lett 2,3, Jason D Flatt 4, G Perusi Benson 5, Fayron Epps 6
PMCID: PMC10214655  PMID: 36688593

Abstract

Objectives

Investigate subjective cognitive decline (SCD) among 4 study groups consisting of cisgender and transgender adults who are from minoritized ethnoracial groups (i.e., minoritized ethnoracial transgender, minoritized ethnoracial cisgender) and White cisgender and transgender adults aged 45+ (i.e., White transgender, White cisgender) to determine the odds of SCD by group and to test for group differences.

Methods

Data from the 2015–2020 Behavioral Risk Factor Surveillance System were used in a modified case–control approach to perform an intercategorical intersectional study. Each transgender participant was matched to 2 cisgender men and 2 cisgender women, on state, ethnoracial identity, and age. Multivariable logistic regressions modeled SCD odds by group and post hoc contrasts estimated pairwise odds ratios comparing the SCD odds for each combination of groups.

Results

SCD prevalence was highest among minoritized ethnoracial transgender (21.6%), followed by White transgender (15.0%), minoritized ethnoracial cisgender (12.0%), and White cisgender (9.0%). After accounting for age, education, and survey year, the odds of SCD were higher in minoritized ethnoracial transgender when compared to White cisgender (adjusted odds ratio [aOR] = 2.51, 95% confidence interval [CI]: 1.59–3.96) and minoritized ethnoracial cisgender (aOR = 1.89, 95% CI: 1.16–3.09). The odds of SCD were higher in White transgender compared to White cisgender (aOR = 1.66, 95% CI: 1.20–2.30).

Discussion

When considering the intersection of transgender and ethnoracial identities, we found that transgender adults from minoritized ethnoracial groups reported higher odds of SCD when compared to cisgender adults from minoritized ethnoracial groups. Additional studies are needed to understand the relationship between racialized and gendered inequities in cognitive impairment and how specific mechanisms of systemic transphobia and racism may contribute to this inequity.

Keywords: Cultural factors, Gender, Minority aging (Race/ethnicity), Transgender

Over 6.5 million adults are living with Alzheimer’s disease and related dementias (ADRD) in the United States, and this number is expected to climb to nearly 14 million by 2060 (Alzheimer’s Association, 2022; Rajan et al., 2021). However, little is known about the prevalence and risk of ADRD among transgender adults, as most existing ADRD research was not designed to identify transgender research participants (Flatt et al., 2022). The transgender population represents a sizable and growing population (National Academies of Sciences Engineering and Medicine [NASEM], 2020). It is composed of heterogeneous subgroups of individuals whose gender identity or expression differs from the sex assigned to them at birth (NASEM, 2020). Here, we employ an inclusive definition of “transgender,” encompassing both transbinary individuals, or those who self-identify within the gender binary (e.g., transgender woman and transgender men), as well as those who exist along or outside of the binary gender spectrum (e.g., gender nonconforming, nonbinary; Kronk et al., 2022). Although the risk of ADRD among transgender adults is unknown, two studies found transgender adults had a higher prevalence of ADRD compared to cisgender adults. Using 2015 Medicare claims data, Dragon et al. (2017) discovered transgender adults aged 65+ had a higher prevalence of dementia compared to cisgender adults (18% vs 12%). Researchers examining electronic health records and claims data between January 2012 and July 31, 2020, from the OneFlorida clinical research network (transgender, n = 1,784; cisgender, n = 35,285) found transgender adults had a significantly higher prevalence of ADRD compared to cisgender controls, both overall (1.7% vs 0.8%; p < .001) and in adults aged 18–49 years (1.1% vs 0.3%; p < .001; Guo et al., 2022). Across the life span, transgender people are disproportionately affected by health disparities that are considered risk factors for ADRD in cisgender populations (e.g., cardiovascular disease, diabetes, social isolation, and lower educational attainment; Livingston et al., 2020; NASEM, 2020).

Black or African American and Hispanic or Latino/a/x older adults are disproportionately affected by ADRD with prevalence rates among these communities estimated at nearly double that of White older adults (Alzheimer’s Association, 2022). Physiological and biological consequences stemming from chronic exposure to systematic racism, oppression, and discrimination likely contribute to the disproportionate burden of ADRD among Black and Hispanic Americans (Barnes, 2022; Hill et al., 2015). A growing body of research indicates that higher levels of psychosocial stressors, particularly discrimination, are associated with an increased risk of memory impairment and ADRD in Black older adults and other minoritized communities (Barnes et al., 2012; Han et al., 2021; Lambrou et al., 2022; Shankar & Hinds, 2017; Sutin et al., 2020; Turner et al., 2017; Zahodne et al., 2020). In fact, a recently published study found that transgender adults who experienced transgender-related discrimination within a healthcare environment had 7.5 times greater odds of reporting poor/fair memory and 4.5 times greater odds of worsening memory over the past year than transgender adults who did not experience healthcare discrimination (Lambrou et al., 2022).

Studies examining subjective cognitive decline (SCD), a self-reported experience of worsening or more frequent confusion or memory loss, can illuminate the early stages and initial clinical manifestations of ADRD (Livingston et al., 2020). Similar to the burden of ADRD, Black and Hispanic adults are more likely to experience SCD compared to White adults, and members in these minoritized ethnoracial groups report SCD at an earlier age (Gupta, 2021; Taylor et al., 2018). To our knowledge, two studies provide a glimpse into the memory complaints of transgender adults of all sexual orientations (Flatt et al., 2021; Lambrou et al., 2022). Across both studies, the prevalence of memory complaints endorsed by transgender adults was higher when compared to cisgender sexual minority adults (15.8% vs 11.9% [Lambrou et al., 2022] and 17.3% vs 11.2%–16.8% [Flatt et al., 2021]) and cisgender heterosexual adults (17.3% vs 10.4%–10.7% [Flatt et al., 2021]). Numerous studies reported lesbian, gay, bisexual, and transgender (LGBT) adults having higher SCD prevalence rates compared to non-LGBT adults, but findings were not always disaggregated to elucidate the memory or cognitive complaints of transgender adults or to illuminate the extent of inequities across racial substrata (Brown & Patterson, 2020; Flatt et al., 2018; Flatt et al., 2021; Fredriksen-Goldsen et al., 2018). Although sexual minority and transgender adults experience systemic oppression and stigma due to their identity, transgender adults experience worse health outcomes, poorer social position, and greater ADRD-related health disparities (NASEM, 2020). Moreover, transgender adults from minoritized ethnoracial groups (e.g., Black, Indigenous, Asian, Pacific Islander, Hispanic, and/or Latino/a/x adults) often experience greater health and social inequities than their White counterparts (Lett et al., 2020, 2021).

To date, no study has examined SCD or ADRD among transgender adults from minoritized ethnoracial groups. The health and social inequities experienced by transgender adults from minoritized ethnoracial groups are linked to an increased risk of cognitive impairment in cisgender and transgender adults (Alzheimer’s Association, 2022; Lambrou et al., 2022; Livingston et al., 2020). By employing an intersectional lens, this study investigated SCD among four study groups consisting of cisgender and transgender adults who are from minoritized ethnoracial groups (i.e., minoritized ethnoracial transgender, minoritized ethnoracial cisgender) and White cisgender and transgender adults aged 45+ (i.e., White transgender, White cisgender) to determine the odds of SCD by group and to test for group differences.

Theoretical Framework

Intersectionality is a theoretical framework and analytical tool with roots in Black feminism (Bowleg, 2012, 2020). The term was originated by Kimberlé Crenshaw (Crenshaw, 1989), with foundational work establishing the framework from Crenshaw and Patricia Hill Collins (Collins, 2002; Crenshaw, 1991). Intersectionality situates the individual within interacting and overlapping social structural systems. These systems include systemic racism and White supremacy, ableism, transmisogyny, and others that result in accumulated, unearned privilege (i.e., White privilege) for some members of society at the expense of oppression and exclusion of others (Lett et al., 2022; Nixon, 2019). Intersectionality is increasingly recognized as a critical tool in studying health inequity and has been applied to many studies in transgender health (Lett et al., 2020, 2021). In this study, we use intersectionality to specifically interrogate how systemic racism and transmisogyny may contribute to greater odds of SCD among transgender adults from minoritized ethnoracial groups when compared to cisgender and transgender adults with a higher social position.

Method

We used pooled data from the 2015–2020 Behavioral Risk Factor Surveillance System (BRFSS), the largest continuously conducted health survey in the United States. BRFSS is an annual cross-sectional telephone survey conducted by the U.S. Centers for Disease Control and Prevention and implemented in all states and participating U.S. territories. At the state and territory level, data are collected on the health and health behaviors of noninstitutionalized adults residing in the United States who are aged 18 years or older. BRFSS interviews began with a core set of standardized questions and were followed by optional modules and state-added questions. Beginning in 2014, an optional module assessing sexual orientation and gender identity was available for use, and in 2015, as part of the Healthy Brain Initiative (Centers for Disease Control and Prevention, 2020), an optional module assessing SCD and its associated social and self-care effects among adults aged 45+ was made available. BRFSS participants aged 45+ were able to endorse SCD by affirming that during the past 12 months, they experienced confusion or memory loss that was happening more often or was getting worse (Olivari et al., 2021). We include data from the 38 U.S. states that assessed SCD and gender identity, to allow us to characterize SCD in transgender adults and compare to cisgender adults. This secondary analysis of publicly available, de-identified data met the criteria for exemption and did not require submission to an institutional review board.

We used a modified case–control approach where we matched transgender BRFSS participants to presumed cisgender participants, consistent with previous studies of transgender populations using BRFSS data (Cicero et al., 2020a; Lett et al., 2020, 2021). This approach is also recommended over using BRFSS design-weighted analyses to obtain, presumably, nationally representative estimates because these estimates are potentially biased in transgender populations due to problematic BRFSS sampling methodology (Cicero et al., 2020a; Lett & Everhart, 2022). Our study cohort was a 1:4 matched sample built by matching each transgender participant to two presumed cisgender men and two presumed cisgender women, on state, self-reported ethnoracial identity, and age (±2 years). This created a cisgender comparison sample with similar age and ethnoracial group distributions, by state, to the corresponding transgender sample. Participants in our transgender sample answered “yes” to “Do you consider yourself to be transgender?” and if affirmed, were asked, “Do you consider yourself to be male-to-female, female-to-male, or gender nonconforming?” Participants who answered “no” to being transgender were categorized as cisgender. Cisgender men endorsed a male sex at birth and cisgender women endorsed a female sex distinction. BRFSS participants were able to self-identify their ethnoracial identity(s) by providing responses to two survey items, “Are you Hispanic, Latino/a, or Spanish origin?” and “Which one or more of the following would you say is your race?” Because of the sparsity of specific gender identity–ethnoracial identity cells, we collapsed gender and ethnoracial identities into binary variables and cross-stratified them to create our study groups. For gender identity, we grouped all transgender subgroups into one transgender group, and cisgender women and men, into the cisgender study group. We collapsed all groups from minoritized backgrounds (i.e., groups that are made vulnerable by systemic racism) into a minoritized ethnoracial group. This leads to four study groups of adults aged 45+: minoritized ethnoracial transgender, White transgender, minoritized ethnoracial cisgender, and White cisgender.

For demographic measures, this study accounted for age, education, and BRFSS survey year in our adjusted models. In addition to ethnoracial and gender identity, we included sexual orientation, employment, and annual income to describe our sample (Table 1). BRFSS participants self-reported their age in years; highest grade or year of school completed; current employment status from the following options: employed for wages, self-employed, out of work for 1 year or more, out of work for less than 1 year, a homemaker, a student, retired, unable to work; annual household income from all sources; and indicated their sexual orientation as straight, lesbian or gay, bisexual, other, or don’t know/not sure.

Table 1.

Sample Demographics and Prevalence of SCD by Study Group

Demographic Minoritized ethnoracial transgender (N = 218) White transgender (N = 672) Minoritized ethnoracial cisgender (N = 872) White cisgender (N = 2,688)
Age, mean (SD)a 61.73 (10.60) 64.15 (10.24) 61.74 (10.57) 64.15 (10.23)
Age, median (range) 61 (45–80) 64 (45–80) 61 (45–80) 64 (45–80)
Ethnoracial identity, N (%)a
 American Indian or Alaska native 9 (4.1) — 36 (4.1) —
 Asian 31 (14.2) — 124 (14.2) —
 Black 87 (39.9) — 348 (39.9) —
 Hispanic 52 (23.9) — 208 (23.9) —
 Other race or multiracial 39 (17.9) — 156 (17.9) —
 White — 672 (100.0) — 2,688 (100.0)
Gender identity, N (%)a
 Transgender woman 100 (45.9) 323 (48.1) — —
 Transgender man 67 (30.7) 225 (33.5) — —
 Gender nonconforming 51 (23.4) 124 (18.5) — —
 Cisgender woman — — 436 (50.0) 1,344 (0.0)
 Cisgender man — — 436 (50.0) 1,344 (50.0)
Sexual orientation, N (%)
 Lesbian or gay 14 (6.4) 40 (6.0) 11 (1.3) 34 (1.3)
 Bisexual 19 (8.7) 51 (7.6) 14 (1.6) 21 (0.8)
 Straight 151 (69.3) 524 (78.0) 788 (90.4) 2,581 (96.0)
 Something else 23 (10.6) 42 (6.2) 8 (0.9) 13 (0.5)
 Missing 11 (5.0) 15 (2.2) 51 (5.8) 39 (1.5)
Education, N (%)
 Less than a high school diploma 46 (21.1) 80 (11.9) 124 (14.2) 152 (5.7)
 High school diploma or GED 70 (32.1) 260 (38.7) 255 (29.2) 755 (28.1)
 Some college or technical school 53 (24.3) 165 (24.6) 222 (25.5) 754 (28.1)
 College graduate 48 (22.0) 162 (24.1) 268 (30.7) 1,021 (38.0)
 Missing 1 (0.5) 5 (0.7) 3 (0.3) 6 (0.2)
Employment, N (%)
 Employed/self-employed/student 72 (33.0) 240 (35.7) 370 (42.4) 1153 (42.9)
 Homemaker/retired 84 (38.5) 305 (45.4) 321 (36.8) 1,237 (46.0)
 Unemployed/unable to work 59 (27.1) 125 (18.6) 173 (19.8) 289 (10.8)
 Missing 3 (1.4) 2 (0.3) 8 (0.9) 9 (0.3)
Annual income, N (%)
 <$20,000 71 (32.6) 127 (18.9) 205 (23.5) 309 (11.5)
 $20,000–$50,000 71 (32.6) 222 (33.0) 268 (30.7) 715 (26.6)
 >$50,000 55 (25.2) 209 (31.1) 280 (32.1) 1,247 (46.4)
 Missing 21 (9.6) 114 (17.0) 119 (13.6) 417 (15.5)
Subjective cognitive decline, N (%) 47 (21.6) 101 (15.0) 105 (12.0) 242 (9.0)
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Notes: For data transparency, we report missingness for each variable. Pooled BRFSS data represents 38 U.S. states that utilized the gender identity and SCD optional modules (i.e., AK, AR, CA, CO, CT, DE, FL, GE, HA, ID, IL, IN, IA, KS, KY LA, MD, MA, MI, MN, MS, MO, NV, NY, NC, OH, OK, PA, RI, SC, TN, TX, UT, VT, VA, WA, WV, WI). BRFSS = Behavioral Risk Factor Surveillance System; GED = General Education Development; SCD = subjective cognitive decline.

aThe distribution of age and gender and ethnoracial identity in the cisgender comparison groups are determined by the transgender groups due to matching on these variables.

Statistical Analysis

With the matched sample, we performed an intercategorical intersectional study (McCall, 2005) that specifically compared the odds of SCD across the axes of gender and ethnoracial identities as proxy measures of exposure to transmisogyny and systemic racism, respectively. We used multivariable logistic regression to model the odds of SCD by group. We did not choose a reference category and instead, performed an intercept-free analysis with each study group included as separate indicator variables (Cicero et al., 2020b). With this definition, the parameter estimates corresponding to each level of study group can be interpreted as the group’s departure from the overall cohort log odds of SCD. When the categorical variable for study group was statistically significant (e.g., the likelihood test that the four parameter estimates corresponding to each category are nonzero), we used post hoc contrasts to estimate pairwise odds ratios comparing the odds of SCD for each combination of groups. We took this approach in lieu of the more common practice of defaulting to treating cisgender White as the reference group. We feel that such an approach implies that cisgender and White are the norm and implicitly “otherizing” or making abnormal, individuals outside of those categories—a manifestation of White supremacy and cisnormativity in regular research practices, that we seek to upend (Lett et al., 2022). We report crude and adjusted odds ratios (cOR, aOR) and 95% confidence intervals (CI) for all regression analyses. We also present a cross-tabulation of counts and percentages of transgender adults endorsing SCD by disaggregated ethnoracial and gender identities to avoid sample size-driven exclusion of underrepresented communities. We used the Matching R package (Sekhon, 2011) for matching, and conducted all statistical analyses in R Version 4.0.2 (R Core Team, 2016).

Results

BRFSS data included 906 transgender participants from 38 states who provided a response to the SCD measure. After matching, our analytic sample included 890 transgender adults, each matched to two cisgender men and two cisgender women, on state, ethnoracial identity, and age. Sixteen transgender individuals could not be matched to two cisgender men and two cisgender women and were dropped. Sample demographics by study group are shown in Table 1.

SCD prevalence was highest among minoritized ethnoracial transgender (21.6%), followed by White transgender (15.0%), minoritized ethnoracial cisgender (12.0%), and White cisgender (9.0%; Table 1). Among our transgender cohort, SCD prevalence varied by ethnoracial group and gender identity (Table 2). American Indian or Alaska native (33.3%), Hispanic (28.8%), and Black (21.8%) transgender participants had the highest SCD prevalence by ethnoracial group. When considering gender identity, gender nonconforming participants (21.1%) had the highest SCD prevalence, whereas transgender men (14.0%) had the lowest. At the intersection of ethnoracial group and gender identity, SCD was most endorsed by American Indian or Alaska native and Hispanic transgender men (50.0% and 42.9%, respectively) and American Indian or Alaska native and Hispanic gender nonconforming participants (33.3% and 28.6%, respectively).

Table 2.

Subjective Cognitive Decline by Ethnoracial Group and Gender Identity, N (%)

Ethnoracial group All transgender Transgender women Transgender men Gender nonconforming
American Indian or Alaska native 3 (33.3) 0 (0.0) 2 (50.0) 1 (33.3)
Asian 4 (12.9) 2 (15.4) 1 (9.1) 1 (14.3)
Black 19 (21.8) 11 (23.9) 6 (23.1) 2 (13.3)
Hispanic 15 (28.8) 5 (20.8) 6 (42.9) 4 (28.6)
Other race/multiracial 6 (15.4) 3 (20.0) 1 (8.3) 2 (16.7)
White 101 (15.0) 49 (15.2) 25 (11.1) 27 (21.8)
All ethnoracial groups 148 (16.6) 70 (16.5) 41 (14.0) 37 (21.1)
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Notes: Depicted are count and cell percent (i.e., the percent of participants who have both the gender and ethnoracial identity corresponding to a cell and endorse subjective cognitive decline among all participants who share both identities). Denominators for each cell vary and are not shown to avoid clutter but are reflected in the percentages. For example, for the cell of all transgender individuals from all ethnoracial groups (N = 151) and 16.7% SCD implies the denominator of that cell (total number of transgender individuals in the study) is 906 (151/906 = 0.167). All BRFSS transgender participants with SCD data are included in this table, which represents the prematched analytic sample. BRFSS = Behavioral Risk Factor Surveillance System; SCD = subjective cognitive decline.

Study group was a significant predictor of SCD within the crude and adjusted models. Post hoc pairwise contrasts of the groups (Table 3) indicated that after accounting for age, education, and BRFSS survey year, the odds of SCD were significantly higher in minoritized ethnoracial transgender when compared to White cisgender (aOR = 2.51, 95% CI: 1.59–3.96) and minoritized ethnoracial cisgender (aOR = 1.89, 95% CI: 1.16–3.09). Additionally, the odds of SCD were significantly higher in White transgender compared to White cisgender (aOR = 1.66, 95% CI: 1.20–2.30). There were no other significant contracts among the remaining pairwise study group comparisons.

Table 3.

Pairwise Contrasts of Odds of SCD by Study Group

Pairwise contrasts cOR (95% CI) aOR (95% CI)
Minoritized ethnoracial transgender versus White cisgender 2.78 (1.79–4.32) 2.51 (1.59–3.96)
Minoritized ethnoracial transgender versus minoritized ethnoracial cisgender 2.01 (1.24–3.26) 1.89 (1.16–3.09)
Minoritized ethnoracial transgender versus White transgender 1.55 (0.95–2.53) 1.51 (0.92–2.49)
White transgender versus White cisgender 1.79 (1.30–2.45) 1.66 (1.20–2.30)
White transgender versus minoritized ethnoracial cisgender 1.29 (0.89–1.88) 1.25 (0.85–1.83)
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Notes: aOR = adjusted odds ratio; BRFSS = Behavioral Risk Factor Surveillance System; CI = confidence interval; cOR = crude odds ratio; SCD = subjective cognitive decline. Transgender participants were matched to two cisgender men, and two cisgender women on age (±2 years), ethnoracial identity, and state. Adjusted logistic regression models account for age, education, and BRFSS survey year. All CIs that do not span 1 are statistically significant at the type I error rate of ɑ = 0.05.

Discussion

To our knowledge, this is the first study that used an intercategorical intersectional analytic approach to specifically interrogate how systemic racism and transmisogyny may contribute to a greater odds of SCD among transgender individuals from minoritized ethnoracial groups when compared to cisgender and transgender individuals with a higher social position (i.e., benefiting from White privilege). Our findings suggest that SCD prevalence was highest among transgender adults from minoritized ethnoracial groups, nearly 1.8 times greater than the prevalence of SCD among cisgender adults from minoritized ethnoracial groups in our sample (21.6% vs 12%). After accounting for age, education, and BRFSS survey year, the odds of SCD among transgender adults from minoritized ethnoracial groups were nearly double that of cisgender adults from minoritized ethnoracial groups (aOR = 1.89, 95% CI: 1.16–3.09), a population disproportionately affected by ADRD. Our findings are aligned with prior research that found higher prevalence rates for transgender adults when compared to cisgender adults (Dragon et al., 2017; Guo et al., 2022). However, these studies did not examine SCD at the intersection of ethnoracial group and gender identity.

In addition to being an analytical framework, intersectionality provides an interpretive framework we can use to unpack our findings (Bowleg, 2012). A core tenet of intersectionality illustrates that the health disparities for populations from multiple historically oppressed groups stem from the disproportionate, social, and structural toll of systems of privilege and oppression (Bowleg, 2008). This principle can help discern our findings that transgender adults from minoritized ethnoracial groups had the highest prevalence of SCD compared to White transgender adults as well as cisgender adults from minoritized ethnoracial groups. Across our study groups, transgender adults from minoritized ethnoracial groups have the lowest social position, now and historically (Johnson, 2013; Lett et al., 2020; Wesp et al., 2019), with members from this group enduring chronic and pervasive systemic racism and transphobia across their life span. These conditions can create disproportionate social inequities that limit opportunities for educational attainment, employment, social engagement, and healthcare access (Cicero & Black, 2016; Cicero et al., 2019; James et al., 2016; Lett et al., 2020; NASEM, 2020); factors that shape health trajectories, accelerate aging, and negatively affect the brain health in other marginalized populations (Barnes et al., 2012; Glymour & Manly, 2008; Juster et al., 2010; Shankar & Hinds, 2017; Sutin et al., 2015; Turner et al., 2017; Zahodne et al., 2020).

Within the transgender population and among the transgender subgroups examined in this study, transgender men may have the most social privilege. This may explain why transgender men had the lowest prevalence of SCD among our study groups. However, when evaluating the prevalence rates of SCD at the intersection of ethnoracial group and gender identity (Table 2), SCD was most endorsed by American Indian or Alaska native and Hispanic transgender men (50.0% and 42.9%, respectively) than other transgender groups from various ethnoracial groups. This finding may be a result of the low sample sizes across ethnoracial groups for BRFSS transgender participants, and it underscores the need to use an intersectional lens to ensure adequate representation of historically excluded and underrepresented communities. By applying an intersectional lens to participant recruitment, sampling approaches would target participants with intersecting identities from historically oppressed and marginalized groups (e.g., Black and Hispanic transgender women) versus employing recruitment strategies that aim to only increase racial or gender diversity among study participants. Greater attention to how intersectional inequalities such as systemic racism, transmisogyny, and transphobia create adverse environments and structural inequities contributing toward poor brain health is needed in future research.

Although we are not certain what may be causing the elevated odds of SCD, we postulate that it may be in part due to systemic racism and societal conditions characterized by anti-transgender stigma and prejudice that expose transgender people from minoritized ethnoracial communities across the life span to high rates of mistreatment, violence, and discrimination where they age, live, work, learn, and seek health care. Discrimination is associated with memory impairment and ADRD in other minoritized groups (Barnes et al., 2012; Han et al., 2021) and in a sample of predominantly White transgender adults (Lambrou et al., 2022), but we do not know how it is related to the cognitive health of transgender adults from minoritized ethnoracial groups. The minority stress model may be a useful framework to explore the underlying mechanisms contributing to elevated odds of SCD among transgender adults, particularly those from minoritized ethnoracial groups (Brooks, 1981; Correro & Nielson, 2020; Forrester et al., 2019; Hendricks & Testa, 2012). The minority stress model posits that in addition to everyday stress, individuals from minoritized communities experience a unique set of distal (e.g., discrimination, microaggressions) and proximal stressors (i.e., appraisals and internalization of distal stressors) related to their social identities that contribute to an increased risk of poor health outcomes. The minority stress model may also be helpful for the examination of how racism and transgender-related discrimination affect caregivers of transgender adults with ADRD or memory impairment. It is possible that the impact of these discriminatory and racist experiences could also affect the health and well-being of family and friends who are from minoritized ethnoracial communities and are also caring for someone living with ADRD or memory impairment (Bonds Johnson et al., 2022; Oliver et al., 2022). Systemic racism and transmisogyny may also affect the caregiver’s ability to provide appropriate care to the care recipient living with ADRD or memory impairment and serve as barriers to accessing the healthcare system (Bonds Johnson et al., 2022; Oliver et al., 2022). Ultimately, the care and support received from family caregivers have the potential to be jeopardized as the result of the systemic racism, transmisogyny, and adverse societal conditions experienced by transgender adults from minoritized ethnoracial communities.

Limitations

This study uses social identities as proxy measures of exposure to systemic discrimination, rather than directly measuring transmisogyny and racism. Therefore, it is possible that our findings do not fully capture the intersectional impact that these forms of discrimination may have on minoritized ethnoracial transgender adults. This study is cross-sectional, precluding the possibility of true causal conclusions, nor does it account for chronic or lifetime exposure to systemic discrimination. Future studies with robust, multilevel measures of systemic discrimination (interpersonal and structural), in a longitudinal framework, will allow for a more precise estimation of the causal effect of systemic discrimination on SCD among transgender adults. It is also important to note that our matched study design constrained the demographic distribution of the cisgender population is, therefore, not optimized for comparisons within the cisgender population, which would be better studied with a different approach not centering the transgender population as we have done here.

Conclusion

When considering the intersection of transgender and ethnoracial identities, we found that transgender adults from minoritized ethnoracial groups reported higher odds of SCD when compared to cisgender adults from minoritized ethnoracial groups. It is important for healthcare providers caring for middle-aged and older transgender adults, particularly those from minoritized ethnoracial groups, to ask their patients about their memory and if they are concerned about any memory issues or confusion. Additional studies are needed to understand the relationship between racialized and gendered inequities in cognitive impairment and how specific mechanisms of systemic transphobia and racism may contribute to this inequity. This understanding is necessary to identify targets for intervention to reduce the disproportionate burden of SCD on transgender adults from minoritized ethnoracial communities, reduce potential ADRD risk among all transgender communities, and improve health and quality of life for this understudied population.

Contributor Information

Ethan C Cicero, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA.

Elle Lett, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Applied Transgender Studies, Chicago, Illinois, USA.

Jason D Flatt, School of Public Health, Department of Social and Behavioral Health Program, University of Nevada, Las Vegas, Nevada, USA.

G Perusi Benson, Department of Psychology, North Carolina State University, Raleigh, North Carolina, USA.

Fayron Epps, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA.

Funding

This work was supported by the National Institute on Aging (K23AG065452, F. Epps; R24AG066599 and K01AG056669, J. D. Flatt). The statements in this article are solely the responsibility of the authors and do not necessarily represent the views of the National Institute on Aging or the National Institutes of Health.

Conflict of Interest

None declared.

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