Abstract
This study compares health-related quality of life between US transgender and cisgender adults using data from the largest nationwide health survey to date to address transgender health.
The National Institutes of Health has prioritized research into disparities affecting the transgender population. An important domain in disparities research is health-related quality of life (HRQOL), which reflects the burden of chronic and acute physical and mental health conditions as well as unmet health care needs.1 Historically, a lack of routine, standardized data collection has hindered explorations of transgender population health and HRQOL. In 2014, however, the Centers for Disease Control and Prevention (CDC) introduced an optional Sexual Orientation and Gender Identity module for the Behavioral Risk Factor Surveillance System (BRFSS). In 2014 through 2017, 36 states and territories representing almost 75% of the US population used the module at least once. This study compared HRQOL between transgender and cisgender adults in this rare probability sample of the transgender population.
Methods
The BRFSS is the largest continuously operating health survey in the world and is fielded annually by every state. The Sexual Orientation and Gender Identity module includes a question that asks, “Do you consider yourself to be transgender?” with the following primary answer options: (1) yes, transgender, male to female; (2) yes, transgender, female to male; (3) yes, transgender, gender nonconforming; and (4) no. Gender identity in the pooled 2014 through 2017 BRFSS data set was classified as transgender (response options 1-3; 3075 responses) and cisgender (response option 4; 719 484 responses). Respondents who answered “don’t know/not sure” (response option 7; n = 3799) or refused to answer (n = 5800) were excluded. The need for study approval was waived by the Johns Hopkins School of Public Health Institutional Review Board. Informed consent was not applicable to this study because it is based on publicly available data from the CDC.
A core component of the BRFSS is a standard 4-item set of Healthy Days questions, which constitute the CDC HRQOL-4 measure. These items are (1) self-reported health and, of the past 30 days, the number of days that the respondent (2) felt physically unhealthy, (3) felt mentally unhealthy, and (4) limited usual activities. Following CDC recommendations,2 results of the HRQOL-4 are reported in this analysis as (1) fair or poor health; (2) severe mental distress, defined as 14 or more mentally unhealthy days in the previous 30 days; (3) mean combined physically and mentally unhealthy days; and (4) mean activity-limited days.
Descriptive bivariate comparisons of transgender and cisgender adults were performed using design-corrected F tests. Logistic and zero-inflated negative binomial regression models were estimated for dichotomous and count outcomes, respectively. All models were adjusted for state and, following earlier literature,3 sociodemographic factors and chronic health conditions. All analyses were performed in Stata, version 14 (StataCorp LP) and weighted to account for the BRFSS complex survey design. Variances were scaled to account for strata with single sampling units. Statistical significance was set at 2-sided P = .05.
Results
Transgender individuals comprised an estimated 0.55% (95% CI, 0.51%-0.59%) of the sample, which is equivalent to 1.27 million transgender adults in the general US population. Compared with cisgender adults, more transgender adults reported current cigarette use (19.2% vs 16.3%; P = .04) and physical inactivity (35.0% vs 25.6%; P < .001), and fewer reported having health insurance coverage (79.9% vs 85.4%; P = .001) (Table 1).
Table 1. Characteristics of US Transgender and Cisgender Adults.
| Characteristic | No. (%)a | P Valueb | |
|---|---|---|---|
| Transgender (n = 3075) | Cisgender (n = 719 567) | ||
| Sociodemographic Characteristics | |||
| Age, y | |||
| 18-24 | 314 (21.7) | 36 636 (11.8) | <.001 |
| 25-34 | 349 (15.4) | 65 595 (15.9) | |
| 35-44 | 335 (14.2) | 81 132 (16.1) | |
| 45-54 | 508 (15.0) | 118 056 (17.6) | |
| 55-64 | 676 (16.5) | 164 436 (17.5) | |
| ≥65 | 893 (17.3) | 253 712 (21.2) | |
| Race/ethnicity | |||
| White, non-Hispanic | 2066 (55.4) | 557 261 (63.3) | <.001 |
| Black, non-Hispanic | 317 (16.1) | 53 098 (11.5) | |
| Asian, Native Hawaiian, or Pacific Islander | 144 (5.0) | 24 258 (5.6) | |
| Other, non-Hispanic | 188 (4.6) | 27 745 (2.6) | |
| Hispanic | 298 (18.9) | 46 435 (16.9) | |
| Educational level | |||
| Did not graduate high school | 438 (20.6) | 51 219 (14.0) | <.001 |
| Graduated high school | 1116 (32.9) | 199 671 (28.0) | |
| Some college or technical school | 833 (32.3) | 195 514 (31.3) | |
| Graduated college or technical school | 674 (14.2) | 271 289 (26.7) | |
| Employment | |||
| Employedc | 1376 (50.3) | 358 026 (56.6) | <.001 |
| Unemployed | 210 (8.4) | 29 902 (5.6) | |
| Homemaker, student, or retired | 1064 (29.2) | 276 553 (30.9) | |
| Unable to work | 397 (12.1) | 50 995 (6.9) | |
| Annual income, $ | |||
| <15 000 | 471 (17.0) | 59 455 (10.9) | <.001 |
| 15 000-24 999 | 606 (21.8) | 99 481 (16.5) | |
| 25 000-34 999 | 330 (13.3) | 66 724 (10.5) | |
| 35 000-49 999 | 355 (10.6) | 88 833 (13.6) | |
| 50 000-74 999 | 337 (12.6) | 100 047 (14.9) | |
| ≥75 000 | 535 (24.7) | 202 610 (33.5) | |
| Home ownership | |||
| Own | 1797 (55.0) | 521 886 (68.3) | <.001 |
| Rent | 1054 (35.1) | 162 721 (26.2) | |
| Other arrangement | 211 (9.9) | 31 173 (5.5) | |
| Marital status | |||
| Married or coupled | 1425 (46.5) | 398 808 (56.1) | <.001 |
| Divorced, separated, or widowed | 885 (20.6) | 205 943 (20.7) | |
| Never married | 747 (32.9) | 111 145 (23.2) | |
| Child aged <18 y in household | 740 (32.0) | 185 860 (36.8) | .02 |
| Veteran | 446 (11.8) | 93 017 (10.4) | .25 |
| Sexual orientation | |||
| Heterosexual | 2241 (68.7) | 681 569 (95.9) | <.001 |
| Lesbian or gay | 203 (9.6) | 10 137 (1.7) | |
| Bisexual | 365 (15.2) | 10 808 (2.0) | |
| Other | 130 (6.5) | 2598 (0.4) | |
| Health Risk Factors | |||
| Alcohol use | |||
| None | 1666 (58.4) | 336 302 (47.6) | <.001 |
| Light to moderated | 825 (24.8) | 262 535 (34.6) | |
| ≥1 Episode of binge drinking (≥4 drinks at 1 time) in past 30 d | 475 (16.8) | 101 469 (17.8) | |
| Cigarette use | |||
| Never or past | 2441 (80.9) | 608 230 (83.7) | .04 |
| Current | 608 (19.2) | 105 923 (16.3) | |
| No physical exercise in past 30 d | 984 (35.0) | 185 236 (25.6) | <.001 |
| Health care access | |||
| Insurancee | 1818 (79.9) | 411 946 (85.4) | .001 |
| Regular provider | 2502 (75.9) | 616 442 (79.0) | .08 |
| Checkup in past year | 2270 (73.0) | 540 135 (71.1) | .29 |
| Financial barrier to care | 448 (19.1) | 69 396 (13.1) | <.001 |
| Health conditions | |||
| No chronic conditionsf | 1316 (54.6) | 307 002 (52.4) | .11 |
| 1 Chronic condition | 806 (23.1) | 210 160 (26.5) | |
| ≥2 Chronic conditions | 953 (22.3) | 202 303 (21.0) | |
| Ever diagnosed with depression | 865 (29.4) | 135 637 (18.1) | <.001 |
Numbers are raw frequencies; percentages are calculated using design weights.
P values reflect design-corrected F tests for differences between the weighted proportions of transgender and cisgender respondents.
Employed indicates for wages or self-employed.
Light to moderate alcohol use was defined as 1 to 3 drinks maximum at any time in the past 30 days.
Insurance data are given only for individuals younger than 65 years.
Chronic conditions were defined as having ever received a diagnosis of angina, arthritis, asthma, cancer, chronic obstructive pulmonary disease, coronary heart disease, diabetes, or chronic kidney disease or having a history of myocardial infarction or stroke.
Transgender adults were more likely to report diminished HRQOL in the previous 30 days as measured by greater odds of fair or poor health (adjusted odds ratio [AOR], 1.30; 95% CI, 1.03-1.62; P = .02) or severe mental distress (AOR, 1.66; 95% CI, 1.36-2.01; P < .001) (Table 2). They also reported more days of combined poor physical and mental health (adjusted mean [SE] difference: 1.20 [0.04] days; P < .001) and of activity limitation (1.34 [0.09] days; P < .001).
Table 2. Health-Related Quality of Life by Gender Identitya.
| Health-Related Quality of Life | Transgender (n = 3075) | Cisgender (n = 719 567) | Unadjusted OR (95% CI) or Unadjusted Mean Difference (SE) | P Valueb | AOR (95% CI) or Adjusted Mean Difference (SE) | P Valueb |
|---|---|---|---|---|---|---|
| Fair or poor health, No. (%)c | 819 (24.5) | 132 486 (18.2) | 1.46 (1.21-1.75) | <.001 | 1.30 (1.03-1.62) | .02 |
| Severe mental distress in last 30 d, No. (%)c | 566 (20.3) | 73 396 (11.6) | 1.94 (1.61-2.34) | <.001 | 1.66 (1.36-2.01) | <.001 |
| Total mentally and physically unhealthy days in past 30 d | 9.40 (0.46)d | 6.57 (0.03)d | 2.83 (0.46)e | <.001 | 1.20 (0.04)f | <.001 |
| Activity-limited days in past 30 d | 4.53 (0.37)d | 2.57 (0.02)d | 1.96 (0.37)e | <.001 | 1.34 (0.09)f | <.001 |
Abbreviations: AOR, adjusted odds ratio; OR, odds ratio.
Data are based on answers to the standard 4-item set of Healthy Days questions in the Behavioral Risk Factor Surveillance System. The questions are listed in the Methods section. All analyses were adjusted for number of multiple chronic conditions, race/ethnicity, age, marital status, educational level, and state.
P values reflect weighted data analyses.
Numbers are raw frequencies; percentages were calculated using design weights.
Unadjusted mean (SE).
Unadjusted mean difference (SE).
Adjusted mean difference (SE) (weighted zero-inflated negative binomial regression coefficient).
Discussion
This analysis confirms the findings of previous studies that have identified severe health and HRQOL disparities affecting the transgender population.4,5 These disparities require informed attention from clinicians and policy makers and further investigation by researchers. Until all states and territories field the BRFSS Sexual Orientation and Gender Module, however, the generalizability of the findings in this study remains limited. Given ongoing nationwide debates about public accommodations access, nondiscrimination protections, and other issues that influence transgender health,6 all states and territories should field the module to facilitate research that draws on fully representative samples of the US transgender population. Furthermore, future analyses should investigate differences within the transgender population by factors such as gender, race/ethnicity, and sexual orientation.
References
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