Cross-Sectional Analysis of Medical Conditions in the U.S. Deaf Transgender Community

Abstract

Purpose: This first U.S.-based, descriptive study of transgender Deaf adults looks to contribute to the gap in research regarding those who lie at the intersection of Deaf and transgender identities. The study objective is to identify characteristics that associate with medical conditions, including depression and anxiety disorders, among Deaf transgender adults.

Methods: We gathered self-reported data from 74 Deaf transgender adults who used American Sign Language. Modified Poisson regression with robust standard errors was used to calculate relative risk estimates of having a medical condition among nonbinary individuals compared with gender binary individuals.

Results: The sample lifetime prevalence for medical conditions in the Deaf transgender sample were as follows: 48.6% for depression/anxiety disorders, 28.8% for hypertension, 20.3% for lung conditions, 16.2% for arthritis/rheumatism, 12.3% for diabetes, 7.0% for cirrhosis/liver/kidney problems, 5.5% for heart conditions, and 2.7% for cancer. In cross-tabulation analysis across binary and nonbinary subsamples, the lifetime prevalence was significantly different only for depression and anxiety disorder with higher percentage in the nonbinary subsample. After adjusting for covariates in a regression model, identification as nonbinary increased a Deaf person's risk for being diagnosed with depression or anxiety disorder by 80% (95% confidence interval, 1.11–2.90) relative to Deaf people who self-identified as a binary gender.

Conclusion: Study findings suggest that the Deaf transgender community is at risk for developing mental and physical health conditions.

Introduction

The suspected prevalence of mental and physical health disorders remains disproportionately higher in the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community as compared with heterosexual populations.^1–3 While individual identities vary, for the purposes of this article, the term “transgender” includes all forms of gender diverse and gender expansive people, including genderqueer and nonbinary identities. Transgender people—in particular those facing stressors related to ableism, poverty, and racial or ethnic discrimination—are disproportionately overrepresented among those with diagnosed health issues; inflated diagnostic numbers are represented in categories of disorders that include depression, anxiety, suicidality, post-traumatic stress disorder, eating disorders, gender dysphoria, alcoholism, and physical health conditions.^2,4,5 Moreover, research indicates that the aforementioned mental and physical health conditions may be linked to experiences of social stigma, gender-related microaggressions, discrimination, and constricted access to health care resources.^6,7 With specific regard to health care access, studies suggest that transgender people may be less likely than cisgender people to receive adequate health care; similarly, they may be more likely to delay seeking primary care due to past negative experiences with uninformed and biased providers.^8–11

Discrimination, victimization, and limited social support have been identified as risk factors for mental health outcomes specific to depression, anxiety, and self-injurious behaviors in transgender and gender minority populations.^7,12,13 A 2010 study of 91 transgender respondents and 676 cisgender respondents found that self-reported transgender identity was associated with elevated likelihood of experiencing depression symptoms.¹⁴ The same study also concluded that self-acceptance of LGBT identity was associated with lower odds of depression symptomatology.

Transgender people are more likely than cisgender people to experience physical and mental health disorders.^15–17 Studies have indicated that older transgender adults (ages 65 and older) living without social support are at higher risk for poor physical health, chronic illness, and depression compared with younger transgender adults.¹⁸ Known physical health disparities for transgender adults include increased alcoholism, cigarette smoking, obesity, and autoimmune disorder.^15,16,19

Despite mental and physical health disparities seen in transgender populations, there are a number of factors that predict mental wellbeing. An online study of 865 transgender found that having social support was linked to reporting fewer depression and anxiety symptoms.²⁰ Similarly, another study found that peer support from other transgender individuals may mediate the relationship between depression/anxiety and transgender-related stigma.²¹ A recent study concluded that access to a transgender-inclusive primary care provider was one of the strongest indicators for not delaying care and seeking medical interventions.²²

As demonstrated above, research initiatives regarding mental and physical health issues within the transgender population continue to increase. However, there is little research on mental health and health outcomes of transgender people who are Deaf. For the purposes of this article, the term Deaf refers to those who identify as either culturally Deaf or hard-of-hearing, and who use American Sign Language (ASL).²³ The scarcity of research on Deaf transgender people's mental health and health outcomes is a concerning gap given the significantly higher rates of depression and anxiety diagnoses (as told by health care professionals) in 25% of 1704 Deaf adults as compared with 22% of 3287 hearing adults in a cross-tabulation analysis.²⁴ Within the Deaf sample in this study, after controlling for correlates of depression and anxiety, being White, younger, women (regardless of gender assigned at birth), educated, or single were associated with significantly higher likelihood of receiving a depression or anxiety disorder diagnosis from a health care provider. Similarly, a recent study of Deaf mid-to-older adults included comparison of sample subgroups of 178 self-identified LGBTQ and 803 non-LGBTQ adults.²⁵ group disparity was noted in several mental and physical health conditions, that is, self-identification as LGBTQ was found to be significantly associated with higher risk for conditions such as arthritis, depression/anxiety, lung disease/emphysema/asthma/chronic bronchitis, and comorbid disorders.²⁵

Consistent with the general literature on social support as a contributor to LGBTQ population health, the role of social support in fostering health awareness among Deaf LGBTQ people was indicated in a study of 121 Deaf gay, bisexual, and queer men.²⁶ In this study, participants who reported engaging in regular discussion of LGBTQ-related issues online (e.g., through social networking sites) were three times more likely than those not engaging in such discussions to perceive preexposure prophylaxis as being effective in terms of not acquiring HIV. Notably, consistent with general literature linking patient/physician relationships and LGBTQ self-acceptance,²² Deaf LGBTQ adults who reported feeling accepted by loved ones stated they were more likely to disclose their sexual orientation/gender identity to their providers.²⁷ In addition, self-disclosure of sexual orientation/gender identity to provider was also associated with patients' perception of their providers as offering high patient-centered communication care.²⁷

Previous research indicates that rates of depression and anxiety are high in the transgender community.^6,14,28 Similarly, Deaf LGBTQ adults are at disparity for certain medical conditions compared with Deaf non-LGBTQ adults.²⁵ Thus, Deaf transgender populations may be at even greater risk for mental and physical health issues.

This first U.S.-based, descriptive study of transgender Deaf adults looks to contribute to the gap in research regarding those who lie at the intersection of Deaf and transgender identities. The study objective is to identify characteristics that associate with medical conditions, including depression and anxiety disorders, among Deaf transgender adults.

Methods

Survey items and data source

With approval from the Institutional Review Board, data collection for the transgender subgroup occurred between April 2015 and April 2019 as part of a larger, multiyear study that used a bilingual ASL/English online survey.^29,30 Following approval by Gallaudet University's IRB, research staff recruited Deaf adults who were born or became deaf in both ears before 13 years of age (prepuberty stage). Recruitment methods included snowball sampling through personal networks, distribution of flyers, and advertisements on Deaf-centered organizations' websites and e-newsletters. Those who provided consent completed the bilingual ASL/English online survey in ∼1 h. A compensation of $25 was provided to each participant.

Before data collection, health-related items were translated and back translated by Deaf bilingual professionals. The translated measure was then tested for clarity and understanding through interviews with Deaf adults who had a high school education or less.²⁹ The finalized translation was then filmed and included in an online survey that was administered to a nationwide sample of Deaf adults who used ASL. For the purpose of the current study, the following items were included in the analysis: age, race/ethnicity (White, non-White), and education (high school, some college, college graduate). Participants were also asked if they had health insurance coverage and if they saw a doctor regularly in the past 12 months. Sexual orientation and gender identity and medical condition items are described as follows:

• Sexual orientation: What is your sexual orientation?

• Gay

• Lesbian

• Heterosexual

• Bisexual

• Asexual

• Queer

• Other, please specify.

• Gender identity: Are you…

• Male

• Female

• Other, please specify.

• Transgender: Are you transgender?

• Yes

• No

• Medical conditions: Has a doctor or other health professional ever told you that you had any of the following medical conditions:

• Depression or anxiety disorder

• Cancer

• Diabetes

• Hypertension

• Cardiovascular diseases

• Chronic lung disease/asthma/emphysema/chronic bronchitis

• Arthritis/rheumatism

• Cirrhosis/liver/kidney problems

• Stroke

Statistical analyses

Descriptive and cross-tabulation statistics were used to summarize the sample characteristics of Deaf adults identifying as transgender who answered questions relevant to this study. Modified Poisson regression with robust standard errors was used to calculate relative risk estimates. Ninety-five percent confidence intervals (CIs) were used for all medical conditions with the binary/nonbinary group as main predictor, adjusting for age, body mass index, race/ethnicity, education, employment, sex, and regular provider covariates. The modified Poisson approach was recommended for models with binomial outcomes, and the application of robust standard errors helped rectify the overestimation for the relative risk of having a medical condition. The relative risk ratios (RRRs) were used to estimate the relative risks of having a medical condition among nonbinary individuals compared with binary individuals (reference category). Data analyses were conducted using SPSS version 26.

Results

Our U.S. sample consisted of 74 gender minority adults who were born or became Deaf early, with 45% (n=33) falling in the binary subsample and 55% (n=41) falling in the nonbinary subsample. About 23% and 77% self-reported males and females at birth, respectively. The sample mean age was 37 years old (standard deviation=13), but the mean age in the nonbinary subsample was significantly younger than in the binary subsample (Table 1). Over half had a college degree; however, many were not employed at the time of study participation and most were in the low- to middle-income brackets. Also, 66% were not in a partnership. A majority of the participants' parents were hearing. When asked about self-reported ability to understand speech in a quiet room, about 33% could understand all or most of what the hearing person was saying.

Table 1.

Unweighted Sociodemographic Characteristics Across Binary and Nonbinary Groups (n=74)

		Binary		Nonbinary		Statistic
Variables		n*	Mean (SD)	n*	Mean (SD)	F-test; p
Age		41	40.61 (13)	33	31.42 (10)	11.14; <0.001
Variables	Subgroup	n*	%*			Chi-square; p
Sociodemographics
Birth sex						2.54; <0.111
	Male	17	41.5	7	23.3
	Female	24	58.5	23	76.7
Gender identity						73.00; <0.001
	Male	24	58.5	0	0
	Female	17	41.5	0	0
	Genderqueer	0	0	33	100
Sexual orientation						19.58; <0.001
	Heterosexual	19	50.0	1	3.1
	Gay/lesbian	10	26.3	12	37.5
	Bisexual/asexual/other	9	23.7	19	59.4
Race/ethnicity						0.72; <0.396
	White	31	75.6	22	66.7
	Non-White	10	24.4	11	33.3
Education						0.51; <0.473
	No college degree	17	41.5	11	33.3
	College degree	24	58.5	22	66.7
Parents' hearing status						0.08; <0.773
	Deaf	13	33.3	11	36.7
	Hearing	26	66.7	19	63.3
Income						3.29; <0.194
	Lower	21	51.2	13	40.6
	Middle	17	41.5	12	37.5
	Upper	3	7.3	7	21.9
Employment						0.75; <0.387
	Employed	19	46.3	12	36.4
	Not employed	22	53.7	21	63.6
Partnership status						0.40; <0.525
	Not in a partnership	27	65.9	24	72.7
	In a partnership	14	34.1	9	27.3

Frequencies not summing to total reflect missing data.

Values in bold indicate statistical significance at p = 0.05.

SD, standard deviation.

Self-identification as bisexual, asexual, or other categories was proportionally higher among nonbinary respondents (59.4% compared with 32.7% in the binary gender subsample). The race/ethnic distribution for the full sample was 72% self-identifying as White and 28% as persons of color (breakdown is not disclosed to protect the confidentiality of the participants). While 87% of the sample had health insurance, about 65% saw a provider regularly. Just over half (54%) used interpreters to communicate with the health care professional that they saw the most, although the interpreter-use trend was relatively higher in the binary subsample than the nonbinary subsample (Table 2). No significant differences between binary and nonbinary groups were observed across body mass index or health insurance.

Table 2.

Unweighted Health Characteristics Across Binary and Nonbinary Groups (n=74)

		Binary		Nonbinary		Statistic
Variables		n*	Mean (SD)	n*	Mean (SD)	F-test; p
Body mass index		41	27.26 (6)	33	26.55(7)	0.25; <0.621
Variables	Subgroup	n*	%*			Chi-square; p
Health
Health insurance						0.06; <0.802
	Yes	35	89.7	29	87.9
	No	4	10.3	4	12.1
Regular provider						4.87; <0.027
	Yes	31	69.5	17	54.8
	No	8	20.5	14	45.2
Communication with provider						0.64; <0.727
	Through interpreter	24	61.5	16	53.3
	English (spoken/written)	12	30.8	12	40.0
	Sign language	3	7.7	2	6.7
Medical condition as told by physician
	Diabetes	5	12.5	4	12.1	0.02; <0.96
	Hypertension/HBP	14	35.0	7	21.2	1.68; <0.195
	Heart condition	3	7.5	1	3.0	0.70; <0.404
	Chronic lung disease/asthma/emphysema/chronic bronchitis	7	17.5	8	25.0	0.61; <0.436
	Arthritis/rheumatism	8	20.0	4	12.1	0.82; <0.366
	Stroke	2	2.7	0	0.0	1.79; <0.181
	Cirrhosis/liver problems or kidney problems	3	7.9	2	6.1	0.09; <0.763
	Cancer	2	5.1	0	0.0	1.74; <0.187
	Depression or anxiety disorder	15	37.5	21	63.6	4.94; <0.026

Frequencies not summing to total reflect missing data.

Values in bold indicate statistical significance at p = 0.05.

HBP, high blood pressure.

The sample lifetime prevalence for medical conditions were as follows: 48.6% for depression/anxiety disorders, 28.8% for hypertension, 20.3% for lung conditions, 16.2% for arthritis/rheumatism, 12.3% for diabetes, 7.0% for cirrhosis/liver/kidney problems, 5.5% for heart conditions, and 2.7% for cancer. When these medical conditions were entered in a cross-tabulation analysis across binary and nonbinary subsamples, the lifetime prevalence was significantly different only for depression and anxiety disorder with higher percentage in the nonbinary subsample (Table 2). After adjusting for covariates in a regression model, identification as nonbinary increased a person's risk for being diagnosed with depression or anxiety disorder by 80% (Table 3: 95% CI, 1.11–2.90) relative to people who self-identified as a binary gender.

Table 3.

Relative Risk Ratio Estimates for Each Medical Condition by Binary/Nonbinary Group

	Binary group
	RRR	95% CI	p
Diabetes	0.83	0.11–6.03	0.85
Hypertension	0.80	0.023–2.78	0.73
Heart condition	0.31	0.07–1.44	0.14
Lung disease	1.63	0.55–4.83	0.38
Cancer	0.15	0.01–1.99	0.15
Arthritis	1.08	0.21–5.55	0.93
Cirrhosis/kidney disease	0.91	0.04–23.13	0.96
Depression/anxiety disorder	1.80	1.11–2.90	0.02

Binary is the reference group.

Values in bold indicate statistical significance at p=0.05.

Adjusted for age, body mass index, race/ethnicity, education, employment, sex, and regular provider status; REF: binary group.

CI, confidence interval; REF, reference; RRR, relative risk ratio.

Discussion

This study is the first to explore the lifetime prevalence of mental health and health conditions in a medically underserved population that lies within the intersection of Deaf and transgender communities in the United States. While additional data will be required to conduct intersectional analyses (i.e., Deaf men and women who are transgender within the Deaf binary group, further racial comparisons), the current study findings provide novel insights into the Deaf transgender community's mental and health outcomes.

Current study findings suggest that the Deaf transgender community is at risk for experiencing mental and physical health conditions. In a comparative study of U.S. Deaf and hearing adults who answered questions about depression or anxiety disorder as told by their health care professionals, the prevalence rate for self-reported mental health diagnosis was 25% in the Deaf U.S. sample that had over 1,500 respondents (Kushalnagar et al., 2019). In the current study of 74 Deaf transgender adults, the prevalence rate for self-reported mental health diagnosis is much higher at 49%. In the general subpopulation of 452 transgender adults in the United States, the lifetime prevalence for depression and anxiety disorders were 47% and 42%, respectively (Reisner and Hughto, 2019).⁷ When this was further divided into binary and nonbinary gender subsamples, the reported rate of being diagnosed with depression or anxiety disorder was proportionally lower in the nonbinary subsample (38% for anxiety; 46% for depression) compared with the binary subsample (48% for anxiety; 45% for depression). Contrary to these findings, the prevalence for anxiety and depression disorders as told by health care professionals within the current sample was 38% for Deaf binary subsample and 64% for Deaf nonbinary sample.

The discrepancy in the lifetime prevalence rates of depression and anxiety disorders between the current Deaf nonbinary sample and Reisner and Hughto's (2019) hearing nonbinary study sample may be explained in part by the language difference. Hearing transgender persons whose primary language is spoken English are able to rely on English-based information dissemination through the community and online media. In contrast, Deaf transgender people who use ASL as their primary language may experience barriers to accessing information and resources that are typically made available in English. This language barrier creates a knowledge gap among affected Deaf individuals who may not have a full understanding or acceptance of nonbinary identities. The ambivalence and uncertainness may contribute to depression or anxiety among Deaf individuals with nonbinary gender identity. To address this disparity, ASL-based resources are needed, including greater educational efforts to increase awareness so to promote self-acceptance of their gender identity and management of their health.

A serious issue facing the Deaf community is the paucity of sign language-fluent mental health professionals. Even fewer professionals are qualified or culturally competent to work with Deaf transgender individuals who may not live in the same region as these professionals. The regional service challenge may be met through telemental health services.³¹ Given that few medical and mental health providers exist with both fluency in ASL, and an awareness of the intersectionality between Deaf Culture and LGBT identity, the impact of our research on increasing tele- and in-person mental health services for this underserved group becomes even more important and necessary.

In conclusion, previous studies have shown that, individually, transgender and Deaf communities are susceptible to increased risks regarding their health. We posit that the same risks that exist for these two separate minority groups compound upon each other, thus contributing to higher rates of health issues within those sampled. When a person holds multiple marginalized identities (e.g., Deaf, Black, and Transgender), this individual may experience compounding chronic stress from prejudice and discrimination, making them vulnerable to chronic diseases. The disparate health outcomes may be a cumulative effect linked to the lack of inclusive and linguistically accessible health resources and Deaf-related and gender-related microaggressions, social stigma, and discrimination.

Limitations

While the current study is the first to reveal insights into the lifetime prevalence of medical conditions in the previously invisible Deaf transgender population, there are several limitations that bear emphasis, including small sample size. The composition of the study sample is driven by self-selection and word-of-mouth recruitment through the close-knit networks of both the transgender and Deaf communities. The resulting small percentage of transgender Deaf individuals from underrepresented groups prevented additional analyses at intersectional levels, which could potentially disclose identity of these Deaf transgender individuals. Results from the binary grouping should be interpreted with caution, given the heterogeneity of multiple gender identities within the binary group. Finally, the transgender-identified sample is overrepresentative of White respondents assigned female at birth. Hearing people who are transgender were not included due to the study focus on the Deaf population. Despite these limitations, the current study provides much-needed data on the lifetime prevalence of medical conditions in the transgender and Deaf communities.

Abbreviations Used

ASL

American Sign Language

CI

confidence interval

HBP

high blood pressure

REF

reference

RRR

relative risk ratio

SD

standard deviation

Author Contributions

K.S., A.L., C.M., & P.K. were responsible for conceptualizing and designing the full study. K.S. and A.L. participated in the linguistic translation of transgender items and assisted with recruitment of transgender and nonbinary-identified individuals. P.K. coordinated data collection and conducted statistical analyses. K.W., C.M., & P.K. drafted a review of the literature. K.S., A.L., O.S., L.D., & P.K. reviewed and interpreted the results. A.L. and O.S. drafted the discussion. All participated in revising the manuscript for content. All give final approval of the published version and are accountable for all aspects of the work related to accuracy and integrity.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Ethics Approval and Consent to Participate

The institutional human subjects Review Board approved the study. All human subjects provided signed consent to participate in the study.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This work was supported by the National Institute on Deafness and Other Communication Disorders (NIDCD) of the National Institutes of Health (R01DC014463-01A1 and R01DC014463-03S1 to P.K.).

Cite this article as: Sanfacon K, Leffers A, Miller C, Stabbe O, DeWindt L, Wagner K, Kushalnagar P (2021) Cross-sectional analysis of medical conditions in the U.S. deaf transgender community, Transgender Health 6:3, 132–138, DOI: 10.1089/trgh.2020.0028.