Association Between Gender Minority Status and Self-Reported Physical and Mental Health in the United States

The National Institutes of Health (NIH) has underscored the need to better understand the health of gender minorities, including transgender and gender-nonconforming individuals.¹ There is a dearth of nationally representative data identifying gender minorities.² In 2013, the Centers for Disease Control and Prevention (CDC) developed³ a gender identity question module for the Behavioral Risk Factors Surveillance System (BRFSS); states had the option to administer this module beginning in 2014. Our study aimed to examine the health status of gender minorities in the United States compared with cisgender (gender identity that corresponds to gender at birth) peers.

The BRFSS is a surveillance system conducted by state health departments in collaboration with the CDC.⁴ Beginning in 2014, respondents could be asked “Do you consider yourself to be transgender?” with the following responses: (1) yes, transgender, male-to-female; (2) yes, transgender, female-to-male; (3) yes, transgender, gender non-conforming; (4) no; (5) don’t know/not sure; and (6) refused to answer. Of individuals completing the gender identity questionnaire (n = 315 893) from the 2014 and 2015 BRFSS, we classified respondents as gender minority (n = 1443) or cisgender (n = 314 450); we excluded those who responded as don’t know/not sure (n = 2084) or refused (n = 2992). Data and analyses were deemed exempt by Brigham and Women’s Hospital institutional review board.

Based on prior literature,² we examined 3 self-reported health outcomes: (1) overall health status; (2) limitation in any way in any activities because of physical, mental, or emotional problems; and (3) serious difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition.

We adjusted for factors drawn from prior literature,² including sociodemographic characteristics, proxies for health care access, health conditions, and health behaviors (alcohol and cigarette use). We categorized alcohol consumption as (1) nonconsumers (less than monthly), (2) rare consumers (≤1 drinks per week but ≥1 drinks per month), (3) moderate consumers (>1 drink per week but not heavy consumers), and (4) heavy consumers (>2 drinks per day for males and >1 drink per day for females).

We used descriptive statistics to characterize the study sample and estimate the prevalence of self-reported health. Bivariable analyses were used to compare sociodemographic characteristics, proxies for health care access, health conditions, and health behaviors across gender categories. We estimated logistic regression models for each outcome to assess differences across gender identity after adjustment. Analyses were performed using SAS, version 9.4 (SAS Institute Inc); data were weighted to reflect estimates representative of the geographic areas studied.

Compared with cisgender adults, gender minority adults were younger, less likely to be non-Hispanic white, married or living with a partner, have a minor child in the household, or be English speaking. Gender minority adults were more likely to have lower income, be unemployed, be uninsured, have unmet medical care due to cost, be overweight, and report depression (Table 1).

In addition, gender minority adults were more likely to report poor or fair health; difficulty concentrating, remembering, or making decisions; and being limited in any way. These outcomes remained significant after adjustment (Table 2).

This study confirms that gender minority adults in the United States experience health disparities compared with their cisgender peers.² However, until all states and territories collect gender identity data, the generalizability of our findings remains limited. Because disparities in outcomes persisted after adjustment, further study is needed to characterize these disparities; research suggests that discrimination toward gender minorities contributes to worse health outcomes.⁵ To begin to eliminate health disparities, all states and territories should administer the CDC-approved module to provide widespread collection of gender identity data using standard, reliable questions.^2,6 Our findings signal to public health professionals and practitioners to pay attention to the health of this vulnerable population.

Accepted for Publication: March 14, 2017.

Corresponding Author: Carl G. Streed Jr, MD, Division of General Internal Medicine, Department of Medicine, Brigham & Women’s Hospital, 1620 Tremont St, Boston, MA 02120 (cstreed@bwh.harvard.edu).

Published Online: May 30, 2017. doi:10.1001/jamainternmed.2017.1460

Author Contributions: Dr Streed had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Streed, Haas.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Streed, McCarthy.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Streed, McCarthy.

Obtained funding: Haas.

Administrative, technical, or material support: McCarthy, Haas.

Supervision: Haas.

Conflict of Interest Disclosures: None reported.