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Table 1.  
Characteristics of US Transgender and Cisgender Adults
Characteristics of US Transgender and Cisgender Adults
Table 2.  
Health-Related Quality of Life by Gender Identitya
Health-Related Quality of Life by Gender Identitya
1.
Moriarty  DG, Zack  MM, Kobau  R.  The Centers for Disease Control and Prevention’s Healthy Days Measures—population tracking of perceived physical and mental health over time.  Health Qual Life Outcomes. 2003;1:37. doi:10.1186/1477-7525-1-37PubMedGoogle ScholarCrossref
2.
Centers for Disease Control and Prevention.  Measuring Healthy Days. Atlanta, GA: CDC; 2000.
3.
Streed  CG  Jr, McCarthy  EP, Haas  JS.  Association between gender minority status and self-reported physical and mental health in the United States.  JAMA Intern Med. 2017;177(8):1210-1212. doi:10.1001/jamainternmed.2017.1460PubMedGoogle ScholarCrossref
4.
Meyer  IH, Brown  TN, Herman  JL, Reisner  SL, Bockting  WO.  Demographic characteristics and health status of transgender adults in select US regions: Behavioral Risk Factor Surveillance System, 2014.  Am J Public Health. 2017;107(4):582-589. doi:10.2105/AJPH.2016.303648PubMedGoogle ScholarCrossref
5.
James  SE, Herman  JL, Rankin  S, Keisling  M, Mottet  L, Anafi  M.  The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016.
6.
Schuster  MA, Reisner  SL, Onorato  SE.  Beyond bathrooms—meeting the health needs of transgender people.  N Engl J Med. 2016;375(2):101-103. doi:10.1056/NEJMp1605912PubMedGoogle ScholarCrossref
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    Research Letter
    April 22, 2019

    Findings From the Behavioral Risk Factor Surveillance System on Health-Related Quality of Life Among US Transgender Adults, 2014-2017

    Author Affiliations
    • 1Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
    JAMA Intern Med. Published online April 22, 2019. doi:10.1001/jamainternmed.2018.7931

    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).

    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).

    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.

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    Article Information

    Accepted for Publication: November 19, 2018.

    Corresponding Author: Kellan E. Baker, MPH, MA, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205 (kbaker39@jhu.edu).

    Published Online: April 22, 2019. doi:10.1001/jamainternmed.2018.7931

    Conflict of Interest Disclosures: None reported.

    References
    1.
    Moriarty  DG, Zack  MM, Kobau  R.  The Centers for Disease Control and Prevention’s Healthy Days Measures—population tracking of perceived physical and mental health over time.  Health Qual Life Outcomes. 2003;1:37. doi:10.1186/1477-7525-1-37PubMedGoogle ScholarCrossref
    2.
    Centers for Disease Control and Prevention.  Measuring Healthy Days. Atlanta, GA: CDC; 2000.
    3.
    Streed  CG  Jr, McCarthy  EP, Haas  JS.  Association between gender minority status and self-reported physical and mental health in the United States.  JAMA Intern Med. 2017;177(8):1210-1212. doi:10.1001/jamainternmed.2017.1460PubMedGoogle ScholarCrossref
    4.
    Meyer  IH, Brown  TN, Herman  JL, Reisner  SL, Bockting  WO.  Demographic characteristics and health status of transgender adults in select US regions: Behavioral Risk Factor Surveillance System, 2014.  Am J Public Health. 2017;107(4):582-589. doi:10.2105/AJPH.2016.303648PubMedGoogle ScholarCrossref
    5.
    James  SE, Herman  JL, Rankin  S, Keisling  M, Mottet  L, Anafi  M.  The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016.
    6.
    Schuster  MA, Reisner  SL, Onorato  SE.  Beyond bathrooms—meeting the health needs of transgender people.  N Engl J Med. 2016;375(2):101-103. doi:10.1056/NEJMp1605912PubMedGoogle ScholarCrossref
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