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.
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.
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).
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.
