Looking at Population Health Beyond “Male” and “Female”: Implications of Transgender Identity and Gender Nonconformity for Population Health

Abstract

Looking beyond binary measurements of “male” or “female” can illuminate health inequality patterns that correspond to gender identity rather than biological sex. This study examines disparities in overall health among transgender men, transgender women, gender-nonconforming adults, and cisgender (nontransgender) men and women in the U.S. population. Behavioral Risk Factor Surveillance System (BRFSS) data from 32 U.S. states and territories between 2014 and 2016 yield an analytic sample that identifies 2,229 transgender and gender-nonconforming adults and 516,753 cisgender adults. Estimates from logistic regression models, using cisgender men as a reference group, show that gender-nonconforming respondents have significantly higher odds of reporting poor self-rated health than any other gender identity group. Transgender men also display higher odds of reporting poor health in some models, corresponding to their relative socioeconomic disadvantage. I find no apparent health disadvantage among transgender women and a persistent, if slight, disadvantage among cisgender women. Gender-nonconforming respondents’ predicted probabilities of reporting poor health remain nearly twice as high as those of cisgender men after adjustments for demographic, socioeconomic, and behavioral factors. Their persistent patterns of health-related disadvantage underscore the need for higher-quality data on gender-nonconforming respondents that account for sex assigned at birth.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2

References

  1. Amos, A., Greaves, L., Nichter, M., & Bloch, M. (2012). Women and tobacco: A call for including gender in tobacco control research, policy and practice. Tobacco Control, 21, 236–243.

    Article  Google Scholar 

  2. Baker, K., & Hughes, M. (2016). Sexual orientation and gender identity data collection in the Behavioral Risk Factor Surveillance System. Washington, DC: Center for American Progress.

    Google Scholar 

  3. Bartus, T. (2005). Estimation of marginal effects using margeff. Stata Journal, 5, 309–329.

    Article  Google Scholar 

  4. Benjamini, Y., & Hochberg, Y. (2000). On the adaptive control of the false discovery rate in multiple testing with independent statistics. Journal of Educational and Behavioral Statistics, 25, 60–83.

    Article  Google Scholar 

  5. Benzeval, M., & Judge, K. (2001). Income and health: The time dimension. Social Science & Medicine, 52, 1371–1890.

    Article  Google Scholar 

  6. Biblarz, T. J., & Savci, E. (2010). Lesbian, gay, bisexual, and transgender families. Journal of Marriage and Family, 72, 480–497.

    Article  Google Scholar 

  7. Blosnich, J. R., Lehavot, K., Glass, J. E., & Williams, E. M. (2017). Differences in alcohol use and alcohol-related health care among transgender and nontransgender adults: Findings from the 2014 Behavioral Risk Factor Surveillance System. Journal of Studies on Alcohol and Drugs, 78, 861–866.

    Article  Google Scholar 

  8. Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Hamilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103, 943–951.

    Article  Google Scholar 

  9. Bradford, J., Reisner, S. L., Honnold, J. A., & Xavier, J. (2013). Experiences of transgender-related discrimination and implications for health: Results from the Virginia Transgender Health Initiative Study. American Journal of Public Health, 105, 2108–2116.

    Google Scholar 

  10. Brennan, J., Kuhns, L. M., Johnson, A. K., Belzer, M., Wilson, E. C., & Garofalo, R. (2012). Syndemic theory and HIV-related risk among young transgender women: The role of multiple, co-occurring health problems and social marginalization. American Journal of Public Health, 102, 1751–1757.

    Article  Google Scholar 

  11. Butler, J. (1986). Sex and gender in Simone de Beauvoir’s Second Sex. Yale French Studies, 72, 35–49.

    Article  Google Scholar 

  12. Case, A., & Paxson, C. (2005). Sex differences in morbidity and mortality. Demography, 42, 189–214.

    Article  Google Scholar 

  13. Centers for Disease Control and Prevention (CDC). (2014–2016a). Behavioral Risk Factor Surveillance System Survey data. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.

  14. Centers for Disease Control and Prevention (CDC). (2014–2016b). Behavioral Risk Factor Surveillance System Survey questionnaire. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.

  15. Clements-Nolle, K., Marx, R., Guzman, R., & Katz, M. (2001). HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health intervention. American Journal of Public Health, 91, 915–921.

    Article  Google Scholar 

  16. Compton, D. (2015). LG(BT) families and counting. Sociology Compass, 9, 587–608.

    Article  Google Scholar 

  17. Connell, C. (2010). Doing, undoing, or redoing gender: Learning from the workplace experiences of transpeople. Gender & Society, 24, 31–55.

    Article  Google Scholar 

  18. Connell, R. (2009). Accountable conduct: “Doing gender” in transsexual and political retrospect. Gender & Society, 23, 104–111.

    Article  Google Scholar 

  19. Conron, K. J., Scott, G., Stowell, G. S., & Landers, S. J. (2012). Transgender health in Massachusetts: Results from a household probability sample of adults. American Journal of Public Health, 102, 118–122.

    Article  Google Scholar 

  20. Courtenay, W. H. (2000). Constructions of masculinity and their influence on men’s well-being: A theory of gender and health. Social Science & Medicine, 50, 1385–1401.

    Article  Google Scholar 

  21. Deaton, A. S., & Paxson, C. H. (1998). Aging and inequality in income and health. American Economic Review: Papers and Proceedings, 88, 248–253.

    Google Scholar 

  22. Denney, J. T., Gorman, B. K., & Barrera, C. B. (2013). Families, resources, and adult health: Where do sexual minorities fit? Journal of Health and Social Behavior, 54, 46–63.

    Article  Google Scholar 

  23. DeSalvo, K. B., Bloser, N., Reynolds, K., He, J., & Mutner, P. (2006). Mortality prediction with a single general self-rated health question. Journal of General Internal Medicine, 21, 267–275.

    Article  Google Scholar 

  24. Deutsch, F. (2007). Undoing gender. Gender & Society, 21, 106–127.

    Article  Google Scholar 

  25. Dinno, A., Franks, M. C., Burleton, J., & Smith, T. C. (2014). On the just and accurate representation of transgender persons in research. In H. Pereira & P. Costa (Eds.), Coming-out for LGBT: Psychology in the current international scenario (pp. 241–243). Lisbon, Portugal: International Academy of LGBT Psychology and Related Fields.

    Google Scholar 

  26. Fausto-Sterling, A. (2000). Sexing the body: Gender politics and the construction of gender. New York, NY: Basic Books.

    Google Scholar 

  27. Frankenberg, E., & Jones, N. R. (2004). Self-rated health and mortality: Does the relationship extend to a low income setting? Journal of Health and Social Behavior, 45, 441–452.

    Article  Google Scholar 

  28. Fredriksen-Goldsen, K. I., Cook-Daniels, L., Kim, H., Erosheva, E. A., Emlet, C. A., Hoy-Ellis, C. P., . . . Muraco, A. (2014). Gerontologist, 54, 488–500.

  29. Furtado, D., Marcén, M., & Sevilla, A. (2013). Does culture affect divorce? Evidence from European immigrants in the United States. Demography, 50, 1013–1038.

    Article  Google Scholar 

  30. Gonzalez, G., & Henning-Smith, C. (2017). Barriers to care among transgender and gender-nonconforming adults. Milbank Quarterly, 4, 725–749.

    Google Scholar 

  31. Gorman, B. K., Denney, J. T., Dowdy, H., & Medeiros, R. A. (2015). A new piece of the puzzle: Sexual orientation, gender, and physical health status. Demography, 52, 1357–1382.

    Article  Google Scholar 

  32. Gorman, B. K., & Read, J. G. (2006). Gender disparities in adult health: An examination of three measures of morbidity. Journal of Health and Social Behavior, 47, 95–110.

    Article  Google Scholar 

  33. Gorman, B. K., & Sivaganesan, A. (2007). The role of social support and integration for understanding socioeconomic disparities in self-rated health and hypertension. Social Science & Medicine, 65, 958–975.

    Article  Google Scholar 

  34. Grant, J. M., Mottet, L., Tanis, J. E., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at every turn: A report of the National Transgender Discrimination Survey. Washington, DC: National Center for Transgender Equality and National LGBTQ Task Force.

    Google Scholar 

  35. Harrison, J., Grant, J., & Herman, J. L. (2012). “A gender not listed here”: Genderqueers, gender rebels, and otherwise in the National Transgender Discrimination Survey. LGBTQ Public Policy Journal at the Harvard Kennedy School, 2, 13–24.

    Google Scholar 

  36. Herman, J. L. (2013). Gendered restrooms and minority stress: The public regulation of gender and its impact on transgender people’s lives. Journal of Public Management & Social Policy, 19, 65–80.

    Google Scholar 

  37. Herman, J. L. (2014). Best practices for asking questions to identify transgender and other gender minority respondents on population-based surveys. Los Angeles, CA: The GenIUSS Group.

    Google Scholar 

  38. Honaker, J., King, G., & Blackwell, M. (2011). Amelia II: A program for missing data. Journal of Statistical Software, 45(7), 1–47.

    Article  Google Scholar 

  39. Hughto, J. M. W., Reisner, S. L., & Pachankis, J. E. (2015). Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. Social Science & Medicine, 147, 222–231.

    Article  Google Scholar 

  40. Idler, E. L., & Benyamini, Y. (1997). Self-rated health and mortality: A review of twenty-seven community studies. Journal of Health and Social Behavior, 38, 21–37.

    Article  Google Scholar 

  41. Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: National Institutes of Health.

    Google Scholar 

  42. James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.

    Google Scholar 

  43. Jylhä, M. (2009). What is self-rated health and why does it predict mortality? Towards a unified conceptual model. Social Science & Medicine, 69, 307–316.

  44. Kalmijn, M. (2013). The educational gradient in marriage: A comparison of 25 European countries. Demography, 50, 1499–1520.

    Article  Google Scholar 

  45. Kane, T. J., & Rouse, C. E. (1995). Labor-market returns to two- and four-year college. American Economic Review, 85, 600–614.

    Google Scholar 

  46. Krieger, N. (2003). Genders, sexes, and health: What are the connections—and why does it matter? International Journal of Epidemiology, 32, 652–657.

    Article  Google Scholar 

  47. Little, R. J. A., & Rubin, D. B. (2014). Statistical analysis with missing data (2nd ed.). New York, NY: John Wiley & Sons.

    Google Scholar 

  48. Lombardi, E. (2009). Varieties of transgender/transsexual lives and their relationship with transphobia. Journal of Homosexuality, 56, 977–992.

    Article  Google Scholar 

  49. Meadow, T. (2010). “A rose is a rose”: On producing legal gender classifications. Gender & Society, 24, 814–837.

    Article  Google Scholar 

  50. Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36, 38–56.

    Article  Google Scholar 

  51. Meyer, I. H., Brown, T. N. T., Herman, J., Reisner, S. L., & Bockting, W. O. (2017). Demographic characteristics and health status of transgender adults in select US regions: Behavioral Risk Factor Surveillance System 2014. American Journal of Public Health, 107, 582–589.

    Article  Google Scholar 

  52. Miller, L. R., & Grollman, E. A. (2015). The social costs of gender nonconformity for transgender adults: Implications for discrimination and health. Sociological Forum, 30, 809–831.

    Article  Google Scholar 

  53. Mood, C. (2010). Logistic regression: Why we cannot do what we think we can do, and what we can do about it. European Sociological Review, 1, 67–82.

    Article  Google Scholar 

  54. Narayan, A., Lebron-Zapata, L., & Morris, E. (2017). Breast cancer screening in transgender patients: Findings from the 2014 BRFSS survey. Breast Cancer Research and Treatment, 166, 875–879.

    Article  Google Scholar 

  55. Nuttbrock, L., Hwahng, S., Bockting, W., Rosenblum, A., Mason, M., Macri, M., & Becker, J. (2009). Lifetime risk factors for HIV/sexually transmitted infections among male-to-female transgender persons. Journal of Acquired Immune Deficiency Syndromes, 52, 417–421.

    Article  Google Scholar 

  56. Park, J., Nawyn, S. J., & Benetsky, M. J. (2015). Feminized intergenerational mobility without assimilation? Post-1965 U.S. immigrants and the gender revolution. Demography, 52, 1601–1626.

    Article  Google Scholar 

  57. Peters, H. E., Simon, K., & Taber, J. R. (2014). Marital disruption and health insurance. Demography, 51, 1397–1421.

    Article  Google Scholar 

  58. Pfeffer, C. A. (2012). Normative resistance and inventive pragmatism: Negotiating structure and agency in transgender families. Gender & Society, 26, 574–602.

    Article  Google Scholar 

  59. Pitasi, M. A., Oraka, E., Clark, H., Town, M., & DiNenno, E. A. (2017). HIV testing among transgender women and men—27 states and Guam, 2014–2015. Morbidity and Mortality Weekly Report, 66, 883–887.

    Article  Google Scholar 

  60. Preston, S. H., & Wang, H. (2006). Sex mortality differences in the United States: The role of cohort smoking patterns. Demography, 43, 631–646.

    Article  Google Scholar 

  61. Quesnel-Valée, A. (2007). Self-rated health: Caught in the crossfire of the quest for “true” health? International Journal of Epidemiology, 36, 1161–1164.

    Article  Google Scholar 

  62. Reisner, S. L., Conron, K. J., Scout, Baker, K., Herman, J. L., Lombardi, E., . . . Matthews, A. K. (2015a). “Counting” transgender and gender nonconforming adults in health research: Recommendations from the Gender Identity in US Surveillance Group. Transgender Studies Quarterly, 2, 34–57.

  63. Reisner, S. L., Greytak, E. A., Parsons, J. T., & Ybarra, M. L. (2015b). Gender minority social stress in adolescence: Disparities in adolescent bullying and substance use by gender identity. Journal of Sex Research, 52, 243–256.

  64. Rendall, M. S., Weden, M. M., Favreault, M. M., & Waldron, H. (2011). The protective effect of marriage for survival: A review and update. Demography, 48, 481–506.

    Article  Google Scholar 

  65. Riley, N. C., Blosnich, J. R., Bear, T. M., & Reisner, S. L. (2017). Vocal timbre and the classification of respondent sex in US phone-based surveys. American Journal of Public Health, 107, 1290–1294.

    Article  Google Scholar 

  66. Risman, B. (2009). From doing to undoing: Gender as we know it. Gender & Society, 23, 81–84.

    Article  Google Scholar 

  67. Rogers, R. G., Everett, B. G., Saint Onge, J. M., & Krueger, P. M. (2010). Social, behavioral, and biological factors, and sex differences in mortality. Demography, 47, 555–578.

    Article  Google Scholar 

  68. Ross, C. E., Masters, R. K., & Hummer, R. A. (2012). Education and the gender gaps in health and mortality. Demography, 49, 1157–1183.

    Article  Google Scholar 

  69. Saltonstall, R. (1993). Healthy bodies, social bodies: Men’s and women’s concepts and practices of health in everyday life. Social Science & Medicine, 36, 7–14.

    Article  Google Scholar 

  70. Schilt, K. (2010). Just one of the guys? Transgender men and the persistence of gender inequality. Chicago, IL: University of Chicago Press.

    Google Scholar 

  71. Schilt, K., & Lagos, D. (2017). The development of transgender studies in sociology. Annual Review of Sociology, 43, 425–443.

    Article  Google Scholar 

  72. Schilt, K., & Westbrook, L. (2009). Gender normal, transgender people, and the social maintenance of heterosexuality. Gender & Society, 23, 440–464.

    Article  Google Scholar 

  73. Sevelius, J. M. (2013). Gender affirmation: A framework for conceptualizing risk behavior for transgender women of color. Sex Roles, 68, 675–689.

    Article  Google Scholar 

  74. shuster, s. m. (2016). Uncertain expertise and the limitations of clinical guidelines in transgender healthcare. Journal of Health and Social Behavior, 57, 319–332.

  75. Smith, E. A., Thomson, K., Offen, N., & Malone, R. E. (2007). “If you know you exist, it’s just marketing poison”: Meanings of tobacco industry targeting in the lesbian, gay, bisexual, and transgender community. American Journal of Public Health, 98, 996–1003.

    Article  Google Scholar 

  76. Springer, K. W., & Mouzon, D. M. (2011). “Macho men” and preventative health care: Implications for older men in different social classes. Journal of Health and Social Behavior, 52, 212–227.

    Article  Google Scholar 

  77. StataCorp (2017). Stata Statistical Software (Release 15.0). College Station, TX: StataCorp LP.

    Google Scholar 

  78. Stroope, S. (2015). Seclusion, decision-making power, and gender disparities in adult health: Examining hypertension in India. Social Science Research, 53, 288–299.

    Article  Google Scholar 

  79. Tyler, J. H., & Lofstrom, M. (2009). Finishing high school: Alternative pathways and dropout recovery. Future of Children, 19(1), 77–103.

    Article  Google Scholar 

  80. Udry, J. R. (1994). The nature of gender. Demography, 31, 561–573.

    Article  Google Scholar 

  81. Umberson, D., Williams, K., Thomas, P. A., Liu, H., & Thomeer, M. B. (2014). Race, gender, and chains of disadvantage: Childhood adversity, social relationships, and health. Journal of Health and Social Behavior, 55, 20–38.

    Article  Google Scholar 

  82. Von Hippel, P. T. (2007). Regression with missing Ys: An improved strategy for analyzing multiply imputed data. Sociological Methodology, 37, 83–117.

    Article  Google Scholar 

  83. Waite, L. J. (1995). Does marriage matter? Demography, 32, 483–507.

    Article  Google Scholar 

  84. Watkins, S. C. (1993). If all we knew about women was what we read in Demography, what would we know? Demography, 30, 551–577.

    Article  Google Scholar 

  85. West, C., & Zimmerman, D. H. (1987). Doing gender. Gender & Society, 1, 125–151.

    Article  Google Scholar 

  86. Westbrook, L., & Saperstein, A. (2015). New categories are not enough: Rethinking the measurement of sex and gender in social surveys. Gender & Society, 29, 534–560.

    Article  Google Scholar 

  87. Westbrook, L., & Schilt, K. (2014). Doing gender, determining gender: Transgender people, gender panics, and the maintenance of the sex/gender/sexuality system. Gender & Society, 28, 32–57.

    Article  Google Scholar 

Download references

Acknowledgments

I thank Jenny Trinitapoli, Kristen Schilt, Anna Mueller, Xi Song, Eliza Brown, and Taylor Winfield for their extensive feedback on this manuscript. I also thank the participants at the session on Sexual and Gender Minorities, Health, and Mortality at the 2017 annual meeting of the Population Association of America and at the Gender and Sexuality Studies Workshop at the University of Chicago, for their helpful input.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Danya Lagos.

Electronic supplementary material

ESM 1

(PDF 356 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Lagos, D. Looking at Population Health Beyond “Male” and “Female”: Implications of Transgender Identity and Gender Nonconformity for Population Health. Demography 55, 2097–2117 (2018). https://doi.org/10.1007/s13524-018-0714-3

Download citation

Keywords

  • Self-rated health
  • Sex
  • Gender identity
  • Transgender
  • Gender-nonconforming