Psychological Distress and Suicidality Among Transgender Young Adults in the United States.

PURPOSE: Transgender young adults (TYA) are burdened by adverse mental health outcomes. Guided by intersectionality and minority stress frameworks, we compared prevalence of psychological distress and suicidality among TYA of different social identities to inform future interventions. METHODS: In this secondary data analysis of 12,738 TYA, ages 18-25 years, from the 2015 United States Transgender Survey, we developed multivariable regression models examining associations between social identities and psychological distress and suicidality, adjusting for relevant covariates. Self-reported identities were used as proxies for minority stress resulting from structural oppressions related to gender binarism, transmisogyny, heterosexism, and racism. RESULTS: Overall, 53% met criteria for serious psychological distress, and 66% reported suicidal ideation. Statistically higher odds of serious psychological distress and suicidal ideation and plan were found for TYA assigned male compared to assigned female at birth (adjusted odds ratios [aORs] = 1.14-1.50). Nonbinary TYA assigned male at birth also had lower odds of all outcomes compared to all other TYA (aORs = 0.6-0.7). Compared to White TYA, Latiné/x TYA were more likely to experience serious psychological distress (aOR = 1.19, 95% confidence interval: 1.02, 1.39) and multiracial TYA were more likely to report suicide plan(s) and attempt(s) (aORs = 1.25-1.30). Finally, compared to heterosexual TYA, bisexual/pansexual TYA were more likely to report suicide plan(s) (aOR = 1.28, 95% confidence intervals: 1.04, 1.52), and all sexual minority TYA were more likely to report serious psychological distress and suicidal ideation (aORs = 1.31-2.00). DISCUSSION: Results highlight complex associations between intersectional minority stress and mental health outcomes among TYA. Associations between identities and mental health morbidity highlight an urgent need for targeted mental health interventions.

Sexual orientation in transgender adults in the United States.

BACKGROUND: Sexual orientation refers to a person's enduring emotional, romantic, or sexual attractions to other people. Sexual orientation measures do not typically consider desires for, or sexual behavior with, transgender people. We describe measures inclusive of transgender people and characterize sexual orientation identity, behavior, and attraction in a representative sample of the U.S. transgender population. METHODS: Between April 2016-December 2018, a U.S. national probability sample of transgender (n = 274) and cisgender (n = 1,162) adults were invited to complete a self-administered web or mailed paper survey. We assessed sexual identity with updated response options inclusive of recent identity terms (e.g., queer), and revised sexual behavior and attraction measures that included transgender people. Multiple response options were allowed for sexual behavior and attraction. Weighted descriptive statistics and sexual orientation differences by gender identity groups were estimated using age-adjusted comparisons. RESULTS: Compared to the cisgender population, the transgender population was more likely to identify as a sexual minority and have heterogeneity in sexual orientation, behavior, and attraction. In the transgender population, the most frequently endorsed sexual orientation identities were "bisexual" (18.9%), "queer" (18.1%), and "straight" (17.6%). Sexually active transgender respondents reported diverse partners in the prior 5 years: 52.6% cisgender women (CW), 42.7% cisgender men (CM), 16.9% transgender women (TW), and 19.5% transgender men (TM); 27.7% did not have sex in the past 5 years. Overall, 73.6% were "somewhat"/ "very" attracted to CW, 58.3% CM, 56.8% TW, 52.4% TM, 59.9% genderqueer/nonbinary-females-at-birth, 51.9% genderqueer/nonbinary-males-at-birth. Sexual orientation identity, behavior, and attraction significantly differed by gender identity for TW, TM, and nonbinary participants (all p < 0.05). CONCLUSIONS: Inclusive measures of sexual orientation captured diverse sexual identities, partner genders, and desires. Future research is needed to cognitively test and validate these measures, especially with cisgender respondents, and to assess the relation of sexual orientation and health for transgender people.

Imputation methods for missing failure times in recurrent-event survival analysis: Application to suicide attempts in the transgender population.

Suicide risk among transgender populations is an important public health issue. In a project evaluating association between gender affirmation and suicide attempts in the US Transgender Survey, we evaluated the relationship between gender affirmation and risk for suicide attempts. One of the challenges is that the age at suicide attempts was only collected for the first and last attempt. The initial zero-inflated negative binomial model enabled us to evaluate the association between gender affirmation and number of suicide attempts per 5 years adjusting for other covariates. However, ignoring missing failure times of recurrent events may have caused bias and loss of efficiency. In this paper, we use a recurrent-event survival analysis incorporating time-varying covariates with three approaches to impute the age at suicide attempt, estimates from three imputation approaches are similar. We were able to confirm the findings from the initial model and identify additional associations that were not detected in the initial analysis. Findings suggest the need to consider additional analytical approaches in settings with high data missingness by design. Research to validate and compare measures that ask first and last attempt to those which enumerate all attempts in this population will be important for future surveys.

Health and health care access in the US transgender population health (TransPop) survey.

BACKGROUND: Probability and nonprobability-based studies of US transgender persons identify different disparities in health and health care access. OBJECTIVES: We used TransPop, the first US national probability survey of transgender persons, to describe and compare measures of health and health access among transgender, nonbinary, and cisgender participants. We directly compared the results with 2015 US Transgender Survey (USTS) data and with previously published analyses from the Behavioral Risk Factor Surveillance System (BRFSS). METHODS: All participants were screened by Gallup Inc., which recruited a probability sample of US adults. Transgender people were identified using a two-step screening process. Eligible participants completed self-administered questionnaires (transgender n = 274, cisgender n = 1162). We obtained weighted proportions/means, then tested for differences between gender groups. Logistic regression was performed to evaluate associations. Bivariate analyses were conducted using the weighted USTS data set for shared variables in USTS and TransPop. RESULTS: Transgender participants were younger and more racially diverse compared to the cisgender group. Despite equally high insurance coverage, transgender people more often avoided care due to cost concerns. Nonbinary persons were less likely to access transgender-related health care providers/clinics than transgender men and women. Transgender respondents more often rated their health as fair/poor, with more frequently occuring poor physical and mental health days compared to cisgender participants. Health conditions including HIV, emphysema, and ulcer were higher among transgender people. TransPop and USTS, unlike BRFSS-based analyses, showed no differences in health or health access. DISCUSSION: Transgender persons experience health access disparities centered on avoidance of care due to cost beyond insured status. Health disparities correspond with models of minority stress, with nonbinary persons having distinct health/health access patterns. Despite different sampling methods, USTS and TransPop appear more similar than BRFSS studies regarding health/health access. CONCLUSION: Future research should elucidate health care costs for transgender and nonbinary people, while addressing methodology in national studies of transgender health.

Gender Identity Disparities in Criminal Victimization: National Crime Victimization Survey, 2017-2018.

Objectives. To estimate the prevalence of personal and household victimizations among transgender people in the United States.Methods. We analyzed pooled 2017 and 2018 data from the National Crime Victimization Survey, the first nationally representative sample that allows identification of transgender respondents.Results. Transgender people experienced 86.2 victimizations per 1000 persons compared with cisgender people's 21.7 per 1000 persons (odds ratio [OR] = 4.24; 90% confidence interval [CI] = 1.49, 7.00). Households that had a transgender person had higher rates of property victimization (214.1 per 1000 households) than households with only cisgender people (108 per 1000 households; OR = 2.25; 90% CI = 1.19, 3.31). Transgender victims whose sex assigned at birth was male were more likely to perceive their victimization as a hate crime than cisgender victims whose sex assigned at birth was male. There were no disparities in reporting victimizations to authorities: only about half of the victimizations of both transgender and cisgender people were reported.Conclusions. Public policy and administration need to consider the unique vulnerabilities transgender people routinely encounter, resulting in disparities in criminal victimization.

Demographics and health outcomes in a U.S. probability sample of transgender parents.

Nonrepresentative estimates indicate that 25%-50% of transgender people are parents. Yet very little is known about their demographic characteristics and health outcomes. The present study compared the quality of life and several mental health (i.e., psychological distress, life satisfaction, happiness, social well-being) and health (i.e., physical health, alcohol and drug use) dimensions by gender identity and parenthood status in a probability sample of 1,436 transgender and cisgender respondents to the U.S. Transgender Population Health Survey (TransPop study). An estimated 18.8% of transgender respondents were parents, with the majority (52.5%) being transgender women. After controlling for age, education, and relationship status, there were no significant differences between trans- and cisgender parents and their nonparent counterparts on any mental health or health dimensions. These findings are important to family practitioners and policymakers so that they do not mistakenly assume that any problems transgender parents may report reveal their unsuitability to parent. Rather, because differences in health outcomes were seen only across gender identities, such problems are more likely related to stigma and discrimination experiences in a cisgenderist/heterosexist society. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Considerations on Sampling in Transgender Health Disparities Research.

Collection of gender identity data in national probability-based surveys began in 2014, an important first step toward the inclusion of gender identity measurements in public health surveillance. However, the findings about health disparities from probability-based samples do not align with those from nonprobability samples traditionally used to study transgender populations. These contradictions have yet to be understood fully. In this article, we suggest that the truth about disparities lies somewhere between nonprobability and probability samples. We discuss why generalizability from studies using probability sampling may remain limited for transgender populations and describe potential improvements in sampling methodology for transgender populations.

Transgender And Cisgender US Veterans Have Few Health Differences.

Transgender people have been able to serve openly in the military since June 2016. However, the administration of President Donald Trump has signaled its interest in reinstating a ban on transgender military service. In March 2018 President Trump issued a revised memorandum that stated, in part, that people with a "history or diagnosis of gender dysphoria" who "may require substantial medical treatment, including medications and surgery-are disqualified from military service except under certain limited circumstances." Whether and how the health of transgender service members differs from that of cisgender service members (that is, those who identify with their sex assigned at birth) is largely unknown. This study used population-level data for 2014-16 from the Behavioral Risk Factor Surveillance System to compare the health of transgender and cisgender veterans and civilians. An estimated 0.5 percent of veterans in the sample identified themselves as transgender. While transgender civilians had worse health than cisgender civilians across most indicators, very few differences existed among veterans. However, transgender veterans had higher odds of having at least one disability compared to cisgender veterans, despite similar levels of access to health care. These findings largely suggest that transgender veterans do not have worse health than cisgender veterans.

Demographic and Health Characteristics of Transgender Adults in California: Findings from the 2015-2016 California Health Interview Survey.

This report provides the first look at demographics, health, and health care access among transgender adults in California who participated in the 2015-2016 California Health Interview Survey (CHIS). In California, about 92,000 (0.35 percent) adults ages 18 to 70 are transgender. Transgender adults are similar to cisgender1 adults in many ways but experience disparities in mental health, disability status, and health care access. Compared to cisgender adults, transgender adults are more than three times more likely to have ever thought about suicide, nearly six times more likely to have ever attempted suicide, nearly four times more likely to have experienced serious psychological distress, and more than three times more likely to have emotions that interfere with their relationships, social life, ability to do chores, and work performance. In regard to health care access, transgender adults are nearly three times more likely than cisgender adults to delay getting medicine prescribed to them by a doctor or to not get the medicine at all. There are no statistically significant differences between transgender and cisgender adults in some demographic characteristics, such as education and U.S. citizenship, and in reports of various physical health conditions, such as diabetes and asthma. However, transgender adults appear more likely to be living with HIV. These and other findings call for future research to explain existing disparities and similarities, as well as for the creation of structural and clinical interventions that will improve health care access and mental and physical health outcomes for the transgender population.

Demographic Characteristics and Health Status of Transgender Adults in Select US Regions: Behavioral Risk Factor Surveillance System, 2014.

OBJECTIVES: To describe the health status of the transgender population in the United States. METHODS: We used 2014 Behavioral Risk Factor Surveillance System data that comprised a probability sample from 19 US states and Guam (n = 151 456). RESULTS: Bivariate analyses showed that, in comparison with cisgender individuals, transgender individuals had a higher prevalence of poor general health (odds ratio [OR] = 1.7; 95% confidence interval [CI] = 1.2, 2.4), more days per month of poor physical (b = 2.43; 95% CI = 0.61, 4.24; P < .01) and mental (b = 1.74; 95% CI = 0.28, 3.19; P = .02) health, and a higher prevalence of myocardial infarction (OR = 1.7; 95% CI = 1.1, 2.5). In addition, more transgender than cisgender people lacked health care coverage (OR = 1.8; 95% CI = 1.2, 2.7) and a health care provider (OR = 1.5; 95% CI = 1.0, 2.1), and they were less likely to have visited a dentist in the preceding year (OR = 0.7; 95% CI = 0.5, 1.0). However, transgender individuals did not differ from cisgender individuals with respect to prevalence of chronic diseases, cancers, or depressive disorders or in terms of health behaviors such as smoking, binge drinking, and always wearing a seatbelt. CONCLUSIONS: Our findings highlight areas of unmet needs in the transgender population.

Disproportionality and Disparities among Sexual Minority Youth in Custody.

Research indicates that sexual minority youth are disproportionately criminalized in the U.S. and subjected to abusive treatment while in correctional facilities. However, the scope and extent of disparities based on sexual orientation remains largely overlooked in the juvenile justice literature. This study, based on a nationally representative federal agency survey conducted in 2012 (N = 8785; 9.9% girls), reveals that 39.4% of girls and 3.2% of boys in juvenile correctional facilities identified as lesbian, gay, or bisexual. These youth, particularly gay and bisexual boys, report higher rates of sexual victimization compared to their heterosexual peers. Sexual minority youth, defined as both lesbian, gay, and bisexual identified youth as well as youth who identified as straight and reported some same-sex attraction, were also 2-3 times more likely than heterosexual youth to report prior episodes of detention lasting a year or more. Implications for future research and public policy are discussed.

Incarceration Rates and Traits of Sexual Minorities in the United States: National Inmate Survey, 2011-2012.

OBJECTIVES: To report characteristics of sexual minority US inmates. METHODS: We drew our data from the National Inmate Survey, 2011-2012, a probability sample of inmates in US prisons and jails. We determined weighted proportions and odds ratios with 95% confidence intervals to estimate differences between sexual minority and heterosexual inmates. RESULTS: Sexual minorities (those who self-identify as lesbian, gay, or bisexual or report a same-sex sexual experience before arrival at the facility) were disproportionately incarcerated: 9.3% of men in prison, 6.2% of men in jail, 42.1% of women in prison, and 35.7% of women in jail were sexual minorities. The incarceration rate of self-identified lesbian, gay, or bisexual persons was 1882 per 100 000, more than 3 times that of the US adult population. Compared with straight inmates, sexual minorities were more likely to have been sexually victimized as children, to have been sexually victimized while incarcerated, to have experienced solitary confinement and other sanctions, and to report current psychological distress. CONCLUSIONS: There is disproportionate incarceration, mistreatment, harsh punishment, and sexual victimization of sexual minority inmates, which calls for special public policy and health interventions.