Health and Cardiometabolic Disease in Transgender Adults in the United States

Behavioral Risk Factor Surveillance System 2015

Natalie J. Nokoff; Sharon Scarbro; Elizabeth Juarez-Colunga; Kerrie L. Moreau; Allison Kempe


J Endo Soc. 2018;2(4):349-360. 

In This Article

Abstract and Introduction


Context Little is known about the health of transgender adults in the United States, a growing population. There have been no large reports examining differences in health status and cardiometabolic disease in subgroups of transgender adults [female-to-male (FTM), male-to-female (MTF), and gender nonconforming (GNC)] in the United States.

Objective Compare the health status and prevalence of cardiometabolic disease among specific subgroups of transgender adults (FTM, MTF, GNC) with those of cisgender adults in the United States.

Design Secondary data analysis based on the 2015 Behavioral Risk Factor Surveillance System survey.

Setting The 22 states in the United States that asked about transgender identity.

Participants Noninstitutionalized adults age ≥18 years who reside in the United States, identified through telephone-based methods.

Main Outcome Measures Data were extracted for respondents who answered the transgender identity question. Weighted percentages are given for all measures. Adjusted odds ratios (ORs) are reported for health status and cardiometabolic disease measures.

Results FTM adults have a higher odds of being uninsured than both cisgender women [OR 3.8; 95% confidence interval (CI), 2.1 to 7.1] and cisgender men (OR 2.5; 95% CI, 1.4 to 4.7). MTF adults have a higher odds of reporting myocardial infarction than cisgender women (OR 2.9; 95% CI, 1.6 to 5.3) but not cisgender men.

Conclusions There are significant differences in health status measures and cardiometabolic health between subgroups of transgender adults and cisgender adults. There is a need for additional research to understand the societal and medical (e.g., hormone therapy) effects on these outcomes.


Recent reports show that 0.5% of adults and 3% of youth in the United States identify as transgender, meaning that their gender identity differs from birth sex.[1–3] Some data suggest that an increasing percentage of young people identify as somewhere in the middle of the gender spectrum, with identities that include gender fluid, gender nonconforming (GNC), agender, and others.[3] Despite increased recognition of transgender people in the United States, many still experience harassment or discrimination in medical settings,[4] medical providers are inadequately trained,[5] and guidelines for care of this population are based largely on expert opinion and small, retrospective studies, primarily from Europe.[6,7] Understanding transgender-specific health needs is a research priority of the Institute of Medicine;[8] however, the health disparities of specific transgender subgroups are likely to be distinct. Furthermore, the majority of transgender adults receive gender-affirming hormone therapy,[4] yet the long-term effects of these therapies on cardiometabolic health are not well understood.

The Behavioral Risk Factor Surveillance System (BRFSS), a large national survey in the United States, began including questions about transgender identity in select states in 2014,[1,2] providing, for the first time, an opportunity to better understand the specific health needs of transgender adults nationally. Initial reports of the 2014 BRFSS survey showed that compared with cisgender adults (those whose gender identity aligns with birth sex), transgender adults were more likely to report fair or poor health, lack access to a personal health care provider, and lack health insurance.[1] However, these analyses did not analyze results by important subgroups, including male-to-female (MTF), female-to-male (FTM), and GNC adults, populations for whom health status measures are likely to be distinct because of the potentially different societal stressors experienced or medical therapies sought. A recent review[9] and meta-analysis[10] found that hormone therapy, including testosterone and estradiol, may be associated with worsening cardiometabolic risk factors, although there are several limitations to the available data.

In this study, we used the 2015 BRFSS database to compare the health status and prevalence of self-reported cardiometabolic disease among specific subgroups of transgender adults (FTM, MTF, and GNC) compared with cisgender adults, adjusting for important covariates. We hypothesized that all subgroups of transgender adults (MTF, FTM, and GNC) would have a higher odds of being uninsured compared with cisgender adults. Additionally, we hypothesized that MTF adults would have a higher odds of myocardial infarction (MI) compared with both cisgender men and women.