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Measuring the Health of an Invisible Population: Lessons from the Colorado Transgender Health Survey [1]

['Christian', 'Robin.Christian Rutgers.Edu', 'University Of Colorado School Of Medicine', 'Aurora', 'Department Of Obstetrics', 'Gynecology', 'Women S Health Rutgers', 'New Jersey Medical School', 'Newark', 'Mellies']

Date: 2018-10-23

A total of 593 individuals participated in the survey—507 identified as transgender or gender nonconforming; 417 provided a valid Colorado zip code or were homeless. Data were further restricted to the 406 respondents ages 18 and older, to allow general comparisons to the overall adult population in Colorado as estimated by the 2014 BRFSS (n = 13,399). Nationwide estimates for illicit and non-medical prescription drug use among adults are presented from the 2014 NSDUH (n = 67,901) as comparable state-level data were not readily available in published tables.27 Unless noted otherwise, all statements describing differences between the CTHS sample and the general population are considered meaningful (the population-based confidence interval does not include the CTHS point estimate).

Table 1 shows the demographic characteristics and transition-related care of CTHS respondents. Among survey respondents, over half identified their gender specifically as transgender men or transgender women. Nearly 20% identified as man or woman, and approximately the same percent identified as gender queer/fluid. While one respondent omitted specifying a gender identity, this individual opted into the survey as gender nonconforming and also indicated plans to use hormone replacement therapy in the future. Approximately one third of respondents reported their sexual orientation as bisexual or pansexual, 22.3% queer, and 20.5% lesbian or gay. Thirteen percent of respondents reported being heterosexual, whereas 96.2% of adults in Colorado identify as such. Over 70% of respondents had ever used hormone replacement therapy—64.3% were currently using, and 79.2% were planning to use hormones in the future. More than one in four respondents had undergone transition-related surgery.

Table 1 Demographic Characteristics and Transition-Related Care, Ages 18 and Older, 2014 CTHS and Colorado BRFSS Full size table

Survey respondents were younger than the general adult population in Colorado (Table 1). More than two thirds of the sample were younger than 45 and only 4.2% were 65 and older, whereas about half of Colorado adults are younger than 45 and 17.0% are 65 and older. A much higher proportion of the transgender sample had pursued education beyond a high school degree than the average adult (90.3 and 66.3%, respectively). Despite more transgender respondents completing a 4-year college degree, rates of unemployment and household incomes under $25,000 per year were twice as high in this group.

Overall, transgender respondents reported poorer health and increased days of activity limitation (Table 2). Some of the largest disparities faced by transgender respondents are seen in substance use and mental health. Suicidal thoughts and suicide attempts were ten times higher in the CTHS sample than in the Colorado adult population in 2009 (most recent BRFSS data available). This result is foreshadowed by the fact that current depression, as well as a lifetime diagnosis of an anxiety disorder, was higher in the CTHS sample than in Colorado adults overall.

Table 2 Select Health-Related Indicators, Ages 18 and Older, Colorado, 2014 CTHS, Colorado BRFSS, and NSDUH Full size table

Current substance use was also elevated among the transgender sample (Table 2). Nearly one third of transgender respondents reported using marijuana and one-fourth reported binge drinking in the past 30 days. Cigarette smoking was only slightly higher in the CTHS sample. Ten percent of CTHS respondents reported non-medical use of prescriptions and 9.3% reported illicit drug use in the past year. Data from the 2014 NSDUH shows that 5.6% of adults nationwide used prescription drugs for non-medical use and 16.6% used illicit drugs in the past year.27

The proportion of individuals with any type of health care coverage was comparable between the CTHS sample (86.6%) and adult Coloradans (87.2%) (Table 2). However, fewer transgender respondents had employer-sponsored coverage (47.0 versus 55.7%) and a greater proportion had Medicaid (16.5 versus 10.6%). Additionally, Medicare coverage was less than half of the general population. These differences are congruent with the CTHS sample being younger with higher rates of unemployment and poverty. Though overall insurance coverage rates were comparable, fewer transgender respondents reported having a regular health care provider and were more than three times more likely to delay care due to cost in the past year. Additionally, 23.1% of respondents delayed care due to an issue with insurance or services not covered by their plan. Thirty-one percent of respondents delayed needed care out of fear of discrimination. These barriers aside, a higher proportion of transgender respondents (64.4 versus 62.7%) received a routine checkup within the past year.

The CTHS asked if respondents felt the healthcare provider they see most regularly provides transgender “inclusive” health care, and why they felt that was the case (Table 3). A majority of respondents felt that they have an inclusive provider, but over one-third disagreed. Those with an inclusive provider were more likely to report that their provider was knowledgeable about and able to address transgender-specific health care needs. A large portion of both groups indicated their provider was comfortable with transgender patients, but this was less common among those without an inclusive provider. Responses from both groups indicated improvements could be made in the area of office policies and forms, with only about half of either group indicating that current policies and forms were transgender-inclusive.

Table 3 Health Care Provider Experiences and Health Outcomes, Ages 18 and Older, Colorado, 2014 CTHS Full size table

Perceiving a provider as inclusive was associated with healthcare utilization and overall health. Those without an inclusive provider were almost twice as likely to delay care because of fear of discrimination (42.8 versus 23.9%) and less likely to have received annual routine exam within the past year (48.3 versus 75.0%). They were also more likely to be currently depressed (53.1 versus 36.8%), to have suicidal thoughts (47.2 versus 29.0%), and to have made a suicide attempt in the past year (15.5 versus 7.4%). Having an inclusive provider was associated with lower rates of fair or poor overall health (15.5 versus 26.4%) and number of days of poor mental health in the past month (10.6 versus 13.2). Despite the protective associations of having an inclusive provider, the prevalence of these negative health outcomes is still higher compared to the Colorado adult population.

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[1] Url: https://link.springer.com/article/10.1007/s11606-018-4450-6

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