JOURNAL OF WOMEN’S HEALTH

Volume 28, Number 2, 2019

ª Mary Ann Liebert, Inc.
DOI: 10.1089/jwh.2018.7411

Gender and Frequent Mental Distress:

Comparing Transgender and Non-Transgender Individuals’
Self-Rated Mental Health

Halley P. Crissman, MD, MPH,1 Daphna Stroumsa, MD, MPH,1,2

Emily K. Kobernik, MPH, CPH,1 and Mitchell B. Berger, MD, PhD1,3
Downloaded by University Of Queensland from www.liebertpub.com at 06/08/19. For personal use only.

Abstract

Background: Transgender individuals are more likely to experience social and economic barriers to health and
health care, and have worse mental health outcomes than cisgender individuals. Our study explores variations in
mental health among minority genders after controlling for sociodemographic factors.
Materials and Methods: Multistate data were obtained from the 2014 to 2016 Centers for Disease Control and
Prevention Behavioral Risk Factor Surveillance System. Data were included from respondents who were asked
whether they identified as transgender, and if so, as male-to-female (MTF), female-to-male (FTM), or gender
nonconforming. Frequent mental distress (‡14 days in the last month of ‘‘not good’’ mental health) was the
primary outcome of interest. Analysis was performed using design-adjusted Chi-square tests and multivariable
logistic regression models of frequent mental distress with gender identity as the independent variable of
interest.
Results: Of 518,986 respondents, 0.51% identified as transgender. Higher rates of frequent mental distress were
found between FTM (24.7% [18.5–32.3]) and gender nonconforming populations (25.4% [18.7–33.5]), com-
pared with the MTF population (14.2% [10.9–18.3]). After controlling for sociodemographic factors, non-
transgender female (adjusted odds ratio [aOR] 1.39 [confidence interval, CI 1.32–1.46]), FTM (aOR 1.93 [CI
1.26–2.95]), and gender nonconforming (aOR 2.05 [CI 1.20–3.50]) identities were associated with increased
odds of frequent mental distress compared with non-transgender males.
Conclusions: Our findings suggest differences in the mental health of transgender and non-transgender indi-
viduals, and between gender minorities within transgender population. The differences persist after controlling
for sociodemographic factors. Our results suggest that considering the spectrum of minority genders within the
transgender population may be important in understanding health outcomes.

Keywords: transgender, LGBT, mental health, frequent mental distress, disparities

Introduction Existing data suggest worse mental health outcomes in

transgender compared to non-transgender cohorts, including

I ndividuals who identify as transgender or gender

nonconforming face significant barriers to health and
health care, including stigma, and institutional and interper-
sonal gender discrimination (impacting housing, employ-
ment, criminal justice system involvement, insurance, and
social support access). Within the health care system itself,
providers often lack knowledge or comfort in providing care
for transgender and gender nonconforming individuals.1–7
disproportionately high rates of suicide, suicide attempts, and
depression.4,7–10
The minority stress model hypothesis attributes these
disparities to stressors induced by the dominant social environ-
ment, including harassment, discrimination, and victimization—
all stressors are experienced at strikingly high levels by
transgender individuals.4,11,12 This theory has been used
previously in gender and sexual minority populations to

1
Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan.
2
Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
3
Main Line HealthCare, Ellis Preserve, Newtown Square, Pennsylvania.

143
 144
explain high rates of tobacco use as a method of coping with
minority stress.13 The minority stress model is supported by
consistent evidence suggesting that mental health outcomes
in the transgender population are significantly improved by
engagement with social support.7,14–16 Furthermore, social
transitioning and use of gender affirming medical care has
also been associated with improved mental health outcomes
among transgender youth and adults.15,17–21
Sociodemographic characteristics of the transgender pop-
ulation in the United States are different from those of the
cisgender population and may, in part, explain differences in
mental health outcomes. Transgender individuals are more
likely to live in poverty, less likely to attend college, and less
likely to identify as white, when compared with the non-
transgender population.10,22 It is unclear whether disparities
in mental health outcomes can be accounted for entirely by
differences in sociodemographic characteristics associated
with poor mental health, including age, poverty, education,
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and race, or whether there are other factors related to iden-
tifying as transgender or gender nonconforming that account
for discrepancies in the mental health outcomes of trans-
gender compared with non-transgender people.23,24
Overall population level data have consistently shown a
higher incidence of frequent mental distress and depression
among women compared with men, without accounting for
transgender versus cisgender status.25–28 The etiology of
gendered differences in depression is unclear, with theories
suggesting the potential for both biologic differences and
socioenvironmental factors.25 Systematic reviews have con-
sistently failed to associate depression with fluctuations in sex
hormones, such as in the context of menopause, oral contra-
ceptive use, pregnancy, and hormone replacement therapy.25,29
The transgender community is heterogeneous, both in
terms of gender and other demographic characteristics.10,22
There has been a limited assessment to date of mental health
outcomes among various gender identities within the trans-
gender community, particularly regarding people who iden-
tify as nonbinary.10 Moreover, population level demographic
and health research on the transgender community has been
limited by the conflation of sex and gender in the majority of
national surveys, resulting in reliance on convenience sam-
ples that may be limited in generalizability.30,31 The results of
such studies offer inconsistent evidence regarding differ-
ences in the mental health outcomes of transmasculine and
transfeminine cohorts.8,20,32–34 More information is needed
regarding potential differences in mental health outcomes
between minority genders within the transgender community
to target and track efforts to eliminate disparities and improve
mental health outcomes.
We address these gaps in the literature by exploring self-
rated mental health and depression disorder diagnosis in a
multistate probability sample, allowing for a comparison of
the mental health of transgender and non-transgender people,
as well as between different minority genders. Based on the
theoretical framework of the minority stress model and ex-
isting data, we hypothesize that the self-rated mental health
of transgender people is worse than that of cisgender people.
We also hypothesize that these differences will be incom-
pletely explained by sociodemographic factors, reflecting the
effects of stigma and discrimination felt by the transgender
community. In addition, we anticipate differences between
minority gender groups within the transgender community.
CRISSMAN ET AL.
Materials and Methods
Data were obtained from the Behavioral Risk Factor Sur-
veillance System (BRFSS)—an annual cross-sectional land-
line and cellular telephone state-based survey conducted by
the Centers for Disease Control and Prevention to collect
health prevalence data. A complex probability sampling
technique was used to sample English and Spanish speak-
ing United States residents at least 18 years of age. For this
analysis, survey data from 2014 to 2016 was pooled.35
The BRFSS includes modules, which states may choose to
include or exclude in their annual survey. In 2014, an optional
‘‘gender identity’’ module was added. This module was in-
cluded by 20–26 states and territories during each annual
survey from 2014 to 2016. In participating states or territo-
ries, survey respondents were asked, ‘‘Do you consider
yourself to be transgender?’’ Individuals who identified as
transgender were then asked, ‘‘Do you consider yourself to be
male-to-female, female-to-male, or gender nonconform-
ing?’’ We classified individuals as transgender if they af-
firmed transgender identity, and will use the terminology
male-to-female (MTF), female-to-male (FTM), and gender
nonconforming in this article to align with the terminology
for minority genders used in the original survey. Given that
individuals who stated that they were not transgender were
not asked whether they were cisgender, or more precisely,
were not asked their sex assigned at birth and current gender
identity align, we will use the language non-transgender to
refer to those respondents who did not identify as transgen-
der, rather than the term cisgender. In 2014–2015 ‘‘sex’’ (not
specified as sex assigned at birth or current self-identified
sex) was determined by the interviewer, with ‘‘clarification if
necessary’’; in 2016, respondents were asked, ‘‘are you male
or female?’’ For the purposes of analysis, respondents were
categorized as having a natal female sex if they identified as
non-transgender and their sex was coded as female, or if
they identified as transgender and FTM, regardless of docu-
mented sex.
Frequent mental distress was the primary outcome of in-
terest. Frequent mental distress is defined as 14 or more days
in the last month of self-rated ‘‘not good’’ mental health.
Frequent mental distress data provide an assessment of
mental health in a single question, with excellent specificity
and reasonable sensitivity.36 Frequent mental distress was
chosen as the primary outcome of interest, given known
disparities in access of transgender individuals to the health
system, and risk of provider conflation of gender dysphoria
with other mental health diagnoses.4 Ever having been given
a diagnosis of a depressive disorder was considered as a
secondary outcome of interest (Were you ‘‘ever told you had
a depressive disorder, including depression, major depres-
sion, dysthymia, or minor depression?’’).
Covariates of interest included: age, race, marital status,
education (less than college vs. any college), employment
outside the home (self-employed or employed for wages vs.
all other employment statuses), poverty, whether respondents
had health care insurance, whether respondents had a per-
sonal health care provider, poor self-rated physical health
(14 or more days of self-rated ‘‘not good’’ physical health in
the last 30 days). Participant-reported annual household in-
come range and size were used to create an ordinal measure
of percentage of the federal poverty line. Annual household
 GENDER AND FREQUENT MENTAL DISTRESS
income was recategorized using the midpoint for each in-
come range and to the 80th percentile of annual family in-
come ($112,262) for those who selected the highest income
category.37 The recorded income was divided by 2014
household size-specific weighted average poverty thresh-
olds.37 General self-rated health (‘‘Would you say that in
general your health is excellent, very good, good, fair, or
poor?’’) was dichotomized as poor or fair, compared to good,
very good, or excellent.
All analyses were performed using STATA version 14.0
(StataCorp LP, College Station, TX) using functions appro-
priate for complex survey sample analysis. We restricted the
analytic sample to states that asked about transgender status
and individuals who answered (n = 518,986). We performed
design-adjusted Chi-square tests of the association of trans-
gender identity with frequent mental distress. Multivariable
logistic regression models were created to identify indepen-
dent predictors of frequent mental distress, with gender
Downloaded by University Of Queensland from www.liebertpub.com at 06/08/19. For personal use only.
identity as the independent variable of interest, using BRFSS
sampling weights.
For modeling, the population was further restricted to ex-
clude strata with fewer than two transgender respondents to
facilitate multivariable regression analysis (n = 407,075).
Variables significant in multivariate analysis or identified as
clinically relevant based on existing research were selected as
candidate variables in multivariable models.23,28,38 Specifi-
cally, employment status was dropped given concern for
collinearity with poverty, education, and insurance status,
while insurance status was retained in addition to poverty
given mid-income gaps in Medicaid eligibility. Models were
created, including transgender status as a dichotomous vari-
able (transgender vs. non-transgender), along with natal sex
female (vs. not), and separately with a nominal gender vari-
able (non-transgender male, non-transgender female, MTF,
FTM, and gender nonconforming) to explore differences
between the transgender and non-transgender population as
well as potential heterogeneity within gender minorities.
Interaction terms of transgender status and poverty cate-
gory and transgender status and race were explored based
on a priori concern for interaction. Interaction terms using
five gender categories were not used given sample size
limitations. Statistical significance was assessed at the
a = 0.05 level.
Results
Among 518,986 respondents, 0.51% of identified as
transgender (0.25% MTF, 0.15% FTM, 0.11% gender non-
conforming). The transgender population was younger and of
more likely to identify as Hispanic (19.5% confidence in-
terval [CI 15.6–24.1] vs. 13.8% [CI 13.5–14.0]) than the non-
transgender population (Table 1). Transgender individuals
were also less likely to be married (42.6% [CI 38.4–46.9] vs.
51.9% [CI 51.6–52.2]) and less likely to attend college
(40.1% [CI 36.1–44.2] vs. 57.4% [CI 57.1–57.7]) than non-
transgender individuals. However, the gender nonconform-
ing cohort of the transgender population had rates of college
attendance similar to non-transgender populations (53.5%
[CI 45.0–61.8]). Transgender individuals were more likely to
not be employed outside the home (46.8% (CI 42.7–51.0) vs.
42.6% (CI 42.3–42.9)), and be below the federal poverty line
145
(28.5% (CI 24.4–32.9) vs. 15.9% (CI 15.7–16.2)) compared
to non-transgender individuals.
A higher proportion of transgender individuals rated their
general health as poor or fair (22.3% [CI 19.4–25.6] vs.
17.4% [CI 17.2–17.6]) and their physical health as poor
(15.9% [CI 13.3–19.0] vs. 11.9% [CI 11.7–12.1]) compared
with the non-transgender population. The transgender pop-
ulation was less likely to have health insurance (19.0% [CI
15.7–22.7] vs. 11.3% [CI 11.1–11.5]) and more likely to lack
a personal health care provider (27.0% [CI 23.0–31.4] vs.
19.7% [CI 19.5–20.0]) compared with the non-transgender
population.
The transgender population was more likely to report
frequent mental distress (19.6% [CI 16.6–23.0] vs. 11.2% [CI
11.0–11.4]) and ever having had a depressive disorder diag-
nosis (26.9% [CI 23.5–30.6] vs. 17.4% [CI 17.2–17.6])
compared with the non-transgender population. By gender,
the lowest proportion with frequent mental distress was
among non-transgender males (9.3% [CI 9.1–9.6]). Non-
transgender females and MTF had similar rates of frequent
mental distress (12.9% [CI 12.6–13.1] and 14.2% [CI 10.9–
18.3]), and FTM and gender nonconforming individuals en-
dorsed higher rates of frequent mental distress (24.7% [CI
18.5–32.3] and 25.4% [CI 18.7–33.5], respectively). When
stratified by gender, in unadjusted bivariate analysis, all
gender groups had increased odds of frequent mental dis-
tress compared with non-transgender males (Table 2). Rates
of diagnosis of a depressive disorder among each gender
category were higher than rates of frequent mental distress
(Table 1).
In multivariable logistic regression analysis, after ad-
justing for age, race, marital status, education, poverty
category, insurance status, and self-rated physical health,
transgender identity (adjusted odds ratio [aOR] 1.49 [CI
1.14–1.96]), and female natal sex (aOR 1.39 [CI 1.32–1.46])
remained associated with frequent mental distress (Table 3,
Model 1). Similarly, poverty and poor self-rated physical
health were associated with frequent mental distress, while
being married, attending any college, and older age were
protective (Table 3). In multivariable analysis of frequent
mental distress stratified by gender, identifying as a non-
transgender female (aOR 1.39 [CI 1.32–1.46], FTM (aOR
1.93 [CI 1.26–2.95]), or gender nonconforming individual (aOR
2.05 [CI 1.20–3.50]) was associated with increased odds of
frequent mental distress (Table 4). However, odds of frequent
mental distress among MTF individuals were not statistically
significantly different from non-transgender males. Odds of
depression disorder diagnosis were higher in non-transgender
females, MTF, FTM, and gender nonconforming individuals
compared with non-transgender men. Race and insurance
status were not significantly associated with frequent mental
distress.
The interaction of transgender status with poverty category
was statistically significant in multivariable logistic regres-
sion models (Table 3, Model 2). Among individuals within
0%–99% of the federal poverty line, transgender individuals
did not have a significantly higher predicted probability of
mental distress compared with non-transgender individuals
(Fig. 1). However, among households within ‡200% of the
federal poverty line, transgender individuals had a signifi-
cantly higher predicted probability of mental distress com-
pared with non-transgender individuals. The interaction of
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Table 1. Weighted Sociodemographic and Health Characteristics by Transgender Status and Gender: BRFSS, 2014–2016
Transgender
gender non-
Non-transgender Transgender Non-transgender Non-transgender Transgender Transgender conforming
% (95% CI) % (95% CI) p male % (95% female % (95% MTF % (95% FTM % (95% % (95% CI)
Characteristic (n = 516,757) (n = 2,229) Value CI) (n = 218,366) CI) (n = 289,391) CI) (n = 1,078) CI) (n = 701) (n = 450) p Value
Age, years
18–29 19.3 (19.1–19.6) 28.7 (24.9–32.9) <0.001 20.7 (20.3–21.1) 18.0 (17.7–18.4) 26.0 (20.7–32.2) 26.1 (19.7–33.7) 38.8 (30.7–47.6) <0.001
30–49 32.6 (32.4–32.9) 29.3 (25.6–33.3) 33.3 (32.9–33.7) 32.0 (31.7–32.4) 26.3 (21.4–31.8) 37.9 (30.5–45.9) 24.9 (18.4–32.7)
‡50 48.1 (47.8–48.3) 41.9 (37.9–46.1) 46.1 (45.6–46.4) 49.9 (49.6–50.3) 47.7 (41.5–53.9) 36.0 (29.8–42.7) 36.3 (28.8–44.5)
Race/ethnicity
White, non-Hispanic 66.2 (65.9–66.4) 54.6 (50.2–58.9) <0.001 66.2 (65.7–66.6) 66.2 (65.8–66.6) 57.8 (51.2–64.2) 50.9 (43.3–58.4) 51.9 (43.3–60.3) <0.001
Black, non-Hispanic 11.2 (11.0–11.4) 13.4 (10.7–16.8) 10.4 (10.1–10.7) 11.8 (11.6–12.1) 12.7 (8.9–17.8) 14.3 (9.7–20.6) 13.9 (8.7–21.7)
Hispanic 13.8 (13.5–14.0) 19.5 (15.6–24.1) 14.0 (13.7–14.4) 13.5 (13.2–13.8) 16.3 (10.9–23.7) 24.2 (17.4–32.5) 20.8 (13.8–30.1)
Asian, American 8.9 (8.7–9.1) 12.5 (9.8–15.7) 9.4 (9.2–9.7) 8.5 (8.2–8.7) 13.1 (9.5–18.0) 10.7 (6.1–17.9) 13.4 (8.7–20.2)
Indian, Alaska
and Hawaii natives,
Pacific Islanders,
Other/Multiracial
non-Hispanic

146
Married 51.9 (51.6–52.2) 42.6 (38.4–46.9) <0.001 53.5 (53.1–54.0) 50.4 (50.0–50.7) 46.9 (40.7–53.3) 41.1 (33.8–48.8) 34.3 (26.7–42.8) <0.001
Any college 57.4 (57.1–57.7) 40.1 (36.1–44.2) <0.001 55.5 (55.1–55.9) 59.2 (58.8–59.5) 38.6 (32.9–44.8) 32.7 (26.4–39.6) 53.5 (45.0–61.8) <0.001
Not employed outside 42.6 (42.3–42.9) 46.8 (42.7–51.0) 0.046 35.1 (34.7–35.5) 49.5 (49.1–49.9) 43.1 (37.3–49.2) 47.5 (40.2–54.9) 54.7 (46.3–62.8) <0.001
the home
Percentage poverty linea,b
0–99 15.9 (15.7–16.2) 28.5 (24.4–32.9) <0.001 13.5 (13.1–13.8) 18.3 (17.9–18.6) 26.7 (21.2–33.0) 35.8 (27.7–44.8) 23.2 (16.3–32.0) <0.001
100–199 23.7 (23.5–24.0) 30.5 (26.2–35.3) 22.5 (22.2–22.9) 24.9 (24.5–25.2) 30.9 (24.3–38.4) 31.2 (24.1–39.2) 28.8 (21.1–38.0)
‡200 60.4 (60.1–60.7) 41.0 (36.8–45.4) 64.0 (63.6–64.5) 56.9 (56.5–57.3) 42.4 (36.3–48.7) 33.1 (26.0–41.0) 48.0 (39.0–57.1)
No insurance 11.3 (11.1–11.5) 19.0 (15.7–22.7) <0.001 12.9 (12.6–13.2) 9.8 (9.5–10.1) 18.1 (13.7–23.7) 23.4 (17.0–31.4) 14.7 (9.9–21.4) <0.001
No doctor 19.7 (19.5–20.0) 27.0 (23.0–31.4) <0.001 25.2 (24.8–25.5) 14.7 (14.4–15.0) 25.1 (19.1–32.1) 31.7 (24.7–39.6) 25.1 (18.2–33.7) <0.001
Poor/fair self-rated 17.4 (17.2–17.6) 22.3 (19.4–25.6) <0.001 16.7 (16.3–17.0) 18.2 (17.9–18.5) 18.4 (14.9–22.5) 23.3 (18.1–29.6) 30.3 (23.2–38.5) <0.001
general health
Poor self-rated 11.9 (11.7–12.1) 15.9 (13.3–19.0) 0.002 10.8 (10.5–11.0) 13.0 (12.7–13.2) 14.7 (11.2–19.0) 15.9 (11.6–21.4) 18.9 (12.8–27.0) <0.001
physical health
Frequent mental 11.2 (11.0–11.4) 19.6 (16.6–23.0) <0.001 9.3 (9.1–9.6) 12.9 (12.6–13.1) 14.2 (10.9–18.3) 24.7 (18.5–32.3) 25.4 (18.7–33.5) <0.001
distress
Depression disorder 17.4 (17.2–17.6) 26.9 (23.5–30.6) <0.001 12.8 (12.5–13.1) 21.6 (21.3–21.9) 22.8 (18.4–27.8) 29.9 (23.5–37.1) 32.7 (25.3–41.0) <0.001
diagnosis
All percents and CIs were design-adjusted, sample sizes are not design-adjusted.
a
Data missing for >10% of respondents.
b
Federal poverty thresholds set by the United States Census Bureau in 2014.
BRFSS, Behavioral Risk Factor Surveillance System; CI, confidence interval; MTF, male-to-female; FTM, female-to-male.
 GENDER AND FREQUENT MENTAL DISTRESS 147

Table 2. Unadjusted Odds of Frequent Mental Distress and Depression Disorder Diagnosis
by Sociodemographic and Health Characteristics Among Individuals in Strata
with Two or More Individuals Identifying As Transgender: BRFSS, 2014–2016
OR frequent mental OR depression disorder
distress (95% CI) diagnosis (95% CI)
Characteristic (n = 407,075) p Value (n = 407,075) p Value
Transgender 1.94 (1.56–2.41) <0.001 1.78 (1.47–2.16) <0.001
Gender (non-transgender, male)
MTF 1.59 (1.15–2.19) 0.005 2.05 (1.54–2.73) <0.001
FTM 3.33 (2.24–4.96) <0.001 3.07 (2.18–4.32) <0.001
Gender nonconforming 3.24 (2.15–4.89) <0.001 3.21 (2.19–4.70) <0.001
Non-transgender, female 1.43 (1.38–1.50) <0.001 1.89 (1.83–1.96) <0.001
Age, years (18–29)
30–49 0.86 (0.81–0.91) <0.001 1.03 (0.97–1.08) 0.262
‡50 0.68 (0.64–0.71) <0.001 1.01 (0.96–1.06) 0.796
Race/ethnicity (white non-Hispanic)
Black, non-Hispanic 1.16 (1.09–1.24) <0.001 0.72 (0.68–0.77) <0.001
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Hispanic 0.96 (0.90–1.03) 0.309 0.67 (0.63–0.71) <0.001

Asian, American Indian, 0.96 (0.89–1.04) 0.338 0.62 (0.58–0.67) <0.001
Alaska and Hawaii natives,
Pacific Islanders, Other/
Multiracial non-Hispanic
Married 0.52 (0.49–0.54) <0.001 0.61 (0.59–0.63) <0.001
Any college 0.67 (0.64–0.70) <0.001 0.86 (0.84–0.89) <0.001
Not employed outside the home 1.85 (1.77–1.92) <0.001 1.88 (1.82–1.94) <0.001
Percentage poverty linea,b (>200%)
0–99 3.10 (2.92–3.28) <0.001 2.16 (2.06–2.27) <0.001
100–199 1.95 (1.85–2.05) <0.001 1.67 (1.60–1.73) <0.001
No insurance 1.35 (1.27–1.45) <0.001 0.93 (0.87–0.99) 0.017
No doctor 1.05 (1.00–1.11) 0.068 0.68 (0.65–0.72) <0.001
Poor/fair self-rated overall health 4.78 (4.58–4.99) <0.001 3.48 (3.35–3.61) <0.001
Poor self-rated physical health 6.62 (6.33–6.93) <0.001 3.92 (3.76–4.08) <0.001
Depression disorder diagnosis 9.63 (9.22–10.10) <0.001 n/a
Frequent mental distress n/a 9.63 (9.22–10.06) <0.001
All percents and CIs were design-adjusted, sample sizes are not design-adjusted.
a
Data missing for >10% of respondents.
b
Federal poverty thresholds set by the United States Census Bureau in 2014.
n/a, not applicable; OR, odds ratio.

transgender status with race was not statistically significant
(data not shown).
Discussion
Findings from this multistate probability sample suggest
significant heterogeneity of the sociodemographics and
of self-rated mental health of minority genders within the
transgender population. In addition, our findings indi-
cate higher rates of frequent mental distress and depressive
disorder diagnosis in transgender compared to non-transgender
populations, consistent with previously published data.4,8–10
These findings remained statistically significant after con-
trolling for age, race, marital status, college attendance,
poverty, health insurance status, and poor self-rated physi-
cal health.
We found significant sociodemographic differences between
the non-transgender and transgender population, including
factors associated with mental health.23,28,38 Consistent with
previous studies, we found that the transgender community
was more racially diverse than the non-transgender com-
munity, with a statistically smaller proportion of white non-
Hispanic individuals and a larger proportion of Hispanic
individuals as well as individuals identified with races or
ethnicities other than white, black, or Hispanic (Table 1).10
As expected, based on previous findings, we found that
transgender individuals were also more likely to be in pov-
erty, have poor or fair general health, report poor physical
health, and were less likely to have attended any college,
have health insurance, or have a primary care provider.10,22
In contrast to analyses of the 2014 BRFSS data alone, where
no difference in the proportion of married individuals was
noted between the transgender and non-transgender popula-
tion, we found that the transgender population was signifi-
cantly less likely to be married than the non-transgender
population.10,22 This finding is likely a reflection of increased
power with increased sample size.
Our findings of higher rates of frequent mental distress and
depression disorder diagnosis among transgender compared
with non-transgender populations align with existing re-
search on mental health outcomes in transgender compared
with cisgender cohorts.4,8–10 However, few studies have
explored differences in mental health outcomes within gen-
der minority populations; those that have explored have
inconsistently identified gendered differences and have
been conducted using convenience samples that may lack
 Table 3. Multivariable Logistic Regression and Odds of Frequent Mental Distress
by Transgender Status and Natal Sex Among Individuals in Strata with Two
or More Individuals Identifying As Transgender: BRFSS, 2014–2016
Frequent mental distress Depression
Model 1 Model 2 Model 3
Characteristics aOR (95% CI) p aOR (95% CI) p aOR (95% CI) p
(reference) (n = 337,886) Value (n = 337,886) Value (n = 340,168) Value
Transgender 1.49 (1.14–1.96) 0.004 2.17 (1.47–3.20) <0.001 1.80 (1.44–2.25) <0.001
Female natal sex 1.39 (1.32–1.46) <0.001 1.39 (1.32–1.46) <0.001 1.85 (1.78–1.92) <0.001
Age, years (18–29)
30–49 0.92 (0.86–0.99) 0.035 0.92 (0.86–1.00) 0.037 1.21 (1.14–1.28) <0.001
‡50 0.61 (0.56–0.65) <0.001 0.61 (0.560.65) <0.001 1.06 (1.00–1.12) 0.058
Black, non-Hispanic 0.95 (0.87–1.03) 0.185 0.95 (0.87–1.03) 0.184 0.64 (0.59–0.68) <0.001
Married 0.67 (0.64–0.70) <0.001 0.67 (0.64–0.70) <0.001 0.67 (0.65–0.70) <0.001
Any college 0.91 (0.87–0.96) 0.001 0.91 0.87–0.96) 0.001 1.12 (1.07–1.17) <0.001
Percentage poverty linea,b (‡200%)
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0–99 1.87 (1.74–2.01) <0.001 1.88 (1.75–2.02) <0.001 1.77 (1.67–1.87) <0.001
100–199 1.42 (1.34–1.51) <0.001 1.42 (1.34–1.51) <0.001 1.43 (1.37–1.50) <0.001
No insurance 0.99 (0.91–1.08) 0.802 0.99 (0.91–1.08) 0.803 0.78 (0.72–0.84) <0.001
Poor self-rated physical health 6.53 (6.20–6.88) <0.001 6.53 (6.19–6.88) <0.001 3.49 (3.33–3.65) <0.001
Transgender · Percentage poverty line (‡200%)
Transgender · 0%–99% 0.52 (0.27–0.99) 0.046
Transgender · 100%–199% 0.63 (0.35–1.13) 0.119
All percents and CIs were design-adjusted, sample sizes are not design-adjusted.
a
Data missing for >10% of respondents.
b
Federal poverty thresholds set by the United States Census Bureau in 2014.

Table 4. Multivariable Logistic Regression, Odds of Frequent Mental Distress, and Depression Disorder
Diagnosis by Gender Among Individuals in Strata with Two or More Individuals Identifying
As Transgender: BRFSS, 2014–2016
Frequent mental distress Depression disorder diagnosis
aOR (95% CI) aOR (95% CI)
Characteristics (n = 338,391) p Value (n = 338,391) p Value
Gender (non-transgender, male)
MTF 1.31 (0.85–2.03) 0.225 1.64 (1.20–2.34) 0.002
FTM 1.93 (1.26–2.95) 0.003 2.55 (1.67–3.89) <0.001
Gender nonconforming 2.05 (1.20–3.50) 0.008 3.03 (1.93–4.74) <0.001
Non-transgender, female 1.39 (1.32–1.46) <0.001 1.86 (1.79–1.93) <0.001
Age, years (18–29)
30–49 0.92 (0.86–0.99) 0.036 1.21 (1.14–1.29) <0.001
‡50 0.61 (0.56–0.65) <0.001 1.06 (1.00–1.12) 0.055
Black, non-Hispanic 0.95 (0.87–1.03) 0.182 0.64 (0.59–0.68) <0.001
Married 0.67 (0.64–0.70) <0.001 0.67 (0.65–0.70) <0.001
Any college 0.91 (0.87–0.96) 0.001 1.12 (1.07–1.16) <0.001
Percentage poverty linea,b (>200%)
0–99 1.87 (1.75–2.01) <0.001 1.77 (1.67–1.87) <0.001
100–199 1.42 (1.34–1.51) <0.001 1.43 (1.37–1.50) <0.001
No insurance 0.99 (0.91–1.08) 0.807 0.78 (0.73–0.84) <0.001
Poor self-rated physical health 6.53 (6.19–6.88) <0.001 3.49 (3.33–3.65) <0.001
All percents and CIs were design-adjusted, sample sizes are not design-adjusted.
a
Data missing for >10% of respondents.
b
Federal poverty thresholds set by the United States Census Bureau in 2014.

148
 GENDER AND FREQUENT MENTAL DISTRESS
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generalizability to the broader transgender population. In a
predominantly white, highly educated (87.5% with some
college or more), internet-based convenience sample survey
of transgender individuals, higher rates of depression among
transwomen compared with transmen were reported (49.1%
vs. 37.3%).8 Similarly, Clements-Nolle et al. found a trend
toward higher rates of depression among MTF compared
with FTM individuals in a convenience sample.33 However, a
retrospective chart review of individuals covered by a single
health plan found a higher rate of depression among FTM
compared with MTF individuals.32
Our study suggests heterogeneity in mental health out-
comes among various genders represented within the trans-
gender identity. We found higher rates of frequent mental
distress among the FTM and gender nonconforming popu-
lations, compared with the MTF population (Table 1). In
adjusted multivariable models, non-transgender females,
FTM, and gender nonconforming individuals had increased
odds of frequent mental distress compared with non-transgender
males, while there was not a statistically significant difference
in odds of frequent mental distress between MTFs and non-
transgender males (Table 4). These findings serve as a re-
minder to research and clinical communities to be cautious in
recognizing the gendered differences that may be overlooked
when work related to gender minority groups is simplified into
a comparison of transgender and cisgender people. These
findings suggest nuanced heterogeneity within various genders
in the transgender population, just as there are known vari-
ances in genders within the cisgender population.
Explanation for the higher rate of frequent mental dis-
tress among FTM individuals compared to MTFs and non-
transgender males, is likely multifactorial, with possible
contributions from biology and socialization. In binary
comparisons of the mental health of adolescents, gender
differences in depression among presumed cisgender boys
and girls emerge at puberty; among girls depression is as-
sociated with body dissatisfaction and pubertal body chan-
ges, but has not been consistently associated with measures of
femininity.39 Self-rated mental health among the FTM indi-
149
FIG. 1. Predicted proba-
bility of frequent mental
distress in transgender versus
non-transgender individuals
by percent of the poverty
line, generated from multi-
variable model in Table 3,
Model 2. Points show ex-
pected value, whiskers show
confidence interval.
viduals may, in part, reflect effects of socialization as a young
girl or of natal female biology. In addition, recent research
suggests that transgender men are more likely to experience
enacted stigma (e.g., verbal harassment, problems getting a
job) compared with transgender women, which may, in part,
explain higher rates of frequent mental distress in the FTM
population.8
Gender nonbinary individuals are rarely given opportunities
to identify themselves in national surveys, which often offer
only binary gender responses. Thus, little is known about the
sociodemographic and health outcomes of nonbinary indi-
viduals. Our findings suggest that gender nonconforming in-
dividuals are more likely to attend college than MTF or FTM
individuals, but are as likely to be in poverty (Table 1). Gender
nonconforming individuals were also more likely than MTF to
rate their general health as poor or fair, and were additionally
more likely to have frequent mental distress when com-
pared with MTF individuals. Given the impact of gender on
health, and the widespread assumption of gender binaries in
health care research, provision, and institutions, we hypothe-
size nonbinary individuals face unique challenges and may
have different health outcomes than may be anticipated based
on their sex assigned at birth. Unfortunately, in the survey data
analyzed here, participant sex was obtained by interviewer
assumption or by querying the respondent, but without spec-
ifying sex assigned at birth; we are thus unable to comment
accurately on differences by sex assigned at birth among
gender nonconforming individuals. Moreover, lack of clarity
regarding sex data hinders data collection regarding natal sex-
specific issues such as cervical cancer screening in this pop-
ulation. Mental health outcomes among nonbinary individuals
may, in part, reflect lack of social acceptance and public un-
derstanding of nonbinary genders expression.
Sociodemographic diversity within the transgender com-
munity is also an important consideration in exploring physical
and mental health outcomes. The disproportionate impact of
poverty on the transgender community raises concerns for
an impact on the mental health and overall well-being of
gender minority individuals. At the population level, there is
 150
evidence both for poor mental health leading to lower earn-
ings and low socioeconomic status causing depression.23 In
the setting of transgender identity, poverty adds additional
economic barriers to medical gender affirming care and so-
cial transitioning, recourse in the setting of discrimination
and violence, and access to postsecondary education.3 While
improvement in socioeconomic status is associated with
lower odds of frequent mental distress in non-transgender
individuals, this trend was not observed for transgender in-
dividuals (Fig. 1). We hypothesize that this finding reflects
that while all disenfranchised people face economic barriers
to health, transgender individuals continue to face significant
barriers to health, such as discrimination and violence, even
in higher income levels.
In comparison to non-transgender males, all genders had
higher rates of ever having had a diagnosis of a depressive
disorder. More research is needed to explore gendered dif-
ferences in frequent mental distress and in ever having had a
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depression disorder diagnosis. Our findings may suggest a
conflation or co-occurrence of transgender identity with de-
pressive disorders across genders, a gendered difference in
self-described mental health that is not reflected in depressive
disorder diagnostic criteria, a gendered difference in seeking
or responding to treatment, or a difference in the persistence
of symptoms across genders.
Strengths of the current study include the large, multistate
probability sample, which offers improved national gener-
alizability in comparison to convenience sample surveys. Our
study is also strengthened by the exploration of differences
between minority genders within the umbrella of transgender
identity. The lack of inclusion of a two-step sex and gender
question in the demographics section (to confirm both sex
assigned at birth and current gender identity) may have
caused individuals who are not cisgender, but do not identify
as transgender, to not be captured appropriately, inaccuracies
in our assessment of natal female sex, and prohibited an
analysis of the gender nonconforming individuals by sex
assigned at birth.40 While this is a relatively large sample of a
minority community, sample size constraints limit certain
analyses and their interpretation.
Conclusions
Our findings suggest significant heterogeneity within the
transgender population, including differences in mental
health outcomes between minority genders. More work is
needed to explore differences in mental health outcomes for
minority genders across the life course, including in rela-
tionship to puberty, to aging, and to gender-affirming medical
care, as well as socioenviromental factors. Understanding
the protective and provoking factors driving differences in
mental health outcomes is critical to informing efforts to
improve the mental health of transgender individuals and to
stem the high rates of suicide in this population.
Research on the health of transgender individuals has been
limited by inaccurate and conflated measures of sex and
gender and rare inclusion of nonbinary genders. Beyond the
limitations this creates for analyzing health outcomes for the
transgender compared with cisgender population, it hinders
efforts to explore differences in outcomes between various
genders within the transgender population. Enhanced efforts
to capture accurate data on sex assigned at birth and gender
CRISSMAN ET AL.
identity, including nonbinary genders, are needed to facilitate
future efforts to understand and improve health outcomes for
the diverse range of transgender identities.
Acknowledgments
We appreciate the support of the University of Michigan
Department of Obstetrics and Gynecology.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Halley P. Crissman, MD, MPH
Department of Obstetrics and Gynecology
University of Michigan
1500 E. Medical Center Drive
Ann Arbor, MI 48109
E-mail: hcrissma@med.umich.edu