State Policies and Health Disparities between Transgender and Cisgender Adults: Considerations and Challenges Using Population-Based Survey Data.

CONTEXT This study examined the association between state-level policy protections (e.g., inclusive of hate crimes, employment, housing, education, and/or public accommodations) and self-rated health disparities between transgender and cisgender adults. METHODS We used data on transgender (n=4,982) and cisgender (n=1,168,859) adults from the 2014-2019 Behavioral Risk Factor Surveillance System. We estimated state-specific health disparities between transgender and cisgender adults. Multivariable logistic regression models were used to compare adjusted odds ratios (aOR) between transgender and cisgender adults by state-level policy environments. FINDINGS Overall, transgender adults were significantly (p<0.05) more likely to report poor/fair health (aOR=1.26; 95% CI=1.18-1.36), frequent mental distress (aOR=1.79; 95% CI=1.67-1.93), and frequent poor physical health days (aOR=1.26; 1.16-1.36) than cisgender adults. Disparities between transgender and cisgender adults were found in states with strengthened protections and in states with limited protections. Compared to transgender adults in states with limited protections, transgender adults in states with strengthened protections were marginally (p<0.10) less likely to report frequent mental distress (aOR=0.33; 95% CI=0.11-1.05). CONCLUSIONS Transgender adults in most states reported worse self-rated health than their cisgender peers. Much more research and robust data collection on gender identity are critically needed to study the associations between state policies and transgender health and to identify best practices for achieving health equity for transgender Americans.