Intersectionality and Health Inequities for Gender Minority Blacks in the U.S.

  • Elle Lett
    Address correspondence to: Elle Lett, MBiostat, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia PA 19104.
    Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania

    Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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  • Nadia L. Dowshen
    Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania

    Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania

    Craig-Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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  • Kellan E. Baker
    Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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      Gender minority blacks represent the intersection of multiply marginalized populations that experience severe health inequities in the U.S. However, few studies focus on the unique health experiences of this multiply disadvantaged population. This study quantifies the health inequities experienced by gender minority blacks in the U.S. using an intersectional framework.


      This cross-sectional study analyzed data in 2018/2019 from the Behavioral Risk Factor Surveillance System, including all cisgender black, gender minority black, and gender minority white survey respondents who completed the gender identity module between 2014 and 2018. Investigators compared demographics, healthcare access, behavioral risk factors, chronic conditions, and perceived health status of gender minority blacks with those of cisgender blacks and gender minority whites.


      In the primary analysis of weighted survey data, gender minority blacks were more likely to report experiencing severe mental distress (AOR=1.99, 95% CI=1.14, 3.47, p=0.02), longer periods of being physically or mentally unwell (adjusted RR=1.36, 95% CI=1.17, 1.59, p<0.001), and longer periods of activity limitations owing to poor health (adjusted RR=1.53, 95% CI=1.01, 1.41, p=0.003) than cisgender blacks. In a matched analysis, gender minority blacks had worse self-reported health than both cisgender blacks (OR=1.32, 95%: CI=1.05, 1.67, p=0.02) and gender minority whites (OR=1.53, 95% CI=1.15, 2.04, p=0.003).


      Gender minority blacks have health experiences that are distinct from those of both the cisgender black and gender minority populations with which they intersect. Health policies and programs, including data collection efforts, must specifically consider this multiply marginalized population to effectively advance health equity.
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        • Matsuno E
        • Budge SL
        Non-binary/genderqueer identities: a critical review of the literature.
        Curr Sex Health Rep. 2017; 9: 116-120
        • Lefevor GT
        • Boyd-Rogers CC
        • Sprague BM
        • Janis RA
        Health disparities between genderqueer, transgender, and cisgender individuals: an extension of minority stress theory.
        J Couns Psychol. 2019; 66: 385-395
        • Reisner SL
        • Vetters R
        • Leclerc M
        • et al.
        Mental health of transgender youth in care at an adolescent urban community health center: a matched retrospective cohort study.
        J Adolesc Health. 2015; 56: 274-279
        • McDowell A
        • Progovac AM
        • Cook BL
        • Rose S
        Estimating the health status of privately insured gender minority children and adults.
        LGBT Health. 2019; 6: 289-296
        • Blosnich JR
        • Marsiglio MC
        • Gao S
        • et al.
        Mental health of transgender veterans in U.S. states with and without discrimination and hate crime legal protection.
        Am J Public Health. 2016; 106: 534-540
      1. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The report of the 2015 U.S. transgender survey. Washington, DC: National Center for Transgender Equality. Published December 2016. Accessed April 24, 2020.

        • Wierckx K
        • Elaut E
        • Declercq E
        • et al.
        Prevalence of cardiovascular disease and cancer during cross-sex hormone therapy in a large cohort of trans persons: a case-control study.
        Eur J Endocrinol. 2013; 169: 471-478
        • Alzahrani T
        • Nguyen T
        • Ryan A
        • et al.
        Cardiovascular disease risk factors and myocardial infarction in the transgender population.
        Circ Cardiovasc Qual Outcomes. 2019; 12e005597
        • Safford MM
        • Brown TM
        • Muntner PM
        • et al.
        Association of race and sex with risk of incident acute coronary heart disease events.
        JAMA. 2012; 308: 1768-1774
        • Ski CF
        • King-Shier KM
        • Thompson DR
        Gender, socioeconomic and ethnic/racial disparities in cardiovascular disease: a time for change.
        Int J Cardiol. 2014; 170: 255-257
        • Saydah S
        • Imperatore G
        • Cheng Y
        • Geiss LS
        • Albright A
        Disparities in diabetes deaths among children and adolescents - United States, 2000-2014.
        MMWR Morb Mortal Wkly Rep. 2017; 66: 502-505
        • Bancks MP
        • Kershaw K
        • Carson AP
        • Gordon-Larsen P
        • Schreiner PJ
        • Carnethon MR
        Association of modifiable risk factors in young adulthood with racial disparity in incident type 2 diabetes during middle adulthood.
        JAMA. 2017; 318: 2457-2465
        • Powe NR
        Let's get serious about racial and ethnic disparities.
        J Am Soc Nephrol. 2008; 19: 1271-1275
        • Norton JM
        • Moxey-Mims MM
        • Eggers PW
        • et al.
        Social determinants of racial disparities in CKD.
        J Am Soc Nephrol. 2016; 27: 2576-2595
        • Canino G
        • McQuaid EL
        • Rand CS
        Addressing asthma health disparities: a multilevel challenge.
        J Allergy Clin Immunol. 2009; 123: 1209-1219
        • Crenshaw K
        Demarginalizing the intersection of race and sex: a black feminist critique of antidiscrimination doctrine, feminisit theory, and antiracist politics.
        Univ Chic Leg Forum. 1989; 8 (Accessed April 24, 2020): 139-168
        • Bowleg L
        • Huang J
        • Brooks K
        • Black A
        • Burkholder G
        Triple jeopardy and beyond: multiple minority stress and resilience among black lesbians.
        J Lesbian Stud. 2003; 7: 87-108
        • Brown GR
        • Jones KT
        Racial health disparities in a cohort of 5,135 transgender veterans.
        J Racial Ethn Health Disparities. 2014; 1: 257-266
        • Holder CL
        • Perez-Gilbe HR
        • Fajardo FJ
        • Garcia S
        • Cyrus E
        Disparities of HIV risk and PrEP use among transgender women of color in South Florida.
        J Natl Med Assoc. 2019; 111: 625-632
        • Reback CJ
        • Fletcher JB
        HIV prevalence, substance use, and sexual risk behaviors among transgender women recruited through outreach.
        AIDS Behav. 2014; 18: 1359-1367
        • Streed Jr, CG
        • McCarthy EP
        • Haas JS
        Association between gender minority status and self-reported physical and mental health in the United States.
        JAMA Intern Med. 2017; 177: 1210-1212
        • Meyer IH
        • Brown TNT
        • Herman JL
        • Reisner SL
        • Bockting WO
        Demographic characteristics and health status of transgender adults in select U.S. regions: Behavioral Risk Factor Surveillance System, 2014.
        Am J Public Health. 2017; 107: 582-589
        • Baker KE
        Findings from the Behavioral Risk Factor Surveillance System on health-related quality of life among U.S. transgender adults, 2014-2017.
        JAMA Intern Med. 2019; 179: 1141-1144
      2. About the Behavioral Risk Factor Surveillance System (BRFSS). Centers for Disease Control and Prevention. Updated May 16, 2014. Accessed November 25, 2019.

        • Tate CC
        • Ledbetter JN
        • Youssef CP
        A two-question method for assessing gender categories in the social and medical sciences.
        J Sex Res. 2013; 50: 767-776
        • Herbst JH
        • Jacobs ED
        • Finlayson TJ
        • et al.
        Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review.
        AIDS Behav. 2008; 12: 1-17
      3. HHS. Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. Division of Adult and Community Health. Measuring healthy days: population assessment of health-related quality of life. Atlanta, GA: HHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Adult and Community Health. Published November 2000. Accessed April 24, 2020.

        • Brooks VR
        Minority Stress and Lesbian Women.
        Lexington Books, Lexington, MA1981
        • Rich AJ
        • Salway T
        • Scheim A
        • Poteat T
        Sexual minority stress theory: remembering and honoring the work of Virginia Brooks.
        LGBT Health. 2020; 7: 124-127
        • Henderson ER
        • Blosnich JR
        • Herman JL
        • Meyer IH
        Considerations on sampling in transgender health disparities research.
        LGBT Health. 2019; 6: 267-270
      4. Cicero EC, Reisner SL, Merwin EI, Humphreys JC, Silva SG. Application of Behavioral Risk Factor Surveillance System sampling weights to transgender health measurement.Nurs Res. In press. Online February 20, 2020.

        • Meyer IH
        Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence.
        Psychol Bull. 2003; 129: 674-697
        • Chodzen G
        • Hidalgo MA
        • Chen D
        • Garofalo R
        Minority stress factors associated with depression and anxiety among transgender and gender-nonconforming youth.
        J Adolesc Health. 2019; 64: 467-471
        • Garofalo R
        • Deleon J
        • Osmer E
        • Doll M
        • Harper GW
        Overlooked, misunderstood and at-risk: exploring the lives and HIV risk of ethnic minority male-to-female transgender youth.
        J Adolesc Health. 2006; 38: 230-236
        • Kattari SK
        • Begun S.
        On the margins of marginalized: transgender homelessness and survival sex.
        Affilia. 2017; 32: 92-103