Demographic characteristics, long-term health conditions and healthcare experiences of 6333 trans and non-binary adults in England: nationally representative evidence from the 2021 GP Patient Survey Original research

The study investigates the demographic characteristics, long-term health conditions, and primary care experiences of trans and non-binary adults in England. Primary care plays a central role across the life course, yet robust population evidence on trans and non-binary people’s demographics, health burden, and experiences is limited. Addressing gaps in access and outcomes for minority groups, including those protected under the UK Equality Act (such as gender reassignment), is an NHS Long Term Plan priority. Existing clinical guidance has focused mainly on transition or HIV rather than broader mental health or primary care needs. To support quality improvement, NHS England began including questions on gender and trans status in national surveys. Using the 2021 GP Patient Survey (GPPS), the study asks: what are the demographics, long-term conditions, and primary care experiences of trans and non-binary adults in England?

Prior evidence indicates persistent disparities for trans and non-binary people in health and healthcare experiences, but comprehensive population-based data have been scarce. Existing guidelines and research have largely focused on transition-related care and HIV, with limited evidence on general primary care, mental health, and the epidemiology of long-term conditions among trans and non-binary adults. Studies suggest higher rates of autism, neurodevelopmental and psychiatric diagnoses in trans and gender-diverse populations, and poorer healthcare experiences. NHS data collection on trans status has historically been limited; the inclusion of gender and trans status in GPPS aims to address this gap and enable quality improvement. The current study builds on earlier work by providing nationally representative estimates and exploring age-related heterogeneity in disparities.

Design: Cross-sectional secondary data analysis of the 2021 GP Patient Survey (GPPS) in England, following a preregistered protocol. Sampling and data collection: In January 2021, GPPS mailed surveys to 2,408,303 adults registered with 6,694 GP practices (with oversampling of historically low-response practices), followed by SMS and postal reminders. Responses were accepted by paper and online. Overall, 850,206 responses were received (35% response rate). Exclusions: 9,515 respondents with missing or 'prefer not to say' for both gender and trans status were excluded, yielding 840,691 included respondents. Definition of trans and non-binary: Respondents were asked (1) gender identity (Female, Male, Non-binary, Prefer to self-describe, Prefer not to say) and (2) whether their gender identity is the same as sex registered at birth (Yes/No/Prefer not to say). Trans and non-binary respondents included those selecting non-binary or self-described gender and/or reporting gender identity different from sex at birth. Measures: Long-term conditions—respondents reported any of 17 options (e.g., dementia, arthritis/back/joints problems, autism spectrum condition, blindness/partial sight, breathing conditions, cancer in last 5 years, deafness/hearing loss, diabetes, heart conditions, high blood pressure, kidney/liver disease, learning disability, mental health condition, neurological condition e.g., epilepsy, stroke, another long-term condition/disability, or none). Patient experience—18 items across domains: before making an appointment, access, continuity, communication, and overall experience; items were coded into binary positive/negative indicators in line with national reporting. Sociodemographics: Age, ethnicity, sexual orientation, and area-level deprivation (Index of Multiple Deprivation quintiles). Weighting: Responses were weighted to the age and gender profile of each GP practice to account for design, non-response and calibration; weighted estimates are nationally representative given near-universal GP registration. Analytic samples: Descriptive analyses included all 840,691; trans and non-binary respondents totaled 6,333 (0.9%). Multivariable analyses included respondents with complete age, ethnicity and deprivation data (n=827,696), of whom 6,091 were trans and/or non-binary. Statistical analysis: For long-term conditions, unadjusted weighted percentages were reported and logistic regression estimated odds ratios (ORs) for trans/non-binary vs all other respondents, adjusted for age, ethnicity and deprivation. Models used fixed effects with cluster-robust standard errors at the practice level; preliminary random-effects models including GP practice yielded similar estimates. Interaction analyses assessed heterogeneity by age, ethnicity, deprivation, sexual orientation and region; age-related heterogeneity was present for 10/15 conditions. Adjusted age-stratified prevalence was estimated using recycled predictions at average deprivation and ethnicity. For patient experience, unadjusted weighted positive response percentages were reported; adjusted fixed-effect models (age, ethnicity, deprivation, practice) estimated ORs. Exploratory regional analyses found minimal impact; trans and non-binary subgroups showed size but not direction differences and were combined per PPI guidance. Software: Stata v15.3. Patient and public involvement: Protocol developed with a trans, non-binary and queer PPI panel; the team met multiple times during the project.

- Sample: Of 840,691 included GPPS respondents, 6,333 (0.9%) were trans and/or non-binary. These respondents were younger, more likely to be from Asian, Black, Mixed or other ethnic groups, more likely to live in more deprived areas, and less likely to be heterosexual than other respondents. - Long-term conditions: After adjustment for age, ethnicity and deprivation, trans and non-binary adults had higher odds of 10/15 conditions relative to others, with the largest disparities for: autism (OR 5.8, 95% CI 5.0–6.6), dementia (3.1, 2.5–3.9), learning disability (2.8, 2.4–3.2) and mental health condition (2.0, 1.9–2.2). They were less likely to report no long-term conditions (OR 0.7, 0.7–0.8). Age-stratified patterns showed: (1) autism and mental health—higher prevalence at younger ages with absolute differences narrowing with age; (2) dementia, learning disability, blindness and neurological conditions—parallel age trends but upward-shifted prevalence; (3) stroke, diabetes, kidney/liver disease—disparities increasing with age; (4) arthritis, hypertension, cancer, breathing problems, heart conditions, deafness—lower adjusted prevalence among trans/non-binary at older ages compared with others. - Patient experience: Overall positive primary care experience was lower (OR 0.8, 0.8–0.9). Differences in access were small (OR range 0.8–1.2 across items). Communication disparities were large: lower odds of positive involvement in decisions (OR ~0.5), confidence and trust (OR ~0.4), and needs being met (OR ~0.5). Trans and non-binary respondents were more likely to have mental health needs during appointments (OR 2.1, 1.9–2.2) and, among those with such needs, less likely to report these were recognised/understood (OR ~0.7). Continuity: markedly higher preference to see a particular GP (OR 1.7, 1.6–1.8) with no significant difference in being able to see the preferred GP (OR ~1.1). - Response distribution: For overall and access items, trans and non-binary respondents were more likely to report both very positive and very negative experiences, indicating polarisation.

Findings from a large, nationally representative survey show that trans and non-binary adults in England report a higher burden of many long-term conditions—particularly autism, dementia, learning disability and mental health—and poorer overall primary care experiences than others. Despite these disparities, the age-related epidemiology of long-term conditions is broadly similar between groups, implying that standard best practices for long-term condition management will be highly relevant for trans and non-binary patients. However, marked inequalities in interpersonal communication indicate a key, targetable quality gap distinct from access. A higher preference for continuity of care suggests potential benefits from sustained relationships with trans-informed GPs, which may be especially important in managing multiple or complex conditions. The heterogeneous age-related disparity patterns likely reflect intersecting mechanisms, including minority stress, behavioral risk factors, biological effects of gender-affirming hormones, cohort/period effects (e.g., legislative and sociocultural changes), and selection effects; trans and non-binary populations are not homogeneous, and subgroup differences likely contribute. These results align with earlier studies documenting elevated neurodevelopmental and psychiatric diagnoses and poorer care experiences among trans and gender-diverse individuals, while extending the evidence base with population-level estimates and age-stratified insights. Quality improvement should prioritise communication skills, recognition and support of mental health needs, and facilitating continuity. Development and adaptation of guidelines beyond transition/HIV care, and ensuring appropriate application of risk prediction models for trans and non-binary patients, are needed. Longitudinal and subgroup-specific research is warranted to disentangle causal pathways and better tailor interventions.

This study provides nationally representative evidence on the demographics, long-term health conditions and primary care experiences of trans and non-binary adults in England. Trans and non-binary respondents were younger, more socioeconomically deprived, more often from minority ethnic groups, and had higher adjusted odds of several long-term conditions—especially autism, dementia, learning disability and mental health problems—while reporting substantially poorer experiences in interpersonal communication and a higher preference for continuity of care. While epidemiologic patterns across ages are broadly similar to other patients, large communication-related disparities highlight actionable targets for primary care quality improvement. Future work should include longitudinal data collections to clarify causal mechanisms and cohort effects; development and evaluation of best-practice guidelines for primary care (including communication and mental health support); refinement of risk prediction and care pathways for trans and non-binary patients; and subgroup analyses to tailor interventions across diverse trans and non-binary populations.

- Potential misclassification of trans and non-binary status due to self-report; cognitive or other factors could contribute to inaccuracies (e.g., possible impact on dementia association). - Exclusion of respondents who did not answer or selected 'prefer not to say' for gender and trans-status may bias estimates if these include trans and non-binary individuals with different experiences. - Findings apply to GP-registered patients; those not registered or using private services are not represented. - Cross-sectional design precludes causal inference and limits assessment of mortality or temporal dynamics in condition prevalence. - Lack of linked clinical data and reliance on self-reported conditions and experiences. - Regional differences were small and not fully detailed; subgroup differences among trans and non-binary respondents (e.g., by identity, treatment status) were not the focus and warrant further study. - The study was not fully co-produced, though it involved a trans, non-binary and queer PPI panel throughout.