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10 TRANSGENDER HEALTH ISSUES 100 births differ in some way from standard definitions of male or female, with about 1 in every 1,500 to 2,000 children born with noticeably atypi- cal genitalia. This category does not include all types of difference (e.g., it does not consider chromosomal abnormalities that do not result in exter- nal differences in genitalia), demonstrating another difficulty in deter- mining how many people are born with intersex characteristics·exactly which characteristics are you considering? Including chromosomal and other conditions within the definition of intersex not surprisingly raises the estimated number of such births, with some estimates running as high as 1.7 percent of all births (17 intersex births per 1,000 births), although that estimate includes conditions that many researchers do not consider intersex. United States Two estimates based on large-scale surveys are available to estimate the number of transgender people in the United States. In 2011, Gary J. Gates used data from surveys conducted in California and Massachusetts to estimate that 0.3 percent of the U.S. adult population (about 700,000 people) identified as transgender. In 2016, Andrew R. Flores and col- leagues used data from the Behavioral Risk Factor Surveillance Sys- tem (BRFSS), a survey conducted annually by the Centers for Disease Control and Prevention (CDC) and state health departments, to estimate that about 0.6 percent of American adults identify as transgender (about 1.4 million people). FloresÊs estimate is based on data from 19 states that used an optional module including the question, „Do you consider yourself to be trans- gender?‰ If that question was answered in the affirmative, the interviewer followed-up with the question, „Do you consider yourself to be male- to-female, female-to-male, or gender nonconforming?‰ Data from these states was then statistically adjusted to estimate the number of transgender people in each state and in the United States as a whole. By their calculations, the state with the highest percentage of peo- ple identifying as transgender is Hawaii (0.78%), followed by Califor- nia (0.76%) and New Mexico (0.75%). The states estimated to have the lowest percentage of transgender people were Wyoming (0.32%), Iowa (0.31%), and North Dakota (0.30%). They also calculated that persons in the 18ă24 years age group were the most likely to identify as transgender (0.66%), followed by people in the 25ă64 years age group (0.58%) and that transgender identification was least likely in people 65 and older (0.50%).