Dr. George R. Brown and Dr. Kenneth T. Jones have recently had published a new study concerning the mental and medical health of transgender veterans: Mental Health and Medical Health Disparities in 5135 Transgender Veterans Receiving Healthcare in the Veterans Health Administration: A Case–Control Study.

There are no large controlled studies of health disparities in transgender (TG) or gender dysphoric patients. The Veterans Health Administration (VHA) is the largest healthcare system in the United States and was an early adopter of electronic health records. We sought to determine whether medical and/or mental health disparities exist in VHA for clinically diagnosed TG veterans compared to matched veterans without a clinical diagnosis consistent with TG status.

The researchers found that the prevalence of veterans with a qualifying diagnosis was 58/100000 patients...so there are an estimated 134,000 transgender veterans, about 19.1% of the estimated total number of transgender people in the country. The researchers studied the health records of 5135 transgender veterans and compared them to a control group of 15405 non-transgender veterans. Significant demographic differences were discovered right off the top. Twenty-two and a half percent of the transgender veterans were married compared to 46% of the non-transgender veterans. Transgender veterans were more likely to be classified as greater than 50% disabled than non-transgender veterans (29% to 22%) and more likely to have a catastrophic disability (8% to 2.91%).

Having very low income was more likely the case with transgender veterans than non-transgender veterans (33% to 25%). Transgender veterans were significantly less likely to live in rural areas than controls and had been homeless at a significantly higher rate (30% to 10%) and incarcerated significantly more (3% to 1%).

Transgender veterans were significantly more likely to have been a combat veteran(13% to 11%) and more likely to have reported military sexual trauma (15% to 6%).

TG veterans were significantly more likely to be diagnosed with all of the included psychiatric and medical conditions, except breast cancer and cirrhosis (cirrhosis was found to be less likely in TG veterans after adjusting for marital status, religious affiliation, and enrollment priority group). Odds of HIV seropositivity were nearly five times greater in TG veterans compared to controls. A 10% or more difference in the prevalence of the following conditions was observed between groups: depression, serious mental illnesses (see Supplementary Appendix A for a list of diagnostic codes), suicidal ideation/attempt, post-traumatic stress disorder, alcohol abuse, obesity, and tobacco use. Prevalence of end-stage renal disease was no longer significant after adjusting for marital status, religious affiliation, and the enrollment priority group. Removal of the TF (transvestic fetishist) group from each of the analyses did not significantly alter the findings.

We know little about the majority of veterans who do not utilize VHA healthcare services or those who self-identify as TG but who do not have a clinical diagnosis. It is critical to the health of TG patients for systems to understand who they are treating so that administrative and clinical services can be properly tailored to the needs of these patients. For example, reminder letters for health screenings like mammograms and prostate exams are inaccurately targeted to patients in a system that does not account for potential differences in birth sex and self-identified gender identity.

Homelessness is a social determinant that can contribute to the significant disparities seen for TG veterans. Homeless and marginally housed individuals are known to suffer from multimorbidities (mental and medical illnesses) and premature mortality. High rates of mental illness and substance use disorders are also associated with homelessness in veterans and nonveterans alike. Incarceration for TG veterans was also found to be two to three times more likely than in the control group. This finding is consistent with estimates of the prevalence of incarceration in TG people in the United States being at least twice higher than expected.

A number of factors can account for the nearly global health disparities reported in this article. In non-VHA settings, it has been reported that TG persons in the community often fear seeking medical care across the continuum of care ranging from preventive care to routine medical care to emergency care. Up to 80% of TG persons surveyed about their concerns regarding accessing healthcare included fear about negative repercussions if their “secret” (i.e., TG identity) was revealed. Distrust of the confidentiality of medical care was frequently expressed by respondents. Results from the largest survey of TG persons ever conducted, 20% of whom were veterans, revealed high levels of discrimination against TG persons in healthcare settings, including 19%–22% reporting being refused treatment altogether and 28% reporting being verbally harassed in a medical setting.

Finally, the lack of collection of both birth sex and self-identified gender identity data for enrolled patients in VHA makes it difficult to determine the exact proportion of TG veterans who identify as transmen, transwomen, or another identity outside of the traditional binary. Disparities and social determinants of health and well-being may well differ between transmen and transwomen, for example, and it is not known how many of the TG veterans in this cohort have changed their “sex” markers in their VA medical records. This is not unique to VHA as a healthcare system, and this problem will likely be ameliorated by adding these new demographic fields to the enrollment process in VHA beginning in 2016. This study also includes a largely non-Hispanic white, birth sex male population that may not reflect the health disparities experienced by TG people of color. We previously published data from this cohort that demonstrated greater health disparities for black TG veterans compared to whites, for example, but the sample size for other racial and ethnic groups was insufficient for a meaningful subanalysis.

The reasons for the differences in the rates of illnesses could be "an unwelcoming environment for transgender veterans at many VHA facilities, lack of knowledgeable clinical staff to provide transgender healthcare, and conscious and unconscious bias from healthcare providers and administrative staff.

--Reuters

The only diagnosis which was more common in the control than among the transgender veterans was breast cancer.