Mental Health and Medical Health Disparities in 5135 Transgender Veterans Receiving Healthcare in the Veterans Health Administration: A Case–Control Study

TLDR

No large controlled studies of health disparities in transgender patients exist, and the Veterans Health Administration— the largest U.S. healthcare system—was an early adopter of electronic health records. The study aimed to determine whether medical and mental health disparities exist for clinically diagnosed transgender veterans in the VHA compared to matched non‑transgender veterans, using a cohort of 5,135 TG veterans identified via ICD‑9‑CM codes from 1996 to 2013. The authors used a retrospective, longitudinal case‑control design, matching each of 5,135 TG veterans to three non‑TG veterans and analyzing electronic health record data to assess disparities in 17 medical and 10 mental health diagnoses, with a 1:3 matching ratio and a 58/100,000 prevalence in 2013.

Abstract

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.Using four ICD-9-CM codes consistent with TG identification, a cohort of 5135 TG veterans treated in VHA between 1996 and 2013 was identified. Veterans without one of these diagnoses were matched 1:3 in a case-control design to determine if medical and/or mental health disparities exist in the TG veteran population.In 2013, the prevalence of TG veterans with a qualifying clinical diagnosis was 58/100,000 patients. Statistically significant disparities were present in the TG cohort for all 10 mental health conditions examined, including depression, suicidality, serious mental illnesses, and post-traumatic stress disorder. TG Veterans were more likely to have been homeless, to have reported sexual trauma while on active duty, and to have been incarcerated. Significant disparities in the prevalence of medical diagnoses for TG veterans were also detected for 16/17 diagnoses examined, with HIV disease representing the largest disparity between groups.This is the first study to examine a large cohort of clinically diagnosed TG patients for psychiatric and medical health outcome disparities using longitudinal, retrospective medical chart data with a matched control group. TG veterans were found to have global disparities in psychiatric and medical diagnoses compared to matched non-TG veterans. These findings have significant implications for policy, healthcare screening, and service delivery in VHA and potentially other healthcare systems.