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Alpert AB, Babbs G, Sanaeikia R, Ellison J, Hughes L, Herington J, Dembroff R. Doing Justice: Ethical Considerations Identifying and Researching Transgender and Gender Diverse People in Insurance Claims Data. J Med Syst 2024; 48:96. [PMID: 39394534 PMCID: PMC11469973 DOI: 10.1007/s10916-024-02111-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 09/18/2024] [Indexed: 10/13/2024]
Abstract
Data on the health of transgender and gender diverse (TGD) people are scarce. Researchers are increasingly turning to insurance claims data to investigate disease burden among TGD people. Since claims do not include gender self-identification or modality (i.e., TGD or not), researchers have developed algorithms to attempt to identify TGD individuals using diagnosis, procedure, and prescription codes, sometimes also inferring sex assigned at birth and gender. Claims-based algorithms introduce epistemological and ethical complexities that have yet to be addressed in data informatics, epidemiology, or health services research. We discuss the implications of claims-based algorithms to identify and categorize TGD populations, including perpetuating cisnormative biases and dismissing TGD individuals' self-identification. Using the framework of epistemic injustice, we outline ethical considerations when undertaking claims-based TGD health research and provide suggestions to minimize harms and maximize benefits to TGD individuals and communities.
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Affiliation(s)
- Ash B Alpert
- Yale Cancer Center, 333 Cedar Street, WWW 205, New Haven, CT, 06511, USA.
- Yale School of Medicine, New Haven, CT, USA.
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA.
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Gray Babbs
- Department of Philosophy, University of Rochester, Rochester, NY, USA
| | - Rebecca Sanaeikia
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jacqueline Ellison
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Innovative Research On Gender Health Equity, Department of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Landon Hughes
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jonathan Herington
- Department of Health Humanities and Bioethics, University of Rochester Medical Center, Rochester, NY, USA
| | - Robin Dembroff
- Department of Philosophy, Yale University, New Haven, CT, USA
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Beltran TG, Lett E, Poteat T, Hincapie-Castillo JM. Computational phenotyping within electronic healthcare data to identify transgender people in the United States: A narrative review. Pharmacoepidemiol Drug Saf 2024; 33:e5732. [PMID: 38009550 DOI: 10.1002/pds.5732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 11/07/2023] [Accepted: 11/10/2023] [Indexed: 11/29/2023]
Abstract
PURPOSE With the expansion of research utilizing electronic healthcare data to identify transgender (TG) population health trends, the validity of computational phenotype (CP) algorithms to identify TG patients is not well understood. We aim to identify the current state of the literature that has utilized CPs to identify TG people within electronic healthcare data and their validity, potential gaps, and a synthesis of future recommendations based on past studies. METHODS Authors searched the National Library of Medicine's PubMed, Scopus, and the American Psychological Association PsycInfo's databases to identify studies published in the United States that applied CPs to identify TG people within electronic healthcare data. RESULTS Twelve studies were able to validate or enhance the positive predictive value (PPV) of their CP through manual chart reviews (n = 5), hierarchy of code mechanisms (n = 4), key text-strings (n = 2), or self-surveys (n = 1). CPs with the highest PPV to identify TG patients within their study population contained diagnosis codes and other components such as key text-strings. However, if key text-strings were not available, researchers have been able to find most TG patients within their electronic healthcare databases through diagnosis codes alone. CONCLUSION CPs with the highest accuracy to identify TG patients contained diagnosis codes along with components such as procedural codes or key text-strings. CPs with high validity are essential to identifying TG patients when self-reported gender identity is not available. Still, self-reported gender identity information should be collected within electronic healthcare data as it is the gold standard method to better understand TG population health patterns.
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Affiliation(s)
- Theo G Beltran
- Department of Epidemiology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA
- Center for Applied Transgender Studies, Chicago, Illinois, USA
| | - Elle Lett
- Center for Applied Transgender Studies, Chicago, Illinois, USA
- Center for Anti-Racism and Community Health, University of Washington School of Public Health, Seattle, Washington, USA
- Health Systems and Population Health, University of Washington School of Public Health, Seattle, Washington, USA
| | - Tonia Poteat
- Division of Healthcare in Adult Populations, Duke University School of Nursing, Durham, North Carolina, USA
| | - Juan M Hincapie-Castillo
- Department of Epidemiology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA
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Ziltzer RS, Lett E, Chambers T, Moayer R. Awareness Among Transgender and Nonbinary Adults of the Otolaryngologist's Role in Providing Gender-Affirming Care Services. Otolaryngol Head Neck Surg 2023; 169:899-905. [PMID: 36934448 DOI: 10.1002/ohn.328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/23/2023] [Indexed: 03/20/2023]
Abstract
OBJECTIVE To assess transgender and nonbinary adults' awareness of Otolaryngologists' (ENT) and speech-language pathologists' (SLP) ability to perform various face, neck, and voice procedures for gender-affirming purposes. STUDY DESIGN Cross-sectional survey. SETTING Online, from February to May 2022. METHODS We developed a list of nonsurgical and surgical gender-affirming face, neck, and voice procedures. We asked transgender and nonbinary (TNB) adults which procedures from this list they knew could be performed by specially-trained ENTs or SLPs for gender-affirmation and which listed procedures they knew existed as gender-affirming treatment before the survey. We assessed awareness of ENTs' and SLPs' ability for each procedure across gender identity using Fisher exact tests. We examined if demographic or socioeconomic factors were associated with the total number of gender-affirming procedures participants knew ENTs or SLPs could perform using univariable linear regression. RESULTS TNB adults (N = 234) generally knew these procedures existed as gender-affirming treatment (64%-93%). However, TNB adults were largely unaware these gender-affirming procedures could be performed by specially-trained ENTs or SLPs (53% or less), especially procedures unrelated to the voice, neck, and nose (26% or less). Knowledge of ENTs' and SLPs' ability was similar across gender identity for most procedures. Total number of procedures known that ENTs or SLPs could perform did not differ by demographic/socioeconomic factors (p > .05). CONCLUSION These findings suggest transgender and nonbinary individuals may not know to seek Otolaryngologists or SLP when desiring gender-affirming face, neck, or voice care. Increased efforts are needed to promote awareness of Otolaryngology's role in providing gender-affirming care. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Ryan S Ziltzer
- Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Elle Lett
- Center for Applied Transgender Studies, Chicago, Illinois, USA
- Boston Children's Hospital, Computational Health Informatics Program, Boston, Massachusetts, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tamara Chambers
- Department of Otolaryngology-Head & Neck Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Roxana Moayer
- Department of Otolaryngology-Head & Neck Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
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Ziltzer RS, Lett E, Su-Genyk P, Chambers T, Moayer R. Needs Assessment of Gender-Affirming Face, Neck, and Voice Procedures and the Role of Gender Dysphoria. Otolaryngol Head Neck Surg 2023; 169:906-916. [PMID: 36942914 DOI: 10.1002/ohn.329] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 02/06/2023] [Accepted: 03/03/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE To assess the needs of transgender and nonbinary (TNB) adults for gender-affirming face, neck, and voice procedures. STUDY DESIGN Cross-sectional survey. SETTING Online, February to May 2022. METHODS Primary outcomes included utilization of otolaryngologists and speech-language pathologists; gender dysphoria felt from the face, neck, and voice self-reported on a 0 to 10 numeric rating scale (0 = no dysphoria, 10 = unbearable); and desire for various gender-affirming face, neck, and voice procedures. We used ordinal logistic and linear regression to assess relationships between site-specific dysphoria and the desire for relevant procedures. RESULTS TNB participants (N = 234) infrequently sought gender-affirming care with speech-language pathologists (23%), facial plastic surgeons (8%), or laryngologists (3%). Participants experienced the strongest dysphoria from the voice (median 7/10), jawline/chin (4/10), and neck (3.5/10). Transmasculine and nonbinary participants typically seeking masculinization (n = 83) frequently desired voice therapy (want = 35%, had = 8%). Transfeminine and nonbinary participants typically seeking feminization (n = 145) frequently desired voice therapy (want = 52%, had = 23%), chondrolaryngoplasty (want = 45%, had = 5%), and hair removal/electrolysis (want = 43%, had = 44%). Many desired at least 1 facial feminization surgery procedure (65%), especially mandible reduction (want = 42%, had = 3%), rhinoplasty (want = 41%, had = 1%), and forehead reduction (want = 37%, had = 4%). Dysphoria ratings were associated with desiring relevant procedures (p < .05 for all), notably voice therapy (odds ratio [OR] = 1.50), chondrolaryngoplasty (OR = 1.46), mandible reduction (OR = 1.38), rhinoplasty (OR = 1.59), and forehead reduction (OR = 1.82). CONCLUSION Gender dysphoria from the face, neck, and voice can be severe for TNB people and is associated with the desire for gender-affirming procedures. The high demand yet low reported access to these procedures highlights the need for providers of gender-affirming face, neck, and voice care.
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Affiliation(s)
- Ryan S Ziltzer
- Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Elle Lett
- Center for Applied Transgender Studies, Chicago, Illinois, USA
- Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peiyi Su-Genyk
- Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Tamara Chambers
- Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Roxana Moayer
- Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
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Hughes LD, King WM, Gamarel KE, Geronimus AT, Panagiotou OA, Hughto JM. Differences in All-Cause Mortality Among Transgender and Non-Transgender People Enrolled in Private Insurance. Demography 2022; 59:1023-1043. [PMID: 35548863 PMCID: PMC9195044 DOI: 10.1215/00703370-9942002] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Few studies have analyzed mortality rates among transgender (trans) populations in the United States and compared them to the rates of non-trans populations. Using private insurance data from 2011 to 2019, we estimated age-specific all-cause mortality rates among a subset of trans people enrolled in private insurance and compared them to a 10% randomly selected non-trans cohort. Overall, we found that trans people were nearly twice as likely to die over the period as their non-trans counterparts. When stratifying by gender, we found key disparities within trans populations, with people on the trans feminine to nonbinary spectrum being at the greatest risk of mortality compared to non-trans males and females. While we found that people on the trans masculine to nonbinary spectrum were at a similar risk of overall mortality compared to non-trans females, their overall mortality rate was statistically smaller than that of non-trans males. These findings provide evidence that some trans and non-trans populations experience substantially different mortality conditions across the life course and necessitate further study.
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Affiliation(s)
- Landon D. Hughes
- School of Public Health and Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Wesley M. King
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Arline T. Geronimus
- School of Public Health and Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
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Yee K, Lind BK, Downing J. Change in Gender on Record and Transgender Adults' Mental or Behavioral Health. Am J Prev Med 2022; 62:696-704. [PMID: 34920916 PMCID: PMC9035075 DOI: 10.1016/j.amepre.2021.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/30/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Within gender-diverse populations, gender-affirming changes in gender on record may improve mental or behavioral health. This study uses claims data to investigate whether sex assigned at birth modifies the association between change in gender on record and mental or behavioral health. METHODS Adult Oregon Medicaid beneficiaries with gender identity-related diagnoses and enrolled during 2010-2019 were included. Sex assigned at birth was inferred from medical and pharmacy claims and was categorized as assigned female, assigned male, or unknown sex assigned at birth. Self-reported gender ascertained at initial enrollment differing from sex assigned at birth indicated a change in gender on record. Multivariable logistic regression estimated the association between change in gender on record and mental (anxiety, depression, suicidal ideation, post-traumatic stress disorder) or behavioral (alcohol, substance, or tobacco use disorders) health. Analyses were conducted in February 2021. RESULTS This study included 2,940 transgender and nonbinary adults. Of the 1,451 self-reporting female gender and 1,489 self-reporting male gender, 449 (30.9%) were assigned male at birth, and 303 (20.3%) were assigned female at birth, classified as changing their gender on record. Predicted probability of mental or behavioral conditions was significantly lower in those who changed their gender on record. Sex assigned at birth modified the association with mental health: assigned female at birth reporting female gender had the highest burdens, followed by assigned male at birth reporting male. Secondary analyses using a modified change in gender definition or alternative sex assigned at birth inference method found similar trends. CONCLUSIONS Oregon Medicaid gender-diverse beneficiaries who changed their gender on record had a meaningfully lower probability of mental and behavioral health conditions. Those assigned female at birth reporting female gender had the highest burdens.
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Affiliation(s)
- Kimberly Yee
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, Oregon.
| | - Bonnie K Lind
- Center for Health Systems Effectiveness, Oregon Health and & Science University, Portland, Oregon
| | - Jae Downing
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, Oregon
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Considerations for Transgender Population Health Research Based on US National Surveys. Ann Epidemiol 2021; 65:65-71. [PMID: 34757013 DOI: 10.1016/j.annepidem.2021.10.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/24/2021] [Accepted: 10/22/2021] [Indexed: 11/23/2022]
Abstract
Transgender identities and health are highly politicized in the United States leading to restrictions on relevant data collection in national health surveillance systems. This has serious implications on transgender population health research; an urgent area of study given the systemic discrimination faced by transgender individuals and the resultant social and health inequities. In this precarious political climate, obtaining high-quality data for research is challenging and in recent years, two data sources have formed the foundation of transgender health research in the United States, namely the 2015 United States Transgender Study and the Behavioral Risk Factor Surveillance System (BRFSS) after the launch of the optional Sexual Orientation and Gender Identity Module in 2014. While useful, there are serious challenges to using these data to study transgender health, specifically related to survey weighting methodologies, ascertainment of gender identity, and study design. In this article, we detail these challenges and discuss the strengths and weaknesses of various methodological approaches that have been implemented as well as clarify several common errors that exist in the literature. We feel that this contribution is necessary to provide accurate interpretation of the evidence that currently informs policy and priority setting for transgender population health and will provide vital insights for future studies with these now ubiquitous sources of data in the field.
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Characterizing Substance Use Disorders among Transgender Adults Receiving Care at a Large Urban Safety Net Hospital. J Addict Med 2021; 16:407-412. [PMID: 34561349 DOI: 10.1097/adm.0000000000000919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In the midst of the opioid crisis, increasing attention has been given to assessing and addressing substance use disorders (SUDs) among transgender and gender diverse (TGD) populations. As electronic health records begin to more uniformly collect gender identity data, clinicians and public health professionals are better able to examine the prevalence of SUDs and the receipt of SUD treatment services in these populations. METHODS We utilized cross-sectional electronic health records data from January 2005 to December 2019 from a large safety-net hospital in Massachusetts. A cohort of TGD patients was identified using self-reported gender identity data as well as diagnostic and procedures codes associated with receipt of gender-affirming care (n = 2000). We calculated odds of SUD diagnosis and receipt of medications for SUD among TGD patients. RESULTS Among a cohort of 2000 TGD patients, 8.8% had a SUD diagnosis. SUD diagnoses were more common among older, Black, and transmasculine patients, as well as those holding public health insurance. SUD diagnoses were less likely among those reporting college-level education. Of those with an opioid use disorder (OUD), 46% were prescribed an FDA-approved medication for OUD. CONCLUSIONS SUD diagnoses among TGD patients were associated with demographic, socioeconomic, and gender-related factors. We found a modestly lower prevalence of non-tobacco SUD among our cohort of TGD patients than the national average of 7.4%. Despite a relatively better receipt of prescription treatment services than the national average, the low rate of treatment overall represents a missed opportunity to address SUDs in these vulnerable populations.
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Hughes L, Shireman TI, Hughto J. Privately Insured Transgender People Are At Elevated Risk For Chronic Conditions Compared With Cisgender Counterparts. Health Aff (Millwood) 2021; 40:1440-1448. [PMID: 34519545 DOI: 10.1377/hlthaff.2021.00546] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The burden of morbidity among privately insured transgender people is largely unknown. We identified transgender people enrolled in private insurance (using claims from 2001-19) and compared their rates of selected chronic conditions, using the Elixhauser Comorbidity Index, with claims for a matched cisgender cohort. We documented disparities between transgender and cisgender people across most conditions and found that transgender people were at elevated risk for nearly all chronic conditions compared with their cisgender counterparts. We also found that trans masculine and nonbinary people had the highest predicted average number of chronic conditions compared with all other gender groups. Our findings highlight key gender differences in morbidity between and within transgender and cisgender populations, and they underscore the importance of collecting gender identity information in national surveillance efforts to increase understanding of the health disparities among transgender and cisgender populations. In addition, these findings underscore the need for nondiscrimination protections for transgender people in the US.
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Affiliation(s)
- Landon Hughes
- Landon Hughes is a doctoral candidate in the Department of Health Behavior and Health Education and a predoctoral trainee in the Population Studies Center, Institute for Social Research, University of Michigan, in Ann Arbor, Michigan
| | - Theresa I Shireman
- Theresa I. Shireman is a professor in the Department of Health Services, Policy, and Practice and director of the Center for Gerontology and Healthcare Research, Brown University School of Public Health, in Providence, Rhode Island
| | - Jaclyn Hughto
- Jaclyn Hughto is an assistant professor in the Departments of Behavioral and Social Sciences and Epidemiology and the Center for Health Promotion and Health Equity, Brown University School of Public Health. She is also an adjunct investigator at the Fenway Institute, Fenway Health, in Boston, Massachusetts
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Frost MC, Blosnich JR, Lehavot K, Chen JA, Rubinsky AD, Glass JE, Williams EC. Disparities in Documented Drug Use Disorders Between Transgender and Cisgender U.S. Veterans Health Administration Patients. J Addict Med 2021; 15:334-340. [PMID: 33252409 PMCID: PMC8384140 DOI: 10.1097/adm.0000000000000769] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Transgender people-those whose gender identity differs from their sex assigned at birth-are at risk for health disparities resulting from stressors such as discrimination and violence. Transgender people report more drug use than cisgender people; however, it is unclear whether they have higher likelihood of drug use disorders. We examined whether transgender patients have increased likelihood of documented drug use disorders relative to cisgender patients in the national Veterans Health Administration (VA). METHODS Electronic health record data were extracted for VA outpatients from 10/1/09 to 7/31/17. Transgender status and past-year documentation of drug use disorders (any, opioid, amphetamine, cocaine, cannabis, sedative, hallucinogen) were measured using diagnostic codes. Logistic regression models estimated odds ratios for drug use disorders among transgender compared to cisgender patients, adjusted for age, race/ethnicity and year. Effect modification by presence of ≥1 mental health condition was tested using multiplicative interaction. RESULTS Among 8,872,793 patients, 8619 (0.1%) were transgender. Transgender patients were more likely than cisgender patients to have any drug use disorder (Adjusted Odds Ratio [aOR] 1.67, 95% confidence interval [CI] 1.53-1.83), amphetamine (aOR 2.22, 95% CI 1.82-2.70), cocaine (aOR 1.59, 95% CI 1.29-1.95), and cannabis (aOR 1.82, 95% CI 1.62-2.05) use disorders. There was no significant interaction by presence of ≥1 mental health condition. CONCLUSIONS Transgender VA patients may have higher likelihood of certain drug use disorders than cisgender VA patients, particularly amphetamine use disorder. Future research should explore mechanisms underlying disparities and potential barriers to accessing treatment and harm reduction services faced by transgender people.
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Affiliation(s)
- Madeline C. Frost
- Department of Health Services, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle WA 98108
| | - John R. Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, USA
- Health Services Research & Development (HSR&D) Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Keren Lehavot
- Department of Health Services, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle WA 98108
- Department of Psychiatry and Behavioral Science, University of Washington, Seattle, WA, USA
| | - Jessica A. Chen
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle WA 98108
- Department of Psychiatry and Behavioral Science, University of Washington, Seattle, WA, USA
| | - Anna D. Rubinsky
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle WA 98108
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Joseph E. Glass
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101
| | - Emily C. Williams
- Department of Health Services, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle WA 98108
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Progovac AM, Tran NM, Mullin BO, De Mello Libardi Maia J, Creedon TB, Dunham E, Reisner SL, McDowell A, Bird N, Sánchez Román MJ, Dunn M, Telingator C, Lu F, Breslow AS, Forstein M, Cook BL. Elevated Rates of Violence Victimization and Suicide Attempt Among Transgender and Gender Diverse Patients in an Urban, Safety Net Health System. WORLD MEDICAL & HEALTH POLICY 2021. [DOI: 10.1002/wmh3.403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Hughto JMW, Quinn EK, Dunbar MS, Rose AJ, Shireman TI, Jasuja GK. Prevalence and Co-occurrence of Alcohol, Nicotine, and Other Substance Use Disorder Diagnoses Among US Transgender and Cisgender Adults. JAMA Netw Open 2021; 4:e2036512. [PMID: 33538824 PMCID: PMC7862992 DOI: 10.1001/jamanetworkopen.2020.36512] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Substance use disorders are a major source of morbidity and mortality in the United States. National data comparing the prevalence of substance use disorder diagnoses (SUDDs) among transgender and cisgender individuals are lacking in the United States. OBJECTIVES To investigate the prevalence of SUDDs among transgender and cisgender adults and to identify within-group and between-group differences by age, gender, and geographic location. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used the OptumLabs Data Warehouse to analyze deidentified claims from approximately 74 million adults aged 18 years or older enrolled in commercial or Medicare Advantage insurance plans in 2017. A total of 15 637 transgender adults were identified based on a previously developed algorithm using a combination of International Classification of Diseases, Tenth Revision (ICD-10) transgender-related diagnosis and procedure codes and sex-discordant hormone prescriptions. A cohort of 46 911 cisgender adults was matched to the transgender cohort in a 3:1 ratio based on age and geographic location. MAIN OUTCOMES AND MEASURES SUDDs, based on ICD-10 codes, were assessed overall and compared between transgender and cisgender cohorts and by geographic region (ie, Northeast, Midwest, South, and West); age groups (eg, 18-25, 26-30, 31-35 years), and gender (ie, transfeminine [TF; assigned male sex at birth, identify along feminine gender spectrum], transmasculine [TM; assigned female sex at birth, identify along masculine gender spectrum], male, and female). RESULTS In this study of 15 637 transgender adults (4955 [31.7%] TM) and 46 911 cisgender adults (23 247 [50.4%] men), most (8627 transgender adults [55.2%]; 51 762 cisgender adults [55.2%]) were aged between 18 and 40 years, and 6482 transgender adults (41.5%) and 19 446 cisgender adults (41.5%) lived in the South. Comparing transgender to cisgender groups, significant differences were found in the prevalence of a nicotine (2594 [16.6%] vs 2551 [5.4%]; P < .001), alcohol (401 [2.6%] vs 438 [0.9%]; P < .001), and drug (678 [4.3%] vs 549 [1.2%]; P < .001) SUDDs. Among transgender adults, cannabis was the most prevalent drug SUDD (321 [2.1%]), followed by opioid SUDD (205 [1.3%]) and cocaine SUDD (81 [0.5%]), whereas among cisgender adults, cannabis and opioid SUDDs were equally prevalent (cannabis, 186 [0.4%]; opioid, 207 [0.4%]), followed by cocaine SUDD (59 [0.1%]). CONCLUSIONS AND RELEVANCE In this study, the prevalence of SUDDs was significantly elevated among transgender adults relative to their cisgender peers. These findings underscore the need for culturally tailored clinical interventions to treat substance use disorder in transgender populations.
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Affiliation(s)
- Jaclyn M. W. Hughto
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island
- Center for Health Promotion and Health Equity, Brown School of Public Health, Brown University, Providence, Rhode Island
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
| | - Emily K. Quinn
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | | | - Adam J. Rose
- School of Public Health, Hebrew University, Jerusalem, Israel
| | - Theresa I. Shireman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Guneet K. Jasuja
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs Medical Center, Bedford, Massachusetts
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
- OptumLabs, Eden Prairie, Minnesota
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Rozga M, Linsenmeyer W, Cantwell Wood J, Darst V, Gradwell E. Hormone therapy, health outcomes and the role of nutrition in transgender individuals: A scoping review. Clin Nutr ESPEN 2020; 40:42-56. [DOI: 10.1016/j.clnesp.2020.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/21/2020] [Accepted: 08/22/2020] [Indexed: 02/06/2023]
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Beyond Gender Identity Disorder Diagnoses Codes: An Examination of Additional Methods to Identify Transgender Individuals in Administrative Databases. Med Care 2020; 58:903-911. [PMID: 32925416 DOI: 10.1097/mlr.0000000000001362] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Large administrative databases often do not capture gender identity data, limiting researchers' ability to identify transgender people and complicating the study of this population. OBJECTIVE The objective of this study was to develop methods for identifying transgender people in a large, national dataset for insured adults. RESEARCH DESIGN This was a retrospective analysis of administrative claims data. After using gender identity disorder (GID) diagnoses codes, the current method for identifying transgender people in administrative data, we used the following 2 strategies to improve the accuracy of identifying transgender people that involved: (1) Endocrine Disorder Not Otherwise Specified (Endo NOS) codes and a transgender-related procedure code; or (2) Receipt of sex hormones not associated with the sex recorded in the patient's chart (sex-discordant hormone therapy) and an Endo NOS code or transgender-related procedure code. SUBJECTS Seventy-four million adults 18 years and above enrolled at some point in commercial or Medicare Advantage plans from 2006 through 2017. RESULTS We identified 27,227 unique transgender people overall; 18,785 (69%) were identified using GID codes alone. Using Endo NOS with a transgender-related procedure code, and sex-discordant hormone therapy with either Endo NOS or transgender-related procedure code, we added 4391 (16%) and 4051 (15%) transgender people, respectively. Of the 27,227 transgender people in our cohort, 8694 (32%) were transmasculine, 3959 (15%) were transfeminine, and 14,574 (54%) could not be classified. CONCLUSION In the absence of gender identity data, additional data elements beyond GID codes improves the identification of transgender people in large, administrative claims databases.
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Lett E, Dowshen NL, Baker KE. Intersectionality and Health Inequities for Gender Minority Blacks in the U.S. Am J Prev Med 2020; 59:639-647. [PMID: 32792281 PMCID: PMC7577994 DOI: 10.1016/j.amepre.2020.04.013] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/13/2020] [Accepted: 04/14/2020] [Indexed: 02/05/2023]
Abstract
INTRODUCTION 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. METHODS 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. RESULTS 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). CONCLUSIONS 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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Affiliation(s)
- Elle Lett
- 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.
| | - 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
| | - Kellan E Baker
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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McDowell A, Raifman J, Progovac AM, Rose S. Association of Nondiscrimination Policies With Mental Health Among Gender Minority Individuals. JAMA Psychiatry 2020; 77:952-958. [PMID: 32374362 PMCID: PMC7203670 DOI: 10.1001/jamapsychiatry.2020.0770] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE In the past decade, many states have implemented policies prohibiting private health insurers from discriminating based on gender identity. Policies banning discrimination have the potential to improve access to care and health outcomes among gender minority (ie, transgender and gender diverse) populations. OBJECTIVE To evaluate whether state-level nondiscrimination policies are associated with suicidality and inpatient mental health hospitalizations among privately insured gender minority individuals. DESIGN, SETTING, AND PARTICIPANTS In this cohort study, difference-in-differences analysis comparing changes in mental health outcomes among gender minority enrollees before and after states implemented nondiscrimination policies in 2009-2017 was conducted. A sample of gender minority children and adults was identified using gender minority-related diagnosis codes obtained from private health insurance claims. The present study was conducted from August 1, 2018, to September 1, 2019. EXPOSURE Living in states that implemented policies banning discrimination based on gender identity in 2013, 2014, 2015, and 2016. MAIN OUTCOMES AND MEASURES The primary outcome was suicidality. The secondary outcome was inpatient mental health hospitalization. RESULTS The study population included 28 980 unique gender minority enrollees (mean [SD] age, 26.5 [15] years) from 2009 to 2017. Relative to comparison states, suicidality decreased in the first year after policy implementation in the 2014 policy cohort (odds ratio [OR], 0.72; 95% CI, 0.58-0.90; P = .005), the 2015 policy cohort (OR, 0.50; 95% CI, 0.39-0.64; P < .001), and the 2016 policy cohort (OR, 0.61; 95% CI, 0.44-0.85; P = .004). This decrease persisted to the second postimplementation year for the 2014 policy cohort (OR, 0.48; 95% CI, 0.41-0.57; P < .001) but not for the 2015 policy cohort (OR, 0.81; 95% CI, 0.47-1.38; P = .43). The 2013 policy cohort experienced no significant change in suicidality after policy implementation in all 4 postimplementation years (2014: OR, 1.19; 95% CI, 0.85-1.67; P = .31; 2015: OR, 0.94; 95% CI, 0.73-1.20; P = .61; 2016: OR, 0.82; 95% CI, 0.65-1.03; P = .10; and 2017: OR, 1.29; 95% CI, 0.90-1.88; P = .18). Mental health hospitalization rates generally decreased or stayed the same for individuals living in policy states vs the comparison group. CONCLUSIONS AND RELEVANCE Implementation of a state-level nondiscrimination policy appears to be associated with decreased or no changes in suicidality among gender minority individuals living in states that implemented these policies from 2013 to 2016. Given high rates of suicidality among gender minority individuals in the US, health insurance nondiscrimination policies may offer a mechanism for reducing barriers to care and mitigating discrimination.
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Affiliation(s)
- Alex McDowell
- PhD Program in Health Policy, Harvard University, Cambridge, Massachusetts,Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Julia Raifman
- Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts
| | - Ana M. Progovac
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Sherri Rose
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Progovac AM, Mullin BO, Dunham E, Reisner SL, McDowell A, Sanchez Roman MJ, Dunn M, Telingator CJ, Lu FQ, Breslow AS, Forstein M, Cook BL. Disparities in Suicidality by Gender Identity Among Medicare Beneficiaries. Am J Prev Med 2020; 58:789-798. [PMID: 32156489 PMCID: PMC7246148 DOI: 10.1016/j.amepre.2020.01.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 01/01/2020] [Accepted: 01/02/2020] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Suicidality is higher for gender minorities than the general population, yet little is known about suicidality in disabled or older adult gender minorities. METHODS This study used 2009-2014 Medicare claims to identify people with gender identity-related diagnosis codes (disabled, n=6,678; older adult, n=2,018) and compared their prevalence of suicidality with a 5% random non-gender minority beneficiary sample (disabled, n=535,801; older adult, n=1,700,008). Correlates of suicidality were assessed (via chi-square) for each of the 4 participant groups separately, and then disparities within eligibility status (disabled or older adult) were assessed using logistic regression models, adjusting first for age and mental health chronic conditions and then additionally for Medicaid eligibility, race/ethnicity, or U.S. region (each separately). The primary hypotheses were that gender minority beneficiaries would have higher suicidality but that suicidality disparities would persist after adjusting for covariates. Data were analyzed between 2017 and 2019. RESULTS Gender minority beneficiaries had higher unadjusted suicidality than non-gender minority beneficiaries in the disabled cohort (18.5% vs 7.1%, p<0.001). Significant suicidality predictors in all 4 groups included the following: age (except in older adult gender minorities), Medicaid eligibility, depression or behavioral health conditions, avoidable hospitalizations, and violence victimization. In age- and mental health-adjusted logistic regression models, gender minorities had higher odds of suicidality than non-gender minority beneficiaries (disabled, OR=1.95, p<0.0001; older adult, OR=2.10, p<0.0001). Disparities were not attenuated after adjusting for Medicaid eligibility, race/ethnicity, or region. CONCLUSIONS Heightened suicidality among identified gender minority Medicare beneficiaries highlights a pressing need to identify and reduce barriers to wellness in this population.
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Affiliation(s)
- Ana M Progovac
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.
| | - Brian O Mullin
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Emilia Dunham
- Office of Behavioral Health, MassHealth, Boston, Massachusetts
| | - Sari L Reisner
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Alex McDowell
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts; Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Maria Jose Sanchez Roman
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts; Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia
| | | | - Cynthia J Telingator
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts; Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Frederick Q Lu
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Aaron Samuel Breslow
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts; PRIME Center for Health Equity, Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Marshall Forstein
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts; Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Benjamin Lê Cook
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts; PRIME Center for Health Equity, Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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Wanta JW, Niforatos JD, Durbak E, Viguera A, Altinay M. Mental Health Diagnoses Among Transgender Patients in the Clinical Setting: An All-Payer Electronic Health Record Study. Transgend Health 2019; 4:313-315. [PMID: 31701012 PMCID: PMC6830528 DOI: 10.1089/trgh.2019.0029] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
We performed a cross-sectional analysis of the prevalence of psychiatric diagnoses among transgender patients in clinical care using an all-payer electronic health record database. Of 10,270 transgender patients identified, 58% (n=5940) had at least one psychiatric diagnosis compared with 13.6% (n=7,311,780) in the control patient population (p<0.0005). Transgender patients had a statistically significant increase in prevalence for all psychiatric diagnoses queried, with major depressive disorder and generalized anxiety disorder being the most common diagnoses (31% and 12%, respectively). Utilizing an all-payer database, although not without limitations, enables assessment of mental health and substance use diagnoses in this otherwise small population.
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Affiliation(s)
- Jonathon W Wanta
- Residency Training Program, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Joshua D Niforatos
- Residency Training Program, Department of Emergency Medicine, Baltimore, Maryland
| | - Emily Durbak
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Adele Viguera
- Department of Psychiatry, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Murat Altinay
- Department of Psychiatry, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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