Non-affirmation minority stress, internalized transphobia, and subjective cognitive decline among transgender and gender diverse veterans aged 45 years and older

OBJECTIVES

To examine the associations of two measures of minority stress, non-affirmation minority stress and internalized transphobia, with subjective cognitive decline (SCD) among transgender and gender diverse (TGD) veterans.

METHOD

We administered a cross-sectional survey from September 2022 to July 2023 to TGD veterans. The final analytic sample included 3,152 TGD veterans aged ≥45 years. We used a generalized linear model with quasi-Poisson distribution to calculate prevalence ratios (PR) and 95% confidence intervals (CIs) measuring the relationship between non-affirmation minority stress and internalized transphobia and past-year SCD.

RESULTS

The mean age was 61.3 years (SD = 9.7) and the majority (70%) identified as trans women or women. Overall, 27.2% (n = 857) reported SCD. Adjusted models revealed that TGD veterans who reported experiencing non-affirmation minority stress or internalized transphobia had greater risk of past-year SCD compared to those who did not report either stressor (aPR: 1.09, 95% CI: 1.04-1.15; aPR: 1.19, 95% CI: 1.12-1.27).

CONCLUSION

Our findings demonstrate that proximal and distal processes of stigma are associated with SCD among TGD veterans and underscore the need for addressing multiple types of discrimination. Above all, these results indicate the lasting sequelae of transphobia and need for systemic changes to prioritize the safety and welfare of TGD people.

Patient Characteristics Associated with Receiving Gender-Affirming Hormone Therapy in the Veterans Health Administration

Purpose

This study aimed to examine patient characteristics associated with receipt of gender-affirming hormone therapy in the Veterans Health Administration (VHA).

Methods

This cross-sectional study included a national cohort of 9555 transgender and gender diverse (TGD) patients with TGD-related diagnosis codes who received care in the VHA from 2006 to 2018. Logistic regression models were used to determine the association of health conditions and documented social stressors with receipt of gender affirming hormone therapy.

Results

Of the 9555 TGD patients, 57.4% received gender-affirming hormone therapy in the VHA. In fully adjusted models, patients who had following characteristics were less likely to obtain gender-affirming hormones in the VHA: Black, non-Hispanic versus white (adjusted odds ratio [aOR]: 0.61; 95% confidence interval [CI]: 0.52-0.72), living in the Northeast versus the West (aOR: 0.72; 95% CI: 0.62-0.84), a documented drug use disorder (aOR: 0.56; 95% CI: 0.47-0.68), ≥3 versus no comorbidities (aOR: 0.44; 95% CI: 0.34-0.57), and ≥3 versus no social stressors (aOR: 0.42; 95% CI: 0.30-0.58; all p<0.001). Younger patients aged 21-29 years were almost 3 times more likely to receive gender affirming hormone therapy in the VHA than those aged ≥60 (aOR: 2.98; 95% CI: 2.55-3.47; p<0.001).

Conclusion

TGD individuals who were older, Black, non-Hispanic, and had more comorbidities and documented social stressors were less likely to receive gender-affirming hormone therapy in the VHA. Further understanding of patient preferences in addition to clinician- and site-level determinants that may impact access to gender-affirming hormone therapy for TGD individuals in the VHA is needed.

Recruitment tools for transgender and gender diverse veterans in health care research

Transgender and gender diverse (TGD) veterans in the Veterans Health Administration experience health and health care disparities, and research with this population is needed to improve gender-affirming care in Veterans Health Administration. However, TGD veterans may experience hesitancy to participate in research. We must address barriers to participation through feasible and acceptable methods. Opt-out letters are an effective tool used to recruit veterans in mental health research. The present study examined the feasibility and acceptability of opt-out letters modified for TGD veterans. Opt-out letters were sent to 54 potential TGD participants at three sites. The letters stated the research team would begin contacting veterans by phone in 2 weeks if they did not opt out of being contacted. Feasibility was measured through response rate. Acceptability was assessed through qualitative template analysis of interview data. Of the 54 potential participants, two opted out, three letters were undeliverable, and eight veterans called to opt in. Veterans reported that they found the letters to be clear and useful. The responses to the opt-out letters resulted in completing recruitment for two of the three sites. The research team then called the veterans who received the letter at the third site (three veterans) and recruited one additional veteran, for a total of nine TGD veterans. Opt-out letters may be a helpful tool to recruit TGD veterans to participate in research. Although these letters were designed to opt out, 89% of participants called the research team to opt in. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Implementation of LGBTQ+ affirming care policies in the Veterans Health Administration: preliminary findings on barriers and facilitators in the southern United States

Background

In the United States Department of Veterans Affairs (VA), veterans who are lesbian, gay, bisexual, transgender, queer, and similar gender and sexual minoritized people (LGBTQ+) experience health disparities compared to cisgender, heterosexual veterans. VA's LGBTQ+ Health Program created two healthcare policies on providing LGBTQ+ affirming care (healthcare that is inclusive, validating, and understanding of the LGBTQ+ population). The current project examines providers' barriers and facilitators to providing LGBTQ+ affirming care and LGBTQ+ veterans' barriers and facilitators to receiving LGBTQ+ affirming care.

Methods

Data collection and analysis were informed by the Consolidated Framework for Implementation Research, which was adapted to include three health equity domains. Data collection involved telephone interviews conducted with 11 VA providers and 12 LGBTQ+ veterans at one rural and one urban VA medical center, and one rural VA community clinic. Qualitative data were rapidly analyzed using template analysis, a data reduction technique.

Results

Providers described limited education, limited time, lack of experience with the population, and a lack of awareness of resources as barriers. Providers discussed comfort with consulting trusted peers, interest in learning more about providing LGBTQ+ affirming care, and openness and acceptance of the LGBTQ+ community as facilitators. LGBTQ+ veterans described a lack of provider awareness of their needs, concerns related to safety and discrimination, and structural discrimination as barriers. LGBTQ+ veterans described positive relationships with providers, knowledge of their own healthcare needs, and ability to advocate for their healthcare needs as facilitators. Although VA's LGBTQ+ affirming care policies are in place, providers and veterans noted a lack of awareness regarding specific healthcare processes.

Conclusion

Allowing more time and capacity for education and engaging LGBTQ+ veterans in determining how to improve their healthcare may be the path forward to increase adherence to LGBTQ+ affirming care policies. Engaging patients, especially those from marginalized backgrounds, in strategies focused on the uptake of policy may be a path to improve policy implementation. It is possible that creating truly collaborative structures in which patients, staff, providers, leadership, and policymakers can work together towards policy implementation may be a useful strategy. In turn, improved policy implementation would result in increased physical and mental health for LGBTQ+ veterans.

A patient-centered model of mental health care for trauma and minority stress in transgender and gender diverse people: A bottom-up network analysis

Transgender and gender diverse (TGD) individuals are disproportionately exposed to traumatic and high-impact minority stressors which can produce an array of transdiagnostic symptoms. Some clinical presentations align well with established evidence-based treatments, but others may require patient-centered modifications or combined approaches to address treatment needs. In this study, we employed a novel, bottom-up approach to derive insights into preferred intervention strategies for a broad range of trauma- and TGD-minority stress-related expressions of clinical distress. Participants (18 TGD individuals, 16 providers) completed a q-sort task by first sorting cards featuring traumatic experiences and/or minority stressors and transdiagnostic psychiatric symptoms into groups based on perceived similarity. Next, participants sorted interventions they believed to be most relevant for addressing these concerns/symptoms. We overlayed networks of stressors and symptoms with intervention networks to evaluate preferred intervention strategies. TGD networks revealed transdiagnostic clustering of intervention strategies and uniquely positioned the expectancy of future harm as a traumatic stressor. Provider networks were more granular in structure; both groups surprisingly emphasized the role of self-defense as intervention. While both networks had high overlap, their discrepancies highlight patient perspectives that practical, material, and structural changes should occur alongside traditional clinical interventions.

Patient Experiences and Provider Perspectives on Accessing Gender-Affirming Surgical Services in the Veterans Health Administration

BACKGROUND

Transgender and gender diverse (TGD) veterans have a greater prevalence of suicide morbidity and mortality than cisgender veterans. Gender-affirming surgery (GAS) has been shown to improve mental health for TGD veterans. In 2021, the Veterans Health Administration (VHA) announced the initiation of a rulemaking process to cover GAS for TGD patients.

OBJECTIVE

This study explores patients' and providers' perspectives about access to GAS and other gender-affirming medical interventions not offered in the VHA including barriers, facilitators, and clinical and policy recommendations.

PARTICIPANTS

TGD patients (n = 30) and VHA providers (n = 22).

APPROACH

Semi-structured telephone interviews conducted from August 2019 through January 2020. Two TGD analysts used conventional and directed content analysis to code transcribed data.

KEY RESULTS

VHA policy exclusions were the most cited barrier to GAS. Additional barriers included finding information about GAS, traveling long distances to non-VHA surgeons, out-of-pocket expenses, post-surgery home care, and psychological challenges related to the procedure. Factors facilitating access included surgical care information from peers and VHA providers coordinating care with non-VHA GAS providers. Pre- and post-operative care through the VHA also facilitated receiving surgery; however, patients and providers indicated that knowledge of these services is not widespread. Respondents recommended disseminating information about GAS-related care and resources to patients and providers to help patients navigate care. Additional recommendations included expanding access to TGD mental health specialists and establishing referrals to non-VHA GAS providers through transgender care coordinators. Finally, transfeminine patients expressed the importance of facial GAS and hair removal.

CONCLUSIONS

A policy change to include GAS in the VHA medical benefits package will allow the largest integrated healthcare system in the United States to provide evidence-based GAS services to TGD patients. For robust and consistent policy implementation, the VHA must better disseminate information about VHA-provided GAS-related care to TGD patients and providers while building capacity for GAS delivery.

Barriers and Facilitators to Gender-affirming Hormone Therapy in the Veterans Health Administration

BACKGROUND

In 2011, the Veterans Health Administration (VHA) established a policy for the delivery of transition-related services, including gender-affirming hormone therapy (GAHT), for transgender and gender diverse (TGD) patients. In the decade since this policy's implementation, limited research has investigated barriers and facilitators of VHA's provision of this evidence-based therapy that can improve life satisfaction among TGD patients.

PURPOSE

This study provides a qualitative summary of barriers and facilitators to GAHT at the individual (e.g., knowledge, coping mechanisms), interpersonal (e.g., interactions with other individuals or groups), and structural (e.g., gender norms, policies) levels.

METHODS

Transgender and gender diverse patients (n = 30) and VHA healthcare providers (n = 22) completed semi-structured, in-depth interviews in 2019 regarding barriers and facilitators to GAHT access and recommendations for overcoming perceived barriers. Two analysts used content analysis to code and analyze transcribed interview data and employed the Sexual and Gender Minority Health Disparities Research Framework to organize themes into multiple levels.

RESULTS

Facilitators included having GAHT offered through primary care or TGD specialty clinics and knowledgeable providers, with patients adding supportive social networks and self-advocacy. Several barriers were identified, including a lack of providers trained or willing to prescribe GAHT, patient dissatisfaction with prescribing practices, and anticipated or enacted stigma. To overcome barriers, participants recommended increasing provider capacity, providing opportunities for continual education, and enhancing communication around VHA policy and training.

CONCLUSIONS

Multi-level system improvements within and outside the VHA are needed to ensure equitable and efficient access to GAHT.

Recruiting Sexual and Gender Minority Veterans for Health Disparities Research: Recruitment Protocol of a Web-Based Prospective Cohort Study

BACKGROUND

The Health for Every Veteran Study is the first Veterans Health Administration-funded, nationwide study on lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) veterans' health that relies exclusively on primary recruitment methods. This study aimed to recruit 1600 veterans with diverse sexual and gender identities to study the mental health and health risk behaviors of this population. A growing body of literature highlights the health inequities faced by LGBTQ+ veterans when compared with their heterosexual or cisgender peer groups. However, there is little to no guidance in the health disparities literature describing the recruitment of LGBTQ+ veterans.

OBJECTIVE

This paper provides an overview of the recruitment methodology of Health for Every Veteran Study. We describe the demographics of the enrolled cohort, challenges faced during recruitment, and considerations for recruiting LGBTQ+ veterans for health research.

METHODS

Recruitment for this study was conducted for 15 months, from September 2019 to December 2020, with the goal of enrolling 1600 veterans evenly split among 8 sexual orientation and gender identity subgroups: cisgender heterosexual women, cisgender lesbian women, cisgender bisexual women, cisgender heterosexual men, cisgender gay men, cisgender bisexual men, transgender women, and transgender men. Three primary recruitment methods were used: social media advertising predominantly through Facebook ads, outreach to community organizations serving veterans and LGBTQ+ individuals across the United States, and contracting with a research recruitment company, Trialfacts.

RESULTS

Of the 3535 participants screened, 1819 participants met the eligibility criteria, and 1062 completed the baseline survey to enroll. At baseline, 25.24% (268/1062) were recruited from Facebook ads, 40.49% (430/1062) from community outreach, and 34.27% (364/1062) from Trialfacts. Most subgroups neared the target enrollment goals, except for cisgender bisexual men, women, and transgender men. An exploratory group of nonbinary and genderqueer veterans and veterans with diverse gender identities was included in the study.

CONCLUSIONS

All recruitment methods contributed to significant portions of the enrolled cohort, suggesting that a multipronged approach was a critical and successful strategy in our study of LGBTQ+ veterans. We discuss the strengths and challenges of all recruitment methods, including factors impacting recruitment such as the COVID-19 pandemic, negative comments on Facebook ads, congressional budget delays, and high-volume surges of heterosexual participants from community outreach. In addition, our subgroup stratification offers important disaggregated insights into the recruitment of specific LGBTQ+ subgroups. Finally, the web-based methodology offers important perspectives not only for reaching veterans outside of the Veterans Health Administration but also for research studies taking place in the COVID-19-impacted world. Overall, this study outlines useful recruitment methodologies and lessons learned to inform future research that seeks to recruit marginalized communities.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43824.

Considerations and complexities of accurate PTSD assessment among transgender and gender diverse adults

Posttraumatic stress disorder (PTSD) assessment among transgender and gender diverse (TGD) adults is complex because the literature offers little guidance on affirming assessment that accurately captures both trauma- and discrimination-related distress. This study aimed to characterize threats to precise PTSD assessment that arose during the Clinician-Administered PTSD Scale for the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (CAPS-5). Our sample (N = 44) included trans women (38%), trans men (25%), nonbinary people (23%), and other TGD identities (14%). Participants were mostly White (75%), non-Latinx (82%), educated (91% at least some college), with a mean age of 37 years (SD = 15.5). Demographic and CAPS-5 scoring data as well as content analysis of audio-recorded CAPS-5 interviews are reported. All participants reported trauma exposure, and nearly half met PTSD diagnostic criteria (49%). Interpersonal assault was a common trauma type linked to posttraumatic symptoms (77%); 41% were sexual assaults; and 41% were discrimination-based (e.g., linked to gender identity) physical or sexual assaults. Qualitative findings suggest how and when discrimination-related experiences may threaten PTSD assessment accuracy, leading to overpathologizing or underdetection of symptoms, for example, (a) initial selection of a noncriterion A discrimination event as "worst event," (b) linking symptoms to internalized transphobia (rather than trauma), and (c) linking victimization to gender identity/expression. Threats to PTSD assessment were more common when symptoms were linked to discrimination-based traumatic events, suggesting the importance of understanding contextual factors of index events. We offer a framework for understanding unique challenges to the assessment of PTSD among TGD people and provide recommendations for improving assessment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A bottom-up approach to developing a unified trauma-minority stress model for transgender and gender diverse people

OBJECTIVE

Transgender and gender diverse (TGD) people are at heightened risk of both Criterion A trauma exposure and other bias-related minority stressors (e.g., discrimination, rejection). In the absence of a unified trauma-minority stress theory, it remains unclear how to best conceptualize psychopathology for people who experience both trauma and minority stress.

METHOD

Using a participant-driven q-sort methodology and network analytic approach, we analyzed card sort data from 18 TGD people and 16 providers with expertise in TGD care to derive thematic networks of trauma and minority stress experiences, as they connected to transdiagnostic symptoms (e.g., hyperarousal, avoidance).

RESULTS

The TGD participants' resulting network illustrates conceptualizations of identity- and nonidentity-based Criterion A traumas as similar and only related to psychiatric symptoms via the shared connection through other minority stressors. The provider network was more granular, although the general pattern was consistent with TGD participants, demonstrating similar perceptions of how these experiences are associated.

CONCLUSIONS

Evidence of inextricable links between trauma and psychiatric symptoms through the conduit of minority stressors lays the groundwork for novel, integrated models of trauma, minority stress, and their transdiagnostic symptom sequelae. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Primary sources of health care among LGBTQ+ veterans: Findings from the Behavioral Risk Factor Surveillance System

OBJECTIVE

This study examined the primary source of health care between veterans with lesbian, gay, bisexual, queer and similar identities (LGBTQ+) and non-LGBTQ+ veterans.

DATA SOURCES AND STUDY SETTING

Veterans (N = 20,497) from 17 states who completed the CDC's Behavioral Risk Factor Surveillance System from 2016 to 2020, including the Sexual Orientation and Gender Identity and Health Care Access modules.

STUDY DESIGN

We used survey-weighted multiple logistic regression to estimate average marginal effects of the prevalence of utilization of Veteran's Health Administration (VHA)/military health care reported between LGBTQ+ and non-LGBTQ+ veterans. Prevalence estimates were adjusted for age group, sex, race and ethnicity, marital status, educational attainment, employment status, survey year, and US state.

DATA COLLECTION METHODS

Study data were gathered via computer-assisted telephone interviews with probability-based samples of adults aged 18 and over. Data are publicly available.

PRINCIPAL FINDINGS

Overall, there was not a statistically significant difference in estimated adjusted prevalence of primary use of VHA/military health care between LGBTQ+ and non-LGBTQ+ veterans (20% vs. 23%, respectively, p = 0.13). When examined by age group, LGBTQ+ veterans aged 34 and younger were significantly less likely to report primary use of VHA/military health care compared to non-LGBTQ+ veterans (25% vs. 44%, respectively; p = 0.009). Similarly, in sex-stratified analyses, fewer female LGBTQ+ veterans than female non-LGBTQ+ veterans reported VHA/military health care as their primary source of care (13% vs. 29%, respectively, p = 0.003). Implications and limitations to these findings are discussed.

CONCLUSIONS

Female and younger LGBTQ+ veterans appear far less likely to use VHA/military for health care compared to their cisgender, heterosexual peers; however, because of small sample sizes, estimates may be imprecise. Future research should corroborate these findings and identify potential reasons for these disparities.

Causes of alcohol-attributable death and associated years of potential life lost among LGB and non-LGB veteran men and women in Veterans Health Administration

BACKGROUND

Alcohol use is a significant concern nationally and research now highlights higher rates of alcohol attributable death (AAD) and years of potential life lost (YPLL) among lesbian, gay, and bisexual (LGB) veterans compared to non-LGB veterans. In this study, we examined specific causes of AAD and associated YPLL between LGB and non-LGB veteran men and women to highlight needed outreach, prevention, and treatment strategies.

METHODS

Using data from the nationwide Veterans Health Administration electronic health record and National Death Index from 2014 to 2018, we examined the top ten ranked causes of AAD among LGB (n = 102,085) and non-LGB veteran (n = 5,300,521) men and women, as well as associated YPLL per AAD.

RESULTS

We observed higher rates of AAD among men than women, but higher rates among LGB veterans relative to their same-sex non-LGB counterparts. We noted greater YPLL per AAD among LGB men and all women compared to non-LGB men, even when of similar or same rank in cause of death. Acute-cause AAD death (e.g., alcohol-related suicide, poisonings) was ranked higher among LGB men and all women. YPLL was greater for both acute- and chronic-cause AAD (e.g., liver disease) among LGB men and all women compared to non-LGB men.

CONCLUSIONS

Causes of AAD differ between LGB and non-LGB men and women. The differences observed highlight disparities in acute- and chronic-cause AAD between groups help explain the higher number of YPLL per AAD that disfavor LGB men and women veterans, and essential next steps in primary and secondary prevention of hazardous drinking and mortality risk.

Trends in Feminizing Hormone Therapy for Transgender Patients, 2006-2017

Combination therapy with estrogen and spironolactone may help some transgender women achieve desired results. We used two databases, OptumLabs® Data Warehouse (OLDW) and Veterans Health Administration (VHA), to examine trends in feminizing therapy. We included 3368 transgender patients from OLDW and 3527 from VHA, all of whom received estrogen, spironolactone, or both between 2006 and 2017. In OLDW, the proportion receiving combination therapy increased from 47% to 75% during this period. Similarly, in VHA, the proportion increased from 39% to 69% during this period. We conclude that the use of combination hormone therapy has become much more common over the past decade.

Social Stressors and Health Among Older Transgender and Gender Diverse Veterans

Purpose: Health disparities in transgender and gender diverse (TGD) veterans compared with cisgender veterans have been documented. However, there is a paucity of literature focused on older TGD veterans. We assessed health conditions and social stressors in older TGD veterans compared with matched cisgender veterans. Methods: Using gender identity disorder diagnosis codes, we identified 1244 TGD veterans (65+ years of age) receiving care in the Veterans Health Administration (VHA) from 2006 to 2018. These TGD veterans were then matched to 3732 cisgender veterans based on age, VHA site, and date of care in VHA. Results: In adjusted models, TGD veterans compared with cisgender veterans were less likely to have alcohol use disorder (adjusted odds ratio [AOR; 95% confidence interval]: [0.70; 0.58-0.85]), drug use disorder (0.59; 0.47-0.74), tobacco use (0.75; 0.65-0.86), and anxiety (0.74; 0.62-0.90). However, compared with cisgender veterans, TGD veterans were more likely to experience depression (1.63; 1.39-1.93), Alzheimer's disease (8.95; 4.25-18.83), cancer (1.83; 1.56-2.14), violence (1.82; 1.14-2.91), social/familial problems (2.45; 1.99-3.02), lack of access to care/transportation (2.23; 1.48-3.37), and military sexual trauma (2.59; 1.93-3.46). Furthermore, compared with cisgender veterans, TGD veterans were more likely to have documentation of a higher count of social stressors: 1 or more stressors (1.64; 1.38-1.95) and 2 or more stressors (1.22; 1.01-1.49). Conclusion: Despite significant disparities in social stressors and health conditions compared with cisgender veterans, TGD veterans had a lower likelihood of substance use and anxiety. Interventions are needed to mitigate social stressors and improve health among the older TGD veteran population.

Alcohol-attributable deaths and years of potential life lost due to alcohol among veterans: Overall and between persons with minoritized and non-minoritized sexual orientations

BACKGROUND

Unhealthy alcohol use is disproportionally experienced by individuals with minoritized sexual orientations. Unlike the general US population, for whom the burden of alcohol as it relates to mortality is consistently monitored across time with national survey data, the impact of unhealthy alcohol use among veterans with minoritized sexual orientations, for whom addressing substance use is a national priority, is largely unknown.

METHODS

Using Alcohol Use Disorders Identification Test Consumption data from the Department of Veterans Affairs electronic health record and underlying cause of death from National Death Index from 2014 to 2018 we quantified alcohol consumption and related mortality among veterans with (n = 102,085) and without minoritized sexual orientations (n = 5300,521). Age adjusted rates of alcohol attributed deaths (AAD) per 100,000 persons and years of potential life lost (YPLL) were estimated by sexual orientation, sex, and sexual orientation stratified by sex.

RESULTS

Alcohol attributable deaths (n = 21,861) were higher among veterans with minoritized sexual orientations than veterans without after adjustment for age (486.5 deaths/100,000 versus 309.7 deaths/100,000, respectively). Veterans with minoritized sexual orientations also experienced more YPLL (13,772.8 years/100,000 versus 7618.9 years/100,000). Years of potential life lost per AAD was higher in women (33.2 years) than men (18.7 years).

CONCLUSIONS

Alcohol consumption results in substantial disability and death among veterans, particularly veterans with minoritized sexual orientations. Findings suggest need for increased alcohol-related services for all VA patients, and potential targeted approaches to for veterans with minoritized sexual orientations and women to offset risk for, and years of potential life lost from, alcohol attributable death.

Indirect effects of dissociation on the relationship between lifetime PTSD symptoms and condomless sex among men who have sex with men with a history of childhood sexual abuse

Posttraumatic stress disorder (PTSD) symptoms may interfere with gay, bisexual and other men who have sex with men's (MSM) ability to engage in safe sex practices. An indirect relationship with dissociation may help to elucidate the relationship between PTSD symptom severity and condomless sex among MSM with childhood sexual abuse (CSA) histories. These relationships have not previously been examined in this group, which has a unique vulnerability for HIV acquisition. A cross-sectional sample of MSM with histories of CSA (N=290) was recruited at study sites in Boston, MA, and Miami, FL. Participants had a mean age of 37.95 years (SD=11.68), 22% were African American and 29.4% identified as Latino. The sample reported a mean of 10.47 (SD=4.38) lifetime PTSD symptoms and 26.4% met the clinical threshold for dissociation. Logistic regression models (adjusted for age, education, and substance use disorder) were used to assess indirect effects of dissociation on the relationship between lifetime PTSD symptoms and condomless anal/vaginal sex episodes with serodiscordant or unknown status partners in the past 3 months. Dissociation accounted for the association between lifetime PTSD symptom severity and condomless sex episodes. The Sobel test (Sobel = 2.04, p= .042; CI 95% bias-corrected bootstrap) suggested significant indirect effects for dissociation. Dissociation among MSM with CSA histories may compromise accurate appraisals of sexual risk and safety and increase vulnerability for HIV acquisition. Further research is warranted to address HIV prevention in the context of PTSD symptom severity to improve the mental health of MSM and increase the effectiveness of HIV prevention interventions.

Identifying Posttraumatic Stress Disorder and Disparity Among Transgender Veterans Using Nationwide Veterans Health Administration Electronic Health Record Data

Purpose: The prevalence of posttraumatic stress disorder (PTSD) and other psychiatric disorders is high among military veterans and even higher among transgender veterans. Prior prevalence estimates have become outdated, and novel methods of estimation have since been developed but not used to estimate PTSD prevalence among transgender veterans. This study provides updated estimates of PTSD prevalence among transgender and cisgender veterans. Methods: We examined Veterans Health Administration (VHA) medical record data from October 1, 1999 to April 1, 2021 for 9995 transgender veterans and 29,985 cisgender veteran comparisons (1:3). We matched on age group at first VHA health care visit, sex assigned at birth, and year of first VHA visit. We employed both probabilistic and rule-based algorithms to estimate the prevalence of PTSD for transgender and cisgender veterans. Results: The prevalence of PTSD was 1.5-1.8 times higher among transgender veterans. Descriptive data suggest that the prevalence of depression, schizophrenia, bipolar disorder, alcohol and non-alcohol substance use disorders, current/former smoking status, and military sexual trauma was also elevated among transgender veterans. Conclusion: The PTSD and overall psychiatric burden observed among transgender veterans was significantly higher than that of their cisgender peers, especially among recent users of VHA care. These PTSD findings are consistent with prior literature and minority stress theory, and they were robust across probabilistic and two rule-based methods employed in this study. As such, enhanced and careful screening, outreach, and evidence-based practices are recommended to help reduce this disparity among transgender veterans.

Estimating prevalence of PTSD among veterans with minoritized sexual orientations using electronic health record data

Objective: Questionnaire studies show people with minoritized sexual orientations (MSOs) face increased risk for conditions including posttraumatic stress disorder (PTSD). This study replicated Harrington et al.'s (2019) electronic health record probabilistic algorithm to evaluate lifetime PTSD prevalence in Veterans Health Administration (VHA)-using veterans. Method: In 115,853 MSO veterans and a 1:3 matched (on sex assigned at birth, and age at and year of first VHA visit) sample of non-MSO veterans. Each veteran was given a probability of "likely PTSD" (0.0-1.0) and thresholds (e.g., 0.7) applied to minimize false positive classifications. Results: Veterans with MSO were 2.35 times, CI [2.33, 2.38], more likely to have "likely PTSD" than veterans with non-MSO. The prevalence of "likely PTSD" using the rule-based International Classification of Diseases (ICD) approach was 40.8% among the MSO group compared to 22.0% among the non-MSO group after excluding those with bipolar or schizophrenia diagnoses and those with limited VHA engagement. Without those exclusions, prevalence was slightly higher in both groups (46.1% vs. 24.3%, respectively; prevalence ratio: 1.90). Despite increased prevalence of exposure to military sexual trauma (MST; MSO = 20.7%; non-MSO = 8.3%) and double "likely PTSD" among MSO veterans, they were less likely to have a service-connected PTSD disability than their matched non-MSO (MSO = 78.1%; non-MSO = 87.6%) comparators. Conclusions: VHA-using veterans with MSO were twice as likely to have "likely PTSD" and exposure to MST than veterans with non-MSO. Veterans with MSO were less likely to be service connected for PTSD than non-MSO counterparts. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Exploring Research Engagement and Priorities of Transgender and Gender Diverse Veterans

INTRODUCTION

In recent years, the U.S. Veterans Health Administration (VHA) has seen an increasing population of transgender and gender diverse (TGD) veterans accessing care. Approximately 139 per 100,000 VHA users had a gender identity disorder diagnosis documented in 2018 compared to 32.9 per 100,000 in 2013. Despite TGD patients being overrepresented within VHA, TGD veterans may distrust or face unique barriers with various aspects of the VHA, including health services research. Existing VHA health research focused on TGD populations is largely limited to secondary analyses of electronic health record data. Identifying strategies to enhance primary data collection is crucial for more deeply investigating health care challenges experienced by TGD veterans using VHA care. Additionally, describing health topics of importance for TGD veterans is important for making the research agenda more patient-centered. In this study, we offer veterans' recommendations for researchers working with underrepresented populations based on our findings.

MATERIALS AND METHODS

From September through October 2019, 30 TGD veterans were recruited through VHA lesbian, gay, bisexual, transgender, and queer/questioning Veteran Care Coordinators (LGBTQ+ VCC) located nationwide. Semi-structured interviews were used to explore barriers and facilitators to research participation, recommendations for improving outreach and engagement, and overall perspectives about priorities in health services research. Transcripts were independently and jointly reviewed and coded by two TGD research analysts, including a veteran using VHA care. Codes were derived inductively. Themes were identified using conventional content analysis. The VA Pittsburgh Healthcare System institutional review board approved this study.

RESULTS

Participants cited privacy concerns of being "outed" and potentially having VHA benefits revoked, in addition to a level of distrust in researchers' intentions as barriers to participating in studies. Facilitators for participating included feeling a sense of serving the TGD community and accessibility to study locations, especially VHA-affiliated sites. Suggestions for recruitment included tailored messaging and using other TGD peers or affirming VHA staff (e.g., LGBTQ+ VCCs) for study outreach. Mental health and gender-affirming hormone therapy were the most understudied topics identified by participants. Additionally, participants prioritized the inclusion and study of underrepresented subpopulations, such as transgender women of color, transgender men, and non-binary/gender diverse veterans, in future research.

CONCLUSIONS

By harnessing the VHA LGBTQ+ VCC network, this study recruited a national sample of TGD veterans to provide insight on methods for more effectively engaging TGD veterans in research and elicited their suggestions for health services research topics. The findings provide numerous suggestions for medicine and public health that are ripe for future research endeavors. Despite the study's lack of gender, racial, and ethnic diversity, findings highlight the need for engagement and study of underrepresented veteran populations. These suggested areas of focus for research in combination with valuable insight on research participation provide researchers with guidance for developing research agendas and designing recruitment and data collection methods that can facilitate future primary research advancing health services research involving TGD patients. Similarly, VHA and non-VHA researchers conducting research involving other underrepresented populations can also gain insight from these findings.

Sexual orientation-related disparities in health conditions that elevate COVID-19 severity

Purpose

The Veterans Health Administration (VA) is the largest single integrated healthcare system in the US and is likely the largest healthcare provider for people with minoritized sexual orientations (e.g., gay, lesbian, bisexual). The purpose of this study was to use electronic health record (EHR) data to replicate self-reported survey findings from the general US population and assess whether sexual orientation is associated with diagnosed physical health conditions that may elevate risk of COVID-19 severity among veterans who utilize the VA.

Methods

A retrospective analysis of VA EHR data from January 10, 1999–January 07, 2019 analyzed in 2021. Veterans with minoritized sexual orientations were included if they had documentation of a minoritized sexual orientation within clinical notes identified via natural language processing. Veterans without minoritized sexual orientation documentation comprised the comparison group. Adjusted prevalence and prevalence ratios (aPR) were calculated overall and by race/ethnicity while accounting for differences in distributions of sex assigned at birth, age, calendar year of first VA visit, volumes of healthcare utilization, and VA priority group.

Results

Data from 108,401 veterans with minoritized sexual orientation and 6,511,698 controls were analyzed. After adjustment, veterans with minoritized sexual orientations had a statistically significant elevated prevalence of 10 of the 11 conditions. Amongst the highest disparities observed were COPD (aPR:1.24 [95% confidence interval:1.23–1.26]), asthma (1.22 [1.20–1.24]), and stroke (1.26 [1.24–1.28]).

Conclusions

Findings largely corroborated patterns among the general US population. Further research is needed to determine if these disparities translate to poorer COVID-19 outcomes for individuals with minoritized sexual orientation.

Fallen Between the Cracks: Protecting Research Staff From Participant-Perpetrated Harassment

There has been a call to identify populations who are at-risk for harassment. At our institution, participant-perpetrated harassment led to the development of an institution-wide program called Cultivating Respect in Research Environments (CuRRE). In this article, we describe the proactive and multipronged approach used to promote and implement the CuRRE program. We describe a policy created to set guidelines and expectations for research participants and discuss the educational and skills-based trainings delivered to principal investigators and research staff members. Research staff members completed anonymous surveys before and after the training. Over half of the attendees reported having been harassed by a participant/patient. Attendees responded favorably to the training; they felt more confident and better equipped to address participant-perpetrated harassment at the conclusion of the training. Given the dearth of literature in this area, we offer our experiences to encourage others to address this issue within their own research environment and institution.

Veterans' Reported Comfort in Disclosing Sexual Orientation and Gender Identity

BACKGROUND

The Veterans Health Administration (VHA) does not routinely collect and document sexual orientation and gender identity (SOGI) data despite research on health disparities among sexual and gender minority (SGM) veterans. Due to the legacy of previous Department of Defense policies that prohibited disclosure of sexual or gender minority identities among active-duty personnel, minority veterans may be reluctant to respond to SOGI questions on confidential VHA surveys and in discussions with their VHA providers. Veterans may generally find SOGI questions uncomfortable and may not appreciate their relevance to health care.

OBJECTIVE

The purpose of this research was to examine veterans' comfort in reporting identity characteristics on confidential VHA surveys and in discussion with their VHA providers and whether comfort differed by sociodemographic characteristics.

RESEARCH DESIGN

The project involves the secondary analysis of quantitative data from a quality improvement survey project.

SUBJECTS

A total of 806 veterans were surveyed.

RESULTS

Overall, 7.15% endorsed sexual or gender minority identity which is a higher rate than the 4.5% noted in the general US population. Cisgender and heterosexual veterans were more comfortable reporting identity characteristics both on VHA confidential surveys and in discussion with VHA providers compared with SGM veterans.

CONCLUSIONS

These data suggest that the majority of veterans feel comfortable reporting their identities both on surveys and in the context of health care. Understanding these perceptions can assist VHA programs in implementing SOGI data collection and disclosure in clinical care, creating a welcoming environment of care for SGM veterans that does not make veterans from other backgrounds feel uncomfortable.

Patient Characteristics Associated With the Receipt of Hormone Therapy Among Transgender Patients in the Veterans Health Administration

Background: Many transgender patients experience gender dysphoria as a result of an incongruence between their gender identity and sex assigned at birth. Gender-affirming hormone therapy improves the quality of life for transgender patients seeking to increase alignment of their secondary sex characteristics and gender identity. However, little is known about the patient factors that are associated with receipt of this therapy which is critical to identifying areas for improvement in care for transgender patients. Objective: To evaluate patient characteristics associated with transgender patients’ receipt of hormone therapy from the Veterans Health Administration (VHA). Methods: Inpatient and outpatient data were reviewed for transgender patients, identified through ICD-9/ICD-10 diagnosis codes for gender identity disorder (GID), receiving VHA health care from January 2006 to December 2018. We evaluated receipt of hormone therapy (testosterone or estrogen +/- spironolactone) from the VHA, socio-demographics, comorbidities, social stressors, military sexual trauma, and documented suicide attempts. Adjusted Odds Ratios (aOR) and 95% Confidence Intervals (CI) were obtained from a multivariable logistic regression model used to ascertain the relationship between patient characteristics and hormone therapy. Results: Of 9,406 patients with documented GID, 5,487 (58.3%) received hormone therapy from the VHA. Compared to patients not receiving hormone therapy, a higher proportion of patients receiving hormone therapy were younger (21-29 years: 18.1% vs. 11.6%; 30-39 years: 20.0% vs. 14.6%; 40-49 years: 16.2% vs. 13.6%), had documentation of a positive military sexual trauma screening (22.2% vs. 16.2%; p&lt;0.0001), and a suicide attempt (11.4% vs. 9.9%; p=0.0067). There were significant associations between receipt of hormone therapy and: 1) younger age (aOR: 1.33; 95% CI: 1.29-1.36; p&lt;0.0001); 2) Black non-Hispanic patients (aOR: 0.58; 95% CI: 050-0.68; p&lt;0.0001); 3) increasing number of comorbidities (aOR: 0.86; 95% CI: 0.84-0.88; p&lt;0.0001); and 4) increasing number of social stressors (aOR: 0.86; 95% CI: 0.83-0.90; p&lt;0.0001). Conclusions: Age, race/ethnicity, comorbidities, and social stressors among other factors are associated with receipt of hormone therapy among transgender patients in the VHA. Subsequent efforts should focus on understanding clinician- and site-level determinants to facilitate the design of effective quality improvement measures that optimize gender affirming hormone therapy through VHA for transgender patients.

Improving affirming care for sexual and gender minority veterans

Lesbian, gay, bisexual, and transgender (LGBT) populations face a range of health disparities that all health care systems must address. In response to known health disparities, the LGBT Health Program of the Veterans Health Administration (VHA) developed policies supporting the provision of affirming care to LGBT veterans. To support policy implementation, the program launched the LGBT Veteran Care Coordinator (LGBT VCC) Program in 2016, requiring every VHA facility to appoint at least one clinical staff member to serve as an LGBT VCC. This quality improvement project reports on LGBT VCCs' perspectives on the state of affirming care at their facilities in the first year of the program. LGBT VCCs (n = 79) completed a brief online survey, including qualitative questions on barriers and facilitators to implementation, and general recommendations for the program. The Consolidated Framework for Implementation Research (CFIR) guided directed content analysis of reported facilitators and barriers. The highest proportion of facilitators and barriers reported by the LGBT VCCs were coded under leadership engagement, available resources, other personal attributes, organizational culture, and networking and communications. LGBT VCCs requested additional support in securing adequate designated administrative time, engaging with facility leadership, improving networking and communication, tailoring programing, and providing professional advancement opportunities. Organizing findings using the CFIR enabled the LGBT Health Program to effectively promote facilitators and address barriers experienced during the startup year of the LGBT VCC Program. The VHA's efforts to reduce LGBT veteran health disparities may serve as a model for other health care systems. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Validating Data-driven Methods to Identify Transgender Individuals in the Veterans Affairs

We sought to operationalize and validate data-driven approaches to identify transgender individuals in the U.S. Department of Veteran Affairs (VA) health care system through a retrospective analysis using VA administrative data from 2006 to 2018. Besides gender identity disorder (GID) diagnoses, a combination of non-GID data elements were used to identify potential transgender veterans, including: 1) endocrine disorder, unspecified or not otherwise specified codes, 2) receipt of sex hormones not associated with the sex documented in the veteran's records (gender-affirming hormone therapy), and 3) change in the administratively recorded sex. Both GID and non-GID data elements were applied to a sample of 13,233,529 veterans utilizing the VA healthcare system between January 2006 and December 2018. We identified 10,769 potential transgender veterans. Based on a high positive predictive value of GID (83%, 95% Confidence Interval (CI)=77-89%) versus non-GID-coded veterans (2%, 95% CI=1-11%) from chart review validation, the final analytical sample comprised of only veterans with a GID diagnosis code (n=9,608). In the absence of self-identified gender identity, findings suggest that relying entirely on GID diagnosis codes are the most reliable approach to identify transgender individuals in the VA.

Suicide, Homicide, and All-Cause Mortality Among Transgender and Cisgender Patients in the Veterans Health Administration

Purpose: This study examines the differences in suicide, homicide, and all-cause mortality between transgender and cisgender Veterans Health Administration (VHA) patients. Methods: VHA electronic medical record data from October 1, 1999 to December 31, 2016 were used to create a sample of transgender and cisgender patients (n = 32,441). Cox proportional hazard regression was used to evaluate differences in survival time (date of birth to death date/study end). Death data were from the National Death Index. Results: Transgender patients had more than twofold greater hazard of suicide than cisgender patients (adjusted hazard ratio [aHR] = 2.77, 95% confidence interval [CI] = 1.88-4.09), especially among younger (18-39 years) (aHR = 3.35, 95% CI = 1.30-8.60) and older (≥65 years) patients (aHR = 9.48, 95% CI = 3.88-23.19). Alternatively, transgender patients had an overall lower hazard of all-cause mortality (aHR = 0.90, 95% CI = 0.84-0.97) compared with cisgender patients, which was driven by patients 40-64 years old (aHR = 0.78, 95% CI = 0.72-0.86) and reversed by those 65 years and older (aHR = 1.17, 95% CI = 1.03-1.33). Conclusion: Transgender patients' hazard of suicide mortality was significantly greater than that of cisgender VHA patients.

Are There Differences in Anti-Gay Beliefs Among U.S. Veterans and Non-Veterans? Results from the General Social Survey

Only since 2011 have sexual minorities been able to serve openly in the U.S. military. The previous anti-gay policies and culture of the military may have increased anti-gay beliefs among veterans. Using data from the 2010-2016 General Social Survey, we tested whether veterans more frequently endorsed anti-gay beliefs than their non-veteran peers. Adjusting for sociodemographic characteristics with multiple logistic regression, we tested the associations of veteran status with five anti-gay beliefs (i.e., disallowing a gay person (1) from publicly speaking or (2) teaching at a university, (3) removing a gay-supportive book from a library, (4) whether same-sex sexual relations are wrong, and (5) support of same-sex marriage. Veteran status was associated with greater disagreement with same-sex marriage (B = 0.16, p = 0.033) but not with other anti-gay beliefs. Most anti-gay beliefs among veterans were explained by other sociodemographic factors and may not be inherent to veteran status.

Addressing Diversity in PTSD Treatment: Clinical Considerations and Guidance for the Treatment of PTSD in LGBTQ Populations

Purpose of review

Trauma exposure is widespread but is especially common among lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals. LGBTQ individuals also experience higher rates of discrimination, victimization, and minority stress which can complicate posttraumatic stress disorder (PTSD) treatment but also represent independent intervention targets. In this review, we highlight existing evidence-based practices, current limitations, and provide recommendations for care in the absence of established guidelines for treatment PTSD among LGBTQ patients.

Recent findings

Trauma-focused therapies (e.g., CPT, PE) and medications (e.g., SSRIs, SNRIs) have shown benefit for people with PTSD. However, evaluations of these interventions have failed to examine the role of LGBTQ identities in recovery from trauma, and existing PTSD treatments do not account for ongoing threat to safety or the pervasive minority stress experienced by LGBTQ patients. In addition, many LGBTQ patients report negative experiences with healthcare, necessitating increased education and cultural awareness on the part of clinicians to provide patient-centered care and, potentially, corrective mental health treatment experiences.

Summary

Providers should routinely assess trauma exposure, PTSD, and minority stress among LGBTQ patients. We provide assessment and screening recommendations, outline current evidence-based treatments, and suggest strategies for integrating existing treatments to treat PTSD among LGBTQ patients.

Use of Veterans Health Administration Homeless Programs Among Transgender and Non-Transgender Veterans Experiencing Self-Reported Housing Instability

INTRODUCTION

Transgender individuals have higher rates of housing instability than non-transgender individuals. This study assessed the extent to which unstably housed transgender veterans participated in Veterans Health Administration (VHA) Homeless Programs.

METHODS

Using VHA medical record data for transgender (n=491) and nontransgender (n=473) veterans who self-reported housing instability during fiscal years 2013-2016, chi-square and t-tests identified differences in socio-demographic characteristics and services use; multiple logistic and negative binomial regression assessed the type and number of VHA Homeless Programs veterans used.

RESULTS

A larger proportion of transgender veterans who self-reported housing instability used at least one VHA Homeless Program; transgender veterans had greater odds of using permanent supportive housing and homelessness prevention and rapid rehousing services.

DISCUSSION

Transgender veterans' housing needs are being met by some VHA Homeless Programs; future research should assess long-term housing outcomes and why particular programs may be less acceptable to transgender veterans with the objective of developing programs to address their unique needs.

Using clinician text notes in electronic medical record data to validate transgender-related diagnosis codes

Objective

Transgender individuals are vulnerable to negative health risks and outcomes, but research remains limited because data sources, such as electronic medical records (EMRs), lack standardized collection of gender identity information. Most EMR do not include the gold standard of self-identified gender identity, but International Classification of Diseases (ICDs) includes diagnostic codes indicating transgender-related clinical services. However, it is unclear if these codes can indicate transgender status. The objective of this study was to determine the extent to which patients' clinician notes in EMR contained transgender-related terms that could corroborate ICD-coded transgender identity.

Methods

Data are from the US Department of Veterans Affairs Corporate Data Warehouse. Transgender patients were defined by the presence of ICD9 and ICD10 codes associated with transgender-related clinical services, and a 3:1 comparison group of nontransgender patients was drawn. Patients' clinician text notes were extracted and searched for transgender-related words and phrases.

Results

Among 7560 patients defined as transgender based on ICD codes, the search algorithm identified 6753 (89.3%) with transgender-related terms. Among 22 072 patients defined as nontransgender without ICD codes, 246 (1.1%) had transgender-related terms; after review, 11 patients were identified as transgender, suggesting a 0.05% false negative rate.

Conclusions

Using ICD-defined transgender status can facilitate health services research when self-identified gender identity data are not available in EMR.

Lesbian, Gay, Bisexual, and Transgender Veterans' Experiences of Discrimination in Health Care and Their Relation to Health Outcomes: A Pilot Study Examining the Moderating Role of Provider Communication

Purpose: Lesbian, gay, bisexual, and transgender (LGBT) veterans report discrimination in health care, which may be associated with negative health outcomes/behaviors and has implications for LGBT identity disclosure to providers. Quality provider communication may serve to offset some of the deleterious effects of discrimination; however, no research to date has examined provider communication with respect to health among LGBT patients.

Methods: Participants were 47 LGBT veterans who completed measures related to past health care experiences, experiences of discrimination in health care, perceptions of provider communication, and measures of anxiety, depression, post-traumatic stress disorder symptoms, and alcohol/tobacco use.

Results: The majority of LGBT veterans reported experiencing LGBT-based discrimination in health care, which was associated with higher rates of tobacco use and less comfort in disclosing their LGBT identity to providers. We also found evidence of moderation, such that high-quality provider communication appeared to buffer these associations.

Conclusion: LGBT veterans face unique challenges with respect to receiving appropriate health care. The high frequencies of reported discrimination in health care is problematic and warrants further research and intervention. These results highlight the important role of provider communication, and the potential for quality communication to buffer against certain effects, particularly with respect to tobacco use and LGBT identity disclosure, which is an important protective factor.

Cognitive Behavioral Therapy for Trauma and Self-Care (CBT-TSC) in Men Who have Sex with Men with a History of Childhood Sexual Abuse: A Randomized Controlled Trial

To address childhood sexual abuse (CSA) related distress and HIV risk in men who have sex with men (MSM) using cognitive-behavioral therapy for trauma and self-care (CBT-TSC), which is a novel intervention integrating HIV risk reduction with modified cognitive and behavioral therapy strategies for post-traumatic stress. We compared CBT-TSC to HIV voluntary counseling and testing (VCT)-only in an initial 2-arm RCT in 43 HIV-negative MSM at with a history of CSA and HIV risk. Serodiscordant condomless anal/vaginal sex (CAS; CAS with HIV-postive or HIV unknown status partners) and posttraumatic stress disorder (PTSD) symptoms (Davidson Trauma Scale: total score and avoidance, intrusions, hyperarousal subscales) were outcomes immediately post-treatment, and at 6- and 9-month follow-up. At post-treatment, CBT-TSC had decreased odds (approximately 60%) of any CAS and greater reductions in CAS compared to VCT-only. Additionally, the CBT-TSC condition experienced greater reductions in total PTSD and avoidance symptoms. At the follow-up visits, CBT-TSC condition had significant reductions in the odds of any CAS and reductions in CAS. However, for PTSD symptoms, only the avoidance subscale remained significantly different compared to VCT-only. CBT-TSC is a potentially efficacious approach to address HIV risk in MSM with a CSA history, with replication and extension in a larger trial needed. This proof-of-concept trial is the first to integrate the treatment of a commonly occurring mental-health syndemic problem in MSM with a health psychology approach to self-care in MSM.Trial Registration Clinicaltrials.gov NCT01266122.

Housing Instability Characteristics Among Transgender Veterans Cared for in the Veterans Health Administration, 2013-2016

Objectives. To characterize housing instability among transgender veterans using Veterans Health Administration (VHA) health care in the United States.Methods. We used administrative data on veterans screened for housing instability from 2013 to 2016; participants included 5717 transgender veterans and 17 133 cisgender veterans. We defined housing instability by a positive screen or VHA Homeless Program use. We identified gender from medical records, reflecting either birth sex or gender identity. We identified transgender identity through transgender-related International Classification of Diseases, Ninth Revision and Tenth Revision codes. A multiple logistic regression assessed the association of transgender identity with housing instability.Results. Prevalence of housing instability was nearly 3 times higher among transgender veterans than among cisgender veterans (19.9% vs 6.7%; P < .001). The difference persisted when we adjusted for sociodemographics (adjusted odds ratio = 2.32; 95% confidence interval = 2.09, 2.57). Transgender veterans experiencing housing instability were more likely than cisgender veterans to be women, younger, unmarried, and White.Conclusions. Transgender veterans experience housing instability more frequently than do cisgender veterans. An increased focus on transgender identity is critical for reducing veteran homelessness.

Evolving Sex and Gender in Electronic Health Records

Development, training, and documentation for the implementation of a self-identified gender identity field in the electronic health record system may improve patient-centered care for transgender and gender nonconforming patients.

Experiences of trauma, discrimination, microaggressions, and minority stress among trauma-exposed LGBT veterans: Unexpected findings and unresolved service gaps

OBJECTIVE

LGBT veterans experience high rates of trauma, discrimination, and minority stress. However, guidelines for case conceptualization and treatment remain limited. The aim of the current study was to examine the experiences of trauma and other high impact experiences among LGBT veterans to inform case conceptualization and treatment.

METHOD

We recruited 47 LGBT veterans with a history of exposure to LGBT-related Criterion A trauma and performed semistructured interviews about their experiences in trauma treatment, barriers to engagement, and treatment needs and preferences. We used thematic analysis of qualitative codes guided by inductive and deductive approaches to characterize the variety of trauma and high impact experiences reported.

RESULTS

LGBT veterans disclosed a range of clinically relevant stressors, including Criterion A traumatic events, minority stress, and microaggression experiences, including interpersonal and institutional discrimination perpetrated by fellow service members/veterans, citizens, therapy group members, and health care providers.

CONCLUSION

These data provide a unique account of LGBT veteran's identity-related trauma and concomitant interpersonal and institutional discrimination, microaggression experiences, minority stress, and traumatic stress symptoms. Findings highlight existing service gaps regarding evidence-based treatments for the sequalae of trauma, discrimination, microaggressions, and minority stress. In addition, we noted past and present issues in military and health care settings that may lead to or exacerbate trauma-related distress and discourage treatment seeking among LGBT veterans. We provide suggestions for clinical work with LGBT veterans and encourage ongoing research and development to eliminate remaining service gaps. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Experiences in the Veterans Health Administration and Impact on Healthcare Utilization: Comparisons Between LGBT and Non-LGBT Women Veterans

PURPOSE

This study aimed to compare experiences related to healthcare of LGBT women and non-LGBT women in a sample of routine users of Veterans Health Administration (VHA) primary care services and examine the impact of those experiences on delaying or missing appointments for VHA care.

METHODS

Women veterans (N = 1391) who had at least three primary care visits in the previous year at 12 VHA facilities were surveyed by phone in January-March 2015 in a baseline wave of a cluster-randomized quality improvement trial. The majority identified as non-LGBT (1201; 85.6%) with 190 (14.4%) women identified as LGBT, based on items measuring sexual orientation and gender identity.

RESULTS

In models controlling for demographics, health status, and positive trauma screens, LGBT identity was predictive of women veterans experiencing harassment from male veterans at VHA in the past 12 months, as well as feeling unwelcome or unsafe at their VHA. Compared with non-LGBT women veterans, LGBT women veterans attributed missing needed care more often in the previous 12 months to concerns about interacting with other veterans. Participant descriptions of harassment indicated that male veterans' comments and actions were distressing and influenced LGBT women's healthcare accessing behavior.

CONCLUSIONS

Compared with non-LGBT women, LGBT women were more likely to report harassment and feeling unwelcome at VHA. Some LGBT women reported delaying or missing needed care, primarily due to concerns about interacting with other veterans. Additional work is necessary to help LGBT women veterans feel safe and welcome at VHA facilities and, thereby, reduce barriers to LGBT women veterans accessing needed care.

Current and Military-Specific Gender Minority Stress Factors and Their Relationship with Suicide Ideation in Transgender Veterans

Research suggests the prevalence of suicide ideation and suicide attempts in the transgender veteran community may be upwards of 20 times higher than nontransgender veterans, who are known to be at increased risk than the general US population. This study aimed to understand the potential influence of external and internal minority stress experienced during and after military service on past-year and recent suicide ideation in a sample of 201 transgender veterans. Nonparametric bootstrapping analyses indicated past-year transgender-specific discrimination and rejection (external minority stress) indirectly predicted frequency of both past-year and past 2-week suicide ideation through past-year shame related to gender identity (internal minority stress). This result was significant when controlling for symptoms of depression and demographics. Similar patterns emerged when examining relationships among military external and internal minority stress on suicide outcomes. These results suggest that attempts to reduce both the experience and impact of minority stressors related to gender identity during and after military service may be an important avenue for suicide prevention.

Utilization of the Veterans Affairs' Transgender E-consultation Program by Health Care Providers: Mixed-Methods Study

Background

In 2015, the Department of Veterans Affairs (VA) nationally implemented a transgender e-consultation (e-consult) program with expert clinical guidance for providers.

Objective

This mixed-methods project aimed to describe providers’ program experiences, reasons for nonuse of the program, and ways to improve the program use.

Methods

From January to May 2017, 15 urban and rural VA providers who submitted at least one e-consult in the last year participated in semistructured interviews about their program experiences, which were analyzed using content analysis. From November to December 2017, 53 providers who encountered transgender patients but did not utilize the program participated in a brief online survey on the reasons for nonuse of the program and the facilitators encouraging use.

Results

Qualitative analysis showed that providers learned of the program through email; colleagues; the electronic health record (EHR) system; and participation in the VA Lesbian, Gay, Bisexual, and Transgender committees or educational trainings. Providers used the program to establish care plans, hormone therapy recommendations, sexual and reproductive health education, surgical treatment education, patient-provider communication guidance, and second opinions. The facilitators of program use included understandable recommendations, ease of use through the EHR system, and status as the only transgender resource for rural providers. Barriers to use included time constraints, communication-related problems with the e-consult, impractical recommendations for underresourced sites, and misunderstanding of the e-consult purpose. Suggestions for improvement included addition of concise or sectioned responses, expansion of program awareness among providers or patients, designation of a follow-up contact person, and increase in provider education about transgender veterans and related care. Quantitative analysis showed that the common reasons for nonuse of the program were no knowledge of the program (54%), no need of the program (32%), and receipt of help from a colleague outside of e-consult (24%). Common suggestions to improve the program use in quantitative analyses included provision of more information about where to find e-consult in the chart, guidance on talking with patients about the program, and e-mail announcements to improve provider awareness of the program. Post hoc exploratory analyses showed no differences between urban and rural providers.

Conclusions

The VA transgender e-consult program is useful for providers, but there are several barriers to implementing recommendations, some of which are especially challenging for rural providers. Addressing the identified barriers and enhancing the facilitators may improve program use and quality care for transgender veterans.

Hormone therapy, gender affirmation surgery, and their association with recent suicidal ideation and depression symptoms in transgender veterans

BACKGROUND

Access to transition-related medical interventions (TRMIs) for transgender veterans has been the subject of substantial public interest and debate. To better inform these important conversations, the current study investigated whether undergoing hormone or surgical transition intervention(s) relates to the frequency of recent suicidal ideation (SI) and symptoms of depression in transgender veterans.

METHODS

This study included a cross-sectional, national sample of 206 self-identified transgender veterans. They self-reported basic demographics, TRMI history, recent SI, and symptoms of depression through an online survey.

RESULTS

Significantly lower levels of SI experienced in the past year and 2-weeks were seen in veterans with a history of both hormone intervention and surgery on both the chest and genitals in comparison with those who endorsed a history of no medical intervention, history of hormone therapy but no surgical intervention, and those with a history of hormone therapy and surgery on either (but not both) the chest or genitals when controlling for sample demographics (e.g., gender identity and annual income). Indirect effect analyses indicated that lower depressive symptoms experienced in the last 2-weeks mediated the relationship between the history of surgery on both chest and genitals and SI in the last 2-weeks.

CONCLUSIONS

Results indicate the potential protective effect that TRMI may have on symptoms of depression and SI in transgender veterans, particularly when both genitals and chest are affirmed with one's gender identity. Implications for policymakers, providers, and researchers are discussed.

Treatment experiences among LGBT veterans with discrimination-based trauma exposure: A pilot study

Past research suggests that rates of trauma exposure and Posttraumatic Stress Disorder (PTSD) are elevated among lesbian, gay, bisexual, and transgender (LGBT) veterans compared to heterosexual and cisgender veterans. Given higher rates of trauma exposure and PTSD, and the culture associated with the Department of Defense's history of policies excluding LGBT people, it is important to understand if LGBT veterans are seeking PTSD treatment following discrimination-based traumatic events, where they seek care, and if they are satisfied with treatment. This study aimed to describe the experiences of discrimination-based trauma-exposed LGBT veterans' (n = 47) experiences with PTSD treatment, including location of treatment (Veterans Health Administration [VHA] versus non-VHA) and satisfaction with care. The majority of veterans had received a PTSD diagnosis from a health-care provider in their lifetimes (78.72%, n = 37), and over half reported currently experiencing PTSD symptoms. Approximately 47% of LGBT veterans with discrimination-based trauma histories preferred to seek PTSD treatment exclusively at VHA (46.81%) or with a combination of VHA and non-VHA services (38.30%). Veterans who received PTSD treatment exclusively from VHA reported higher satisfaction ratings (7.44 on 0-9 scale) than veterans who received PTSD treatment exclusively from outside VHA (5.25 on 0-9 scale). For veterans who sought PTSD treatment at both VHA and non-VHA facilities, there were no significant differences regarding satisfaction ratings for their PTSD treatment in the two settings. Results are discussed in terms of VHA's continued efforts to establish equitable, patient-centered health care for all veterans and the importance of non-VHA facilities to recognize veteran identities.

A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States

Transgender and gender non-conforming (TGNC) populations, including those who do not identify with gender binary constructs (man or woman) are increasingly recognized in health care settings. Research on the health of TGNC people is growing, and disparities are often noted. In this review, we examine 77 studies published between January 1, 1997 and March 22, 2017 which reported mental health outcomes in TGNC populations to (a) characterize what is known about mental health outcomes and (b) describe what gaps persist in this literature. In general, depressive symptoms, suicidality, interpersonal trauma exposure, substance use disorders, anxiety, and general distress have been consistently elevated among TGNC adults. We also used the minority stress model as a framework for summarizing existing literature. While no studies included all elements of the Minority Stress Model, this summary gives an overview of which studies have looked at each element. Findings suggest that TGNC people are exposed to a variety of social stressors, including stigma, discrimination, and bias events that contribute to mental health problems. Social support, community connectedness, and effective coping strategies appear beneficial. We argue that routine collection of gender identity data could advance our understanding mental health risk and resilience factors among TGNC populations.

Impact of Social Determinants of Health on Medical Conditions Among Transgender Veterans

INTRODUCTION

Transgender individuals experience pronounced disparities in health (e.g., mood disorders, suicide risk) and in the prevalence of social determinants of housing instability, financial strain, and violence. The objectives of this study were to understand the prevalence of social determinants among transgender veterans and assess their associations with medical conditions.

METHODS

This project was a records review using administrative data from the U.S. Department of Veterans Affairs databases for 1997-2014. Transgender veterans (N=6,308) were defined as patients with any of four ICD-9 diagnosis codes associated with transgender status. Social determinants were operationalized using ICD-9 codes and Department of Veterans Affairs clinical screens indicating violence, housing instability, or financial strain. Multiple logistic regression was used to assess the associations of social determinants with medical conditions: mood disorder, post-traumatic stress disorder, alcohol abuse disorder, illicit drug abuse disorder, tobacco use disorder, suicidal risk, HIV, and hepatitis C.

RESULTS

After adjusting for sociodemographic variables, housing instability and financial strain were significantly associated with all medical conditions except for HIV, and violence was significantly associated with all medical conditions except for tobacco use disorder and HIV. There was a dose response-like relationship between the increasing number of forms of social determinants being associated with increasing odds for medical conditions.

CONCLUSIONS

Social determinants are prevalent factors in transgender patients' lives, exhibiting strong associations with medical conditions. Documenting social determinants in electronic health records can help providers to identify and address these factors in treatment goals.

Do acceptance and mindfulness moderate the relationship between maladaptive beliefs and posttraumatic distress?

OBJECTIVE

Maladaptive pre- and posttraumatic beliefs are reliable predictors of distress in the wake of trauma. Acceptance and mindfulness skills may be associated with less distress in the presence of these beliefs, but few studies have explored these relationships. This study examined whether individual differences in acceptance and mindfulness moderate the relationship between maladaptive thoughts and distress in postdeployment soldiers.

METHOD

We explored the relationships between posttraumatic maladaptive beliefs, acceptance, mindfulness, and posttraumatic distress (posttraumatic stress disorder [PTSD] and general psychological symptoms) in a sample of recently postdeployed active duty U.S. Army Soldiers (N = 1,524).

RESULTS

Maladaptive thoughts, acceptance, and mindfulness predicted posttraumatic distress, adjusted for combat exposure. In addition, mindfulness partially moderated the relationship between maladaptive thoughts and PTSD symptoms, and acceptance partially moderated the relationship between maladaptive thoughts and general psychological symptoms. Moderation effects were small.

CONCLUSIONS

These findings suggest that individual differences in acceptance and mindfulness may weakly mitigate the relationship between maladaptive thinking and posttraumatic distress, but additional skills may be necessary to fully address maladaptive beliefs in Soldier postdeployment. (PsycINFO Database Record

Advancing LGBT Health Care Policies and Clinical Care Within a Large Academic Health Care System: A Case Study

Culturally competent health care is especially important among sexual and gender minority patients because poor cultural competence contributes to health disparities. There is a need to understand how to improve health care quality and delivery for lesbian, gay, bisexual, and transgender (LGBT) veterans in particular, because they have unique physical and mental health needs as both LGBT individuals and veterans. The following article is a case study that focuses on the policy and clinical care practices related to LGBT clinical competency, professional training, and ethical provision of care for veteran patients in the VA Boston Healthcare System. We apply Betancourt et al.'s (2003) cultural competence framework to outline the steps that VA Boston Healthcare System took to increase cultural competency at the organizational, structural, and clinical level. By sharing our experiences, we aim to provide a model and steps for other health care systems and programs, including other VA health care systems, large academic health care systems, community health care systems, and mental health care systems, interested in developing LGBT health initiatives.