Sex, gender diversity, and brain structure in early adolescence.

There remains little consensus about the relationship between sex and brain structure, particularly in early adolescence. Moreover, few pediatric neuroimaging studies have analyzed both sex and gender as variables of interest-many of which included small sample sizes and relied on binary definitions of gender. The current study examined gender diversity with a continuous felt-gender score and categorized sex based on X and Y allele frequency in a large sample of children ages 9-11 years old (N = 7195). Then, a statistical model-building approach was employed to determine whether gender diversity and sex independently or jointly relate to brain morphology, including subcortical volume, cortical thickness, gyrification, and white matter microstructure. Additional sensitivity analyses found that male versus female differences in gyrification and white matter were largely accounted for by total brain volume, rather than sex per se. The model with sex, but not gender diversity, was the best-fitting model in 60.1% of gray matter regions and 61.9% of white matter regions after adjusting for brain volume. The proportion of variance accounted for by sex was negligible to small in all cases. While models including felt-gender explained a greater amount of variance in a few regions, the felt-gender score alone was not a significant predictor on its own for any white or gray matter regions examined. Overall, these findings demonstrate that at ages 9-11 years old, sex accounts for a small proportion of variance in brain structure, while gender diversity is not directly associated with neurostructural diversity.

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.

Treatment Utilization for Posttraumatic Stress Disorder in a National Sample of Veterans and Nonveterans.

OBJECTIVE: The current study sought to compare rates of posttraumatic stress disorder (PTSD) treatment utilization (medication and psychotherapy) among veterans and nonveterans-and to investigate which factors are associated with treatment utilization among veterans versus nonveterans. METHODS: Participants were 2775 individuals (veteran, n=2508; nonveteran, n=267) meeting criteria for probable PTSD (determined by the PTSD Checklist) drawn from a nationwide, population-based survey. Participants reported demographic information, trauma history, mental health symptoms, insurance coverage, and treatment history. RESULTS: Analyses revealed that the majority of veterans and nonveterans with probable PTSD had not received any PTSD treatment (56% of veterans and 86% of nonveterans). Population-weighted logistic regression models demonstrated that veterans with probable PTSD were substantially more likely to receive medication and psychotherapy for PTSD than nonveterans with probable PTSD. Logistic regression models demonstrated that, among veterans, having Veterans Affairs health care coverage was most strongly associated with receiving PTSD medication and psychotherapy. Black (vs. White) veterans were less likely to have received PTSD medication and psychotherapy. In contrast, among nonveterans, being married or divorced (vs. never married) was most strongly associated with receiving PTSD medication, and reporting a history of sexual trauma was most strongly associated with receiving PTSD psychotherapy. CONCLUSION: Given that most individuals do not receive PTSD treatment, additional understanding of treatment barriers and facilitators for both veterans and nonveterans is needed to improve intervention reach.

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.

Moral injury and peri- and post-military suicide attempts among post-9/11 veterans.

BACKGROUND: Our goal was to examine the association between moral injury, mental health, and suicide attempts during military service and after separation by gender in post-9/11 veterans. METHODS: A nationally representative sample of 14057 veterans completed a cross-sectional survey. To examine associations of exposure to potentially morally injurious events (PMIEs; witnessing, perpetrating, and betrayal) and suicidal self-directed violence, we estimated two series of multivariable logistic regressions stratified by gender, with peri- and post-military suicide attempt as the dependent variables. RESULTS: PMIE exposure accounted for additional risk of suicide attempt during and after military service after controlling for demographic and military characteristics, current mental health status, and pre-military history of suicidal ideation and attempt. Men who endorsed PMIE exposure by perpetration were 50% more likely to attempt suicide during service and twice as likely to attempt suicide after separating from service. Men who endorsed betrayal were nearly twice as likely to attempt suicide during service; however, this association attenuated to non-significance after separation in the fully adjusted models. In contrast, women who endorsed betrayal were over 50% more likely to attempt suicide during service and after separation; PMIE exposure by perpetration did not significantly predict suicide attempts before or after service among women in the fully adjusted models. CONCLUSIONS: Our findings indicate that suicide assessment and prevention programs should consider the impact of moral injury and attend to gender differences in this risk factor in order to provide the most comprehensive care.

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.

Veterans Health Administration (VHA) policy mandates the provision of several gender-affirming health services, including gender-affirming hormone therapy (GAHT). GAHT can improve quality of life among transgender and gender diverse (TGD) patients by more closely aligning their physical self with their internal sense of self. We conducted interviews with 30 TGD patients and 22 VHA healthcare providers to gather their perspectives on barriers and facilitators to GAHT in the VHA. Findings revealed that facilitators of GAHT access included information sharing through social networks and relying on providers in primary care or specialized TGD health clinics for prescribing, while barriers included a shortage of trained providers and patient dissatisfaction with prescribing practices. Anticipating or experiencing stigma from providers and other patients was also identified as a barrier to GAHT. To overcome barriers, participants recommended increasing provider capacity, offering continuous education on GAHT prescribing, and improving communication about VHA policies and training. Comprehensive improvements at various levels, both within and outside the VHA, are necessary to improve access to this important evidence-based treatment for TGD patients.

Relationship of social determinants of health with symptom severity among Veterans and non-Veterans with probable posttraumatic stress disorder or depression.

PURPOSE: Social determinants of health (SDoH) refer to the conditions in the environments in which people live that affect health outcomes and risks. SDoH may provide proximal, actionable targets for interventions. This study examined how SDoH are associated with posttraumatic stress disorder (PTSD) and depression symptoms among Veterans and non-Veterans with probable PTSD or depression. METHODS: Four multiple regressions were conducted. Two multiple regressions with Veterans examined the impact of SDoH on PTSD symptoms and on depression symptoms. Two multiple regressions with non-Veterans examined the impact of SDoH on PTSD symptoms and on depression symptoms. Independent variables included demographic characteristics, adverse experiences (in childhood and adulthood), and SDoH (discrimination, education, employment, economic instability, homelessness, justice involvement, and social support). Correlates that were statistically significant (p < 0.05) and clinically meaningful (rpart >|0.10|) were interpreted. RESULTS: For Veterans, lower social support (rpart = - 0.14) and unemployment (rpart = 0.12) were associated with greater PTSD symptoms. Among non-Veterans, greater economic instability (rpart = 0.19) was associated with greater PTSD symptoms. In the depression models, lower social support (rpart = - 0.23) and greater economic instability (rpart = 0.12) were associated with greater depression for Veterans, while only lower social support was associated with greater depression for non-Veterans (rpart = - 0.14). CONCLUSION: Among Veterans and non-Veterans with probable PTSD or depression, SDoH were associated with PTSD and depression symptoms, particularly social support, economic instability, and employment. Beyond direct treatment of mental health symptoms, addressing social support and economic factors such as instability and employment in the context of PTSD and depression are potential intervention targets that would benefit from future research.

Concordance of Data About Sex From Electronic Health Records and the National Death Index: Implications for Transgender Populations.

BACKGROUND: Transgender individuals have greater health risks than cisgender individuals, which may bode for greater mortality. However, research is limited by lack of gender identity information at the time of death. Novel opportunities to combine administrative data with National Death Index (NDI) data may facilitate mortality research about transgender populations, but binary measures of sex and gender may pose problems for analyses. This study explored differences in sex recorded in Veterans Health Administration (VHA) electronic health record (EHR) and NDI data between transgender and cisgender decedents. METHODS: We used VHA EHR data from fiscal years 2000-2016 to identify deaths among a sample of transgender and cisgender patients. We cross-tabulated sex recorded in the NDI with EHR-based sex from VHA EHR data. We extracted data in 2018 and conducted analyses in 2020. RESULTS: Death occurred for 1109 transgender patients and 7757 cisgender patients. For cisgender decedents, EHR-based sex and NDI-based sex were 100% concordant. For transgender decedents, 46 (4%) were discordant between data sources. Of transgender decedents with female EHR-based sex (n = 259), 17% were indicated as male in NDI data; of those with male EHR-based sex (n = 850), 0.2% were indicated as female in NDI data. CONCLUSIONS: Data linkage between EHR and the NDI can facilitate transgender mortality research, but examining mortality specific to various transgender identities remains difficult. Improved documentation of sex and gender is needed within US mortality surveillance.

Refusal Rates to Sexual Orientation and Gender Identity Items in the Behavioral Risk Factor Surveillance System, 2014-2019.

Objectives. To explore trends in sexual orientation and gender identity (SOGI) item refusal in the Behavioral Risk Factor Surveillance System (BRFSS). Methods. We used annual data from 7 US states that implemented the SOGI module of the BRFSS from 2014 to 2019 to examine prevalence of sexual orientation (n = 373 332) and gender identity (n = 373 336) item refusal. Analyses included the weighted Wald χ2 test of association between refusal and year and logistic regressions predicting refusal by year. We weighted analyses to account for complex sampling design. Results. We found low SOGI item refusal rates, significant declines in these refusal rates over time, and differences in refusal rates by age, sex, race, education, and language. We also found that Hispanic group membership did not explain SOGI item refusal when accounting for interview language; interview language was strongly associated with both sexual orientation and gender identity item refusal. Conclusions. Our results indicate acceptance of SOGI measurement and empirically support continuation of SOGI in health surveillance surveys. Findings indicate a need to further investigate the association between survey translation and item refusal.

Training Death Investigators to Identify Decedents' Sexual Orientation and Gender Identity: A Feasibility Study.

ABSTRACT: There is growing impetus within mortality surveillance to identify decedents' sexual orientation and gender identity (SOGI), but key personnel to this effort (eg, death investigators) are not currently trained to collect SOGI information. To address this gap, we developed a training for death investigators on this topic and tested its feasibility with 114 investigators in 3 states. Participants completed pretraining and posttraining questionnaires that measured 4 perceived outcomes: training relevance, success of delivery, adequacy for future use, and likelihood of future use. Overall, strongly positive responses affirmed the training's relevance, success of delivery, and adequacy for future use. Responses about attempting to identify the decedent's SOGI in future cases were not quite as positive, with close to 80% of the participants saying that they were at least "somewhat likely" to collect this information. Despite design limitations, the study results support the feasibility of training death investigators to gather SOGI information. Although not systematically assessed in the study, investigators' positive endorsement of training outcomes seemed higher in training sites where leadership strongly supported SOGI identification, suggesting that the role of leadership may be key to encouraging SOGI identification among death investigators.

Evictions and tenant-landlord relationships during the 2020-2021 eviction moratorium in the US.

This study provisionally examined the effects of the US eviction moratorium instituted in response to the Coronavirus Disease 2019 (COVID-19) pandemic. Three waves of data collected May 2020-April 2021 from a nationally representative sample of middle- and low-income US tenants (n = 3393 in Wave 1, n = 1311 in Wave 2, and 814 in Wave 3) were analyzed. Across three waves, 4.3% of tenants reported experiencing an eviction during the moratorium and 6%-23% of tenants reported delaying paying rent because of the moratorium. Multivariable analyses found that tenants who delayed paying their rent, were female, or had a history of mental illness or substance use disorder were more likely to report the eviction moratorium had a negative effect on their landlord relationship. COVID-19 infection was not predictive of eviction but tenants with a history of homelessness were more than nine times as likely to report an eviction than those without such a history. Together, these findings suggest the eviction moratorium may have had some unintended consequences on rent payments and tenant-landlord relationships that need to be considered with the end of the federal eviction moratorium.

Validating Data-Driven Methods for Identifying Transgender Individuals in the Veterans Health Administration of the US Department of Veterans Affairs.

We sought to operationalize and validate data-driven approaches for identifying transgender individuals in the Veterans Health Administration (VHA) of the US Department of Veterans Affairs (VA) through a retrospective analysis using VA administrative data from 2006-2018. Besides diagnoses of gender identity disorder (GID), a combination of non-GID data elements was used to identify potentially transgender veterans, including 1) an International Classification of Diseases (Ninth or Tenth Revision) code of endocrine disorder, unspecified or not otherwise specified; 2) receipt of sex hormones not associated with the sex documented in the veteran's records (gender-affirming hormone therapy); and 3) a change in the veteran's administratively recorded sex. Both GID and non-GID data elements were applied to a sample of 13,233,529 veterans utilizing the VHA of the VA between January 2006 and December 2018. We identified 10,769 potentially transgender veterans. Based on a high positive predictive value for GID-coded veterans (83%, 95% confidence interval: 77, 89) versus non-GID-coded veterans (2%, 95% confidence interval: 1, 11) from chart review validation, the final analytical sample comprised 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 is the most reliable approach for identifying transgender individuals in the VHA of the VA.

Gender Differences in the Predictors of Suicide-related Morbidity Among Veterans Reporting Current Housing Instability.

BACKGROUND: Veterans experiencing housing instability are at increased risk of suicide. Research is needed to identify gender differences in the predictors of both suicidal ideation and suicide attempt, particularly among Veterans who are unstably housed. OBJECTIVES: The objective of the present study was to explore whether correlates of suicide-related morbidity among unstably housed Veterans vary by gender and identify implications for improved care for these Veterans. METHODS: The study cohort included 86,325 Veterans who reported current housing instability between October 1, 2013, and September 30, 2016. This cross-sectional study assessed differences in demographic and outcome variables by gender using χ2 analyses and a series of multiple logistic regressions predicting suicidal ideation and suicide attempt, stratified by gender. RESULTS: Among unstably housed female Veterans, being younger than 40 years was associated with more than double the odds of having an indicator of suicidal ideation and >12 times the odds of having an indicator of a suicide attempt. The effect sizes associated with age were much less pronounced among unstably housed male Veterans. The presence of mental health and substance use conditions as well as a positive screen for military sexual trauma were associated with increased risk of suicide morbidity among both women and men. CONCLUSIONS: Intervention and prevention among unstably housed Veterans may be complicated by unpredictable living situations; further research should explore tailored interventions to address the complex needs of unstably housed Veterans and how suicide prevention can be woven throughout.

Differences in Methods of Suicide Death Among Transgender and Nontransgender Patients in the Veterans Health Administration, 1999-2016.

BACKGROUND: Limited research suggests that rates of suicide death among transgender people may be higher than their nontransgender peers. OBJECTIVE: The objective of this study was to compare rates of suicide deaths by different means between transgender and nontransgender patients. RESEARCH DESIGN: This secondary analysis used VHA administrative and electronic health record (EHR) data from October 1, 1999 through December 31, 2016. SUBJECTS: Transgender patients (n=8981) were categorized as such based on a set of International Classification of Disease codes, and a comparison sample was selected by randomly choosing 3 nontransgender patients (n=26,924). MEASURES AND ANALYSES: Cause and date of death data are from the National Death Index. Because of low frequencies amid different methods of suicide death, we combined categories into self-poisoning; hanging, strangulation and suffocation; discharge of firearms; and self-harm by all other and unspecified means. We conducted Cox regression analyses to model time-to-event for each method of suicide, adjusted for age, sex based on EHR, race, ethnicity, marital status, and whether patients had ever been diagnosed with depression. RESULTS: Among transgender patients, 73 died by suicide (22 female EHR-based sex, 51 male EHR-based sex), and among nontransgender patients, 71 died by suicide (4 female EHR-based sex, 67 male EHR-based sex). In adjusted models, transgender patients had significantly greater hazards of death by self-poisoning and firearms than their nontransgender peers. CONCLUSIONS: Differences in methods of suicide death suggest that firearms and self-poisoning may be specific areas of concern for transgender individuals experiencing suicidal crisis, which underscore needs for examining effective delivery of evidence-based care.

Gender Differences in Lifetime Prevalence and Onset Timing of Suicidal Ideation and Suicide Attempt Among Post-9/11 Veterans and Nonveterans.

BACKGROUND: Rising US suicide rates are particularly notable among military veterans, especially women. It is unknown whether these differences extend to suicidal ideation (SI) and suicide attempts (SA), which are major predictors of suicide. Literature comparing SI and SA prevalence and timing of onset between veterans and nonveterans is limited. OBJECTIVE: The objective of this study was to estimate and compare SI and SA prevalence and onset timing relative to age and military service between veterans and nonveterans, by gender. RESEARCH DESIGN: Gender-stratified analysis of cross-sectional data from the Comparative Health Assessment Interview Study. Generalized estimating equations logistic regression was used to compare prevalence and onset of SI and SA between time periods and across groups, controlling for years at risk in each time period. SUBJECTS: National sample of 15,082 post-9/11 veterans (36.7% women) and 4638 nonveterans (30.5% women). MEASURES: Columbia-Suicide Severity Rating Scale adapted to assess SI and SA relative to age (less than 18 y, 18 y and above) and military service (pre-, during, and post-military). RESULTS: Veteran men experienced significantly higher odds of lifetime SI compared with nonveteran men (odds ratio=1.13), whereas veteran women experienced significantly higher odds of lifetime SA compared with nonveteran women (odds ratio=1.35). SI and SA onset varied considerably for veterans and nonveterans and by gender within veteran groups. CONCLUSIONS: Veterans and nonveterans appear to differ in periods of risk for SI and SA. Furthermore, gender differences in SI and SA onset for veterans highlight the need for gender-informed veteran suicide prevention strategies that target periods of highest risk.

Comparison of Patient Experience Between Primary Care Settings Tailored for Homeless Clientele and Mainstream Care Settings.

BACKGROUND: More than 1 million Americans receive primary care from federal homeless health care programs yearly. Vulnerabilities that can make care challenging include pain, addiction, psychological distress, and a lack of shelter. Research on the effectiveness of tailoring services for this population is limited. OBJECTIVE: The aim was to examine whether homeless-tailored primary care programs offer a superior patient experience compared with nontailored ("mainstream") programs overall, and for highly vulnerable patients. RESEARCH DESIGN: National patient survey comparing 26 US Department of Veterans Affairs (VA) Medical Centers' homeless-tailored primary care ("H-PACT"s) to mainstream primary care ("mainstream PACT"s) at the same locations. PARTICIPANTS: A total of 5766 homeless-experienced veterans. MEASURES: Primary care experience on 4 scales: Patient-Clinician Relationship, Cooperation, Accessibility/Coordination, and Homeless-Specific Needs. Mean scores (range: 1-4) were calculated and dichotomized as unfavorable versus not. We counted key vulnerabilities (chronic pain, unsheltered homelessness, severe psychological distress, and history of overdose, 0-4), and categorized homeless-experienced veterans as having fewer (≤1) and more (≥2) vulnerabilities. RESULTS: H-PACTs outscored mainstream PACTs on all scales (all P<0.001). Unfavorable care experiences were more common in mainstream PACTs compared with H-PACTs, with adjusted risk differences of 11.9% (95% CI=6.3-17.4), 12.6% (6.2-19.1), 11.7% (6.0-17.3), and 12.6% (6.2-19.1) for Relationship, Cooperation, Access/Coordination, and Homeless-Specific Needs, respectively. For the Relationship and Cooperation scales, H-PACTs were associated with a greater reduction in unfavorable experience for patients with ≥2 vulnerabilities versus ≤1 (interaction P<0.0001). CONCLUSIONS: Organizations that offer primary care for persons experiencing homelessness can improve the primary care experience by tailoring the design and delivery of services.

Perceptions of Care Coordination Among Homeless Veterans Receiving Medical Care in the Veterans Health Administration and Community Care Settings: Results From a National Survey.

BACKGROUND: Initiatives to expand Veterans' access to purchased health care outside Veterans Health Administration (VHA) facilities ("community care") present care coordination challenges for Veterans experiencing homelessness. OBJECTIVE: Among Veterans with homeless experiences, to evaluate community care use and satisfaction, and compare perceptions of care coordination among Veterans using VHA services and community care to those using VHA services without community care. RESEARCH DESIGN: Cross-sectional analysis of responses to a 2018 mailed survey. SUBJECTS: VHA outpatients with homeless experiences. MEASURES: Self-reported use of community care, Likert-style ratings of satisfaction with that care, and Access/Coordination experiences from the Primary Care Quality-Homeless (PCQ-H) survey. RESULTS: Of 4777 respondents, 1325 (26.7%) reported using community care; most of this subsample affirmed satisfaction with the community care they received (83%) and its timeliness (75%). After covariate adjustment, Veteran characteristics associated with greater community care use included female sex, being of retirement age and nonmarried, and having higher education, more financial hardship, ≥3 chronic conditions, psychological distress, depression, and posttraumatic stress disorder. Satisfaction with community care was lower among patients with travel barriers, psychological distress, and less social support. Compared with those using the VHA without community care, Veterans using VHA services and community care were more likely to report unfavorable access/coordination experiences [odds ratio (OR)=1.34, confidence interval (CI)=1.15-1.57]. This included hassles following referral (OR=1.37, CI=1.14-1.65) and perceived delays in receiving health care (OR=1.38, CI=1.19-1.61). CONCLUSIONS: Veterans with homeless experiences value community care options. Potential access benefits are balanced with risks of unfavorable coordination experiences for vulnerable Veterans with limited resources.

Social Determinants and Military Veterans' Suicide Ideation and Attempt: a Cross-sectional Analysis of Electronic Health Record Data.

BACKGROUND: Health care systems struggle to identify risk factors for suicide. Adverse social determinants of health (SDH) are strong predictors of suicide risk, but most electronic health records (EHR) do not include SDH data. OBJECTIVE: To determine the prevalence of SDH documentation in the EHR and how SDH are associated with suicide ideation and attempt. DESIGN: This cross-sectional analysis included EHR data spanning October 1, 2015-September 30, 2016, from the Veterans Integrated Service Network Region 4. PARTICIPANTS: The study included all patients with at least one inpatient or outpatient visit (n = 293,872). MAIN MEASUREMENTS: Adverse SDH, operationalized using Veterans Health Administration (VHA) coding for services and International Statistical Classification of Diseases and Related Health Problems (ICD)-10 codes, encompassed seven types (violence, housing instability, financial/employment problems, legal problems, familial/social problems, lack of access to care/transportation, and nonspecific psychosocial needs). We defined suicide morbidity by ICD-10 codes and data from the VHA's Suicide Prevention Applications Network. Logistic regression assessed associations of SDH with suicide morbidity, adjusting for socio-demographics and mental health diagnoses (e.g., major depression). Statistical significance was assessed with p < .01. KEY RESULTS: Overall, 16.4% of patients had at least one adverse SDH indicator. Adverse SDH exhibited dose-response-like associations with suicidal ideation and suicide attempt: each additional adverse SDH increased odds of suicidal ideation by 67% (AOR = 1.67, 99%CI = 1.60-1.75; p < .01) and suicide attempt by 49% (AOR = 1.49, 99%CI = 1.33-1.68; p < .01). Independently, each adverse SDH had strong effect sizes, ranging from 1.86 (99%CI = 1.58-2.19; p < .01) for legal issues to 3.10 (99%CI = 2.74-3.50; p < .01) for non-specific psychosocial needs in models assessing suicidal ideation and from 1.58 (99%CI = 1.10-2.27; p < .01) for employment/financial problems to 2.90 (99%CI = 2.30-4.16; p < .01) for violence in models assessing suicide attempt. CONCLUSIONS: SDH were strongly associated with suicidal ideation and suicide attempt even after adjusting for mental health diagnoses. Integration of SDH data in EHR could improve suicide prevention.

Sexual Orientation Change Efforts, Adverse Childhood Experiences, and Suicide Ideation and Attempt Among Sexual Minority Adults, United States, 2016-2018.

Objectives. To examine how sexual orientation change efforts (SOCE) are associated with suicide morbidity after controlling for adverse childhood experiences (ACEs).Methods. Cross-sectional survey data are from the Generations survey, a nationally representative sample of 1518 nontransgender sexual minority adults recruited between March 28, 2016, and March 30, 2018, in the United States. Self-identified transgender individuals were included in a separate, related TransPop study. We used weighted multiple logistic regression analyses to assess the independent association of SOCE with suicidal ideation and suicide attempt while controlling for demographics and ACEs.Results. Approximately 7% experienced SOCE; of them, 80.8% reported SOCE from a religious leader. After adjusting for demographics and ACEs, sexual minorities exposed to SOCE had nearly twice the odds of lifetime suicidal ideation, 75% increased odds of planning to attempt suicide, and 88% increased odds of a suicide attempt with minor injury compared with sexual minorities who did not experience SOCE.Conclusions. Over the lifetime, sexual minorities who experienced SOCE reported a higher prevalence of suicidal ideation and attempts than did sexual minorities who did not experience SOCE.Public Health Implications. Evidence supports minimizing exposure of sexual minorities to SOCE and providing affirming care with SOCE-exposed sexual minorities. (Am J Public Health. Published online ahead of print May 21, 2020: e1-e7. doi:10.2105/AJPH.2020.305637).

Adverse social factors and all-cause mortality among male and female patients receiving care in the Veterans Health Administration.

Social factors account more for health outcomes than medical care, yet health services research in this area is limited due to the lack of social factors data contained within electronic health records (EHR) systems. Few investigations have examined how cumulative burdens of co-occurring adverse social factors impact health outcomes. From 293,872 patients in one region of the Veterans Health Administration (VHA), we examined how increasing numbers of adverse social factors extracted from the EHR were associated with mortality across a one-year period for male and female patients. Adverse social factors were identified using four sources in the EHR: responses to universal VHA screens, International Classification of Disease (ICD) diagnostic codes that indicate social factors, receipt of VHA services related to social factors, and templated social work referrals. Seven types of adverse social factors were coded: violence, housing instability, employment or financial problems, legal issues, social or familial problems, lack of access to care or transportation, and nonspecific psychosocial needs. Overall, each increase in an adverse social factor was associated with 27% increased odds of mortality, after accounting for demographics, medical comorbidity, and military service-related disability. Non-specific psychosocial factors were most strongly associated with mortality, followed by social or familial problems. Although women were more likely than men to have multiple adverse social factors, social factors were not associated with mortality among women as they were among men. By incorporating social factors data, health care systems can better understand patient all-cause mortality and identify potential prevention efforts built around social determinants.