Receipt of Gender-Affirming Surgeries Among Transgender and Gender Diverse Veterans.

BACKGROUND: Gender-affirming surgery (GAS) can be an important part of comprehensive care for transgender and gender diverse (TGD) individuals, but this care is not provided by the Department of Veterans Affairs (VA) because of an exclusion in the medical benefits package. OBJECTIVE: To describe the receipt of GAS by veterans and assess the associations between key sociodemographic characteristics and receipt of chest ("top") and genital ("bottom") surgeries. DESIGN: Cross-sectional national survey (the GendeR Affirming Care Evaluation (GRACE)), among TGD Veterans conducted between September 2022 and July 2023. PARTICIPANTS: A total of 6653 Veterans (54% response rate) completed the survey. MAIN MEASURES: Self-reported "top" and "bottom" GAS were key outcomes. Covariates included gender identity, sex assigned at birth, age, race, ethnicity, income, employment status, education, relationship status, sexual orientation, and geographic region. KEY RESULTS: Among all respondents, 39% had ≥ 1 GAS. Among the 4430 veterans interested in top surgery, 38% received it; 23% of 3911 veterans interested in bottom surgery had received it. In multivariable models, older age (50 + vs. 18-39) was associated with higher receipt of top and bottom surgery while nonbinary gender identity (vs. binary gender identity), lower household income (< $50,000 vs. > $75,000), less education (less than a college graduate vs. Master's degree or more), sexual orientations other than heterosexual, and residing in a region other than the Pacific were associated with lower receipt of top and bottom surgery. Individuals assigned male (vs. assigned female) at birth had lower receipt of top surgery and higher receipt of bottom surgery. CONCLUSIONS: GAS receipt was low and there were important disparities by gender, sex, income, education, sexual orientation, and region. By removing the exclusion to providing GAS, VA could reduce barriers to accessing GAS and decrease disparities among TGD veterans.

Corrigendum: Clinicians in the Veterans Health Administration initiate gender-affirming hormone therapy in concordance with clinical guideline recommendations.

[This corrects the article DOI: 10.3389/fendo.2024.1086158.].

Clinicians in the Veterans Health Administration initiate gender-affirming hormone therapy in concordance with clinical guideline recommendations.

Background: Gender-affirming hormone therapy (GAHT) is a common medical intervention sought by transgender and gender diverse (TGD) individuals. Initiating GAHT in accordance with clinical guideline recommendations ensures delivery of high-quality care. However, no prior studies have examined how current GAHT initiation compares to recommended GAHT initiation. Objective: This study assessed guideline concordance around feminizing and masculinizing GAHT initiation in the Veterans Health Administration (VHA). Methods: The sample included 4,676 veterans with a gender identity disorder diagnosis who initiated feminizing (n=3,547) and masculinizing (n=1,129) GAHT between 2007 and 2018 in VHA. Demographics and health conditions on veterans receiving feminizing and masculinizing GAHT were assessed. Proportion of guideline concordant veterans on six VHA guidelines on feminizing and masculinizing GAHT initiation were determined. Results: Compared to veterans receiving masculinizing GAHT, a higher proportion of veterans receiving feminizing GAHT were older (≥60 years: 23.7% vs. 6.3%), White non-Hispanic (83.5% vs. 57.6%), and had a higher number of comorbidities (≥7: 14.0% vs. 10.6%). A higher proportion of veterans receiving masculinizing GAHT were Black non-Hispanic (21.5% vs. 3.5%), had posttraumatic stress disorder (43.0% vs. 33.9%) and positive military sexual trauma (33.5% vs.16.8%; all p-values<0.001) than veterans receiving feminizing GAHT. Among veterans who started feminizing GAHT with estrogen, 97.0% were guideline concordant due to no documentation of contraindication, including venous thromboembolism, breast cancer, stroke, or myocardial infarction. Among veterans who started spironolactone as part of feminizing GAHT, 98.1% were guideline concordant as they had no documentation of contraindication, including hyperkalemia or acute renal failure. Among veterans starting masculinizing GAHT, 90.1% were guideline concordant due to no documentation of contraindications, such as breast or prostate cancer. Hematocrit had been measured in 91.8% of veterans before initiating masculinizing GAHT, with 96.5% not having an elevated hematocrit (>50%) prior to starting masculinizing GAHT. Among veterans initiating feminizing and masculinizing GAHT, 91.2% had documentation of a gender identity disorder diagnosis prior to GAHT initiation. Conclusion: We observed high concordance between current GAHT initiation practices in VHA and guidelines, particularly for feminizing GAHT. Findings suggest that VHA clinicians are initiating feminizing GAHT in concordance with clinical guidelines. Future work should assess guideline concordance on monitoring and management of GAHT in VHA.

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.

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.

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.

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).

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.

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.

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.

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.

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).

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.

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.

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.

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.

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.

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.

Discrimination Exposure Based on Race, Gender, and Sexual Orientation of Veterans Affairs Health Administration Patients.

This study contributes to research and policy aimed at reducing population-level health disparities by applying a Feminist Standpoint approach to the examination of rates and correlates of health care discrimination among patients at the Veterans Affairs Health Administration (VHA). Drawing on quality improvement survey data (N = 806) collected within the VHA in 2018, we document and describe rates of both direct and vicarious past-year exposure to health care discrimination disaggregated by race/ethnicity, sexual orientation, and gender. The analysis of within- and between-group rates and correlates of health care discrimination exposure reveals important subgroup-specific patterns that prior studies using aggregate or non-stratified data have masked. The findings have important research, theory, and policy implications and support advocacy for an intersectional approach to documenting and addressing health care discrimination.