Racial Health Disparities in a Cohort of 5,135 Transgender Veterans
There are no large-scale studies of racial health disparities in transgender patients. The Veterans Health Administration (VHA) is the largest health-care system in the United States and was an early adopter of electronic health records. We present new data on medical and mental health disparities in a large population of transgender veterans.
Using four ICD-9-CM codes, we identified a cohort of transgender veterans who presented for VHA care from1996–2013. A total of 5,135 transgender veterans were identified, 387 were non-Hispanic Black and 4,120 were non-Hispanic White. These two groups were compared to determine if medical and/or mental health disparities existed.
Black transgender veterans had increased odds to be diagnosed with alcohol abuse (adjusted odds ratio [AOR] = 1.86, 95 % confidence interval [CI] = 1.50–2.31, p < 0.0001), benign prostatic hyperplasia (AOR = 1.36, CI = 1.01–1.84, p < 0.05), congestive heart failure (AOR = 1.51, CI = 1.04–2.19, p < 0.05), HIV/AIDS (AOR = 6.77, CI = 4.60–9.97, p < 0.0001), hypertension (AOR = 1.71, CI = 1.34–2.17, p < 0.0001), end-stage renal disease (AOR = 3.34, CI = 1.65–6.93, p < 0.001), serious mental illness (AOR = 1.35, CI = 1.09–1.68, p < 0.01), and tobacco use (AOR = 1.29, CI = 1.04–1.59, p < 0.05). However, the odds of Black transgender veterans to be diagnosed with the following conditions were reduced: depression (AOR = 0.73, CI = 0.58–0.93, p < 0.01), hypercholesterolemia (AOR = 0.71, CI = 0.57–0.89, p < 0.01), and obesity (AOR = 0.79, CI = 0.63–0.98, p < 0.05). Black transgender veterans’ odds of having a history of incarceration was nearly three times larger (AOR = 2.91, CI = 1.84–4.62, p < 0.0001) and their odds of experiencing homelessness was nearly two times larger (AOR = 1.85, CI = 1.49–2.31, p < 0.0001) than White transgender veterans. The odds of Black transgender veterans to live in a rural area was 65 % less than that of White transgender veterans (AOR = 0.35, CI = 0.27–0.46, p < 0.0001).
This is the first study to examine a large cohort of transgender patients for the presence of racial disparities in psychiatric and medical health outcome disparities using retrospective medical chart data. Black transgender veterans were found to have a greater likelihood of social disadvantage and prevalence of several mental and medical conditions compared to White transgender veterans. Racial disparities occurred in a context of global health disparities in transgender veterans, as a group, compared to non-transgender veterans. These findings may have implications for policy, prevention strategies, and health-care delivery in VA and other health-care systems.
- Diagnostic and statistical manual of mental disorders (4th ed., text rev.). American Psychiatric Press, Washington, DC
- Diagnostic and statistical manual of mental disorders. American Psychiatric Publishing, Arlington
- WHO. World Health Organisation international statistical classification of diseases and related health problems, 9th Revision (ICD-9-CM). Geneva: WHO; 1978.
- The health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding. National Academy of Sciences, Washington, DC
- McDuffie, E, Brown, G (2010) 70 US veterans with gender identity disturbances: a descriptive study. Int J Transgenderism 12: pp. 21-30 CrossRef
- Cole, C, O’Boyle, M, Emory, L, Meyer, W (1997) Comorbidity of gender dysphoria and other major psychiatric diagnoses. Arch Sex Behav 26: pp. 13-26 CrossRef
- Clements-Nolle, K, Marx, R, Guzman, BA, Katz, M (2001) HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: implications for public health intervention. Am J Public Health 91: pp. 915-921 CrossRef
- Cruz, TM (2014) Assessing access to care for transgender and gender nonconforming people: a consideration of diversity in combating discrimination. Soc Sci Med.
- Xavier, J, Bobbin, M, Singer, E (2005) A needs assessment of transgendered people of color living in Washington, DC. Int J Transgenderism 8: pp. 31-47 CrossRef
- Singer, M (1994) AIDS and the health crisis of the urban poor: the perspective of critical medical anthropology. Soc Sci Med 39: pp. 931-948 CrossRef
- Singer, M (1996) A dose of drugs, a touch of violence, a case of AIDS: conceptualizing the SAVA syndemic. Free Inquiry 24: pp. 99-110
- Singer, M, Clair, S (2003) Syndemics and public health: reconceptualizing disease in bio-social context. Med Anthropol Q 17: pp. 423-441 CrossRef
- Stall, RD, Mills, TC, Williamson, J, Hart, T, Greenwood, G, Paul, J (2003) Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. Am J Public Health 93: pp. 939-942 CrossRef
- O’Leary, A, Jemmott, JJ, Stevens, R, Rutledge, SE, Icard, LE (2014) Optimism and education buffer the effects of syndemic conditions on HIV status among African American men who have sex with men. AIDS Behav.
- Grant, JM, Mottet, LA, Tanis, J, Herman, JL, Harrison, J, Keisling, M (2010) National Transgender Discrimination Survey report on health and health care. National Center for Transgender Equality and the National Gay and Lesbian Task Force, Washington, DC
- Shipherd, JC, Mizock, L, Maguen, S, Green, KE (2012) Male-to-female transgender veterans and VA health care utilization. Int J Sex Health 24: pp. 78-87 CrossRef
- Kenagy, G (2005) Transgender health: findings from two needs assessment studies in Philadelphia. Health Soc Work 30: pp. 19-26 CrossRef
- Campo, J, Nujman, H, Merckelbach, , Evers, C (2003) Psychiatric comorbidity of gender identity disorders: a survey among Dutch psychiatrists. Am J Psychiatry 160: pp. 1332-1336 CrossRef
- Hepp, U, Kraemer, B, Schnyder, U, Miller, N, Delsignore, A (2005) Psychiatric comorbidity in gender identity disorder. J Psychosomatic Res 58: pp. 259-261 CrossRef
- Gooren, LJ, Trotsenburg, MA, Giltay, EJ, Diest, PJ (2013) Breast cancer development in transsexual subjects receiving cross-sex hormone treatment. J Sex Med 12: pp. 3129-3134 CrossRef
- Blosnich, JR, Brown, GR, Shipherd, JC, Kauth, M, Piegari, RI, Bossarte, RM (2013) Prevalence of gender identity disorder and suicide risk among transgender veterans utilizing Veterans Health Administration care. Am J Public Health 10: pp. 37-32
- Mattocks, KM, Kauth, MR, Sandfort, T, Matza, AR, Sullivan, JC, Shipherd, JC (2013) Understanding health-care needs of sexual and gender minority veterans: how targeted research and policy can improve health. LGBT Health 1: pp. 30-37
- U.S. Veterans Affairs, Veterans Health Administration. VHA Directive 2011-026: providing health care for transgender and intersex veterans, 2013. www.va.gov/vhapublications. Accessed 15 Feb 2014.
- U.S. Veterans Affairs, Veterans Health Administration. VHA Directive 2013-003: providing health care for transgender and intersex veterans, 2013. www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2863. Accessed 15 Feb 2014.
- Bockting, W, Coleman, E Developmental stages of the transgender coming out process: toward an integrated identity. In: Ettner, R, Monstrey, S, Eyler, A eds. (2007) Principles of transgender medicine and surgery. Haworth, New York, pp. 185-208
- Docter, R (1988) Transvestites and transsexuals: toward a theory of cross-gender behavior. Springer, New York CrossRef
- Person, E, Ovesey, L (1974) The transsexual syndrome in males: II. Secondary transsexualism. Am J Psychotherapy 28: pp. 174-193
- Greenberg, GA, Rosenheck, RA (2009) Mental health and other risk factors for jail incarceration among male veterans. Psychiatr Q 80: pp. 41-53 CrossRef
- Kilbourne, AM, Switzer, G, Hyman, K, Crowley-Matoka, M, Fine, MJ (2006) Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health 96: pp. 2113-2121 CrossRef
- Metraux, S, Clegg, L, Daigh, JD, Culhane, DP, Kane, V (2013) Risk factors for becoming homeless among a cohort of veterans who served in the era of the Iraq and Afghanistan conflicts. Am J Public Health 103: pp. S255-S261 CrossRef
- Tsai J, Desai MU, Cheng AW, Chang J. The effects of race and other socioeconomic factors on health services use among American military veterans. Psychiatr Q. 2013; 1-13.
- Wallace, AE, Weeks, WB, Wang, S, Lee, A, Kazis, LE (2006) Rural and urban disparities in health-related quality of life among veterans with psychiatric disorders. Psychiatr Serv 57: pp. 851-856 CrossRef
- O’Brien, RM (2007) A caution regarding rules of thumb for variance inflation factors. Qual Quant 41: pp. 673-690 CrossRef
- Saha, S, Sanders, DS, Korthuis, PT, Cohn, JA, Sharp, VL, Haidet, P (2011) The role of cultural distance between patient and provider in explaining racial/ethnic disparities in HIV care. Patient Educ Couns 85: pp. e278-e284 CrossRef
- Washington, DL, Villa, V, Brown, A, Damron-Rodriguez, J, Harada, N (2005) Racial/ethnic variations in veterans’ ambulatory care use. Am J Public Health 95: pp. 2231-2237 CrossRef
- Trivedi, AN, Grebla, RC, Wright, SM, Washington, DL (2011) Disparity persists for important clinical outcomes despite improved quality of care in the Veterans Affairs health system. Racial Health Aff 30: pp. 707-715 CrossRef
- Saha, S, Freeman, M, Toure, J, Tippens, KM, Weeks, , Ibrahim, S (2008) Racial and ethnic disparities in the VA health care system: a systematic review. J Gen Int Med 23: pp. 654-671 CrossRef
- Mental health: a report of the surgeon general. Department of Health and Human Services, Rockville
- Asch, SM, Kerr, EA, Keesey, J, Adams, JL, Setodji, CM, Malik, S (2006) Who is at greatest risk for receiving poor-quality health care?. NEJM 354: pp. 1147-1156 CrossRef
- Brown G, Jones K. Mental health and medical outcome disparities in 5135 transgender veterans receiving health care in the Veterans Health Administration: a case-control study. Proceedings of the 32nd annual meeting of the Gay and Lesbian Medical Association. September 11th, 2014.
- Kessler, RC, Nelson, CB, McGonagle, KA, Liu, J (1996) Comorbidity of DSM-III-R major depressive disorder in the general population: Results from the U.S. National Comorbidity Survey. Brit J Psychiatry Suppl 30: pp. 17-30
- Wang, PS, Berglund, P, Kessler, RC (2000) Recent care of common mental disorders in the United States: prevalence and conformance with evidence-based recommendations. J Gen Int Med 15: pp. 284-292 CrossRef
- Rosenheck, R, Fontana, A, Cottrol, C (1995) Effect of clinician-veteran racial pairing in the treatment of post-traumatic stress disorder. Am J Psychiatry 152: pp. 555-563
- Rosenheck, R, Selbyi, CL (1998) Participation and outcome in a residential treatment and work therapy program for addictive disorders: the effects of race. Am J Psychiatry 155: pp. 1029-1034
- Manderscheid RW, Berry JT. Mental health, United States, 2004, US Department of Health and Human Services. Substance abuse and Mental Health Services Administration. http://mentalhealth.samhsa.gov/publications/allpubs/SMA06-4195. Accessed 22 Feb 2014.
- Workforce Management and Consulting Office. Veterans Health Administration workforce succession strategic plan and national plan supplemental report 2013. Washington, DC: Workforce Management and Consulting Office; 2013. http://vaww.va.gov/WMC/docs/2013_VHA_Workforce_Succession_Strategic_Plan_EBook.pdf. Accessed 23 Mar 2014.
- Baca-Garcia, E, Perez-Rodriguez, M, Keyes, K, Oquendo, M, Hasin, D, Grant, B (2010) Suicidal ideation and suicide attempts in the United States: 1991–1992 and 2001–2002. Mol Psychiatry 15: pp. 250-259 CrossRef
- Ogden, CL, Carroll, MD, Kit, BK, Flegal, KM (2012) Prevalence of obesity in the United States, 2009–2010. NCHS Data Brief 82: pp. 1-8
- Flegal, KM, Carroll, MD, Ogden, CL, Curtin, LR (2010) Prevalence and trends in obesity among US adults, 1999–2008. JAMA 303: pp. 235-241 CrossRef
- Wilson, PW, D’Agostino, RB, Sullivan, L, Parise, H, Kannel, WB (2002) Overweight and obesity as determinants of cardiovascular risk: the Framingham experience. Arch Intern Med 162: pp. 1867-1872 CrossRef
- Franssen FM, O’Donnell DE, Goossens GH, Blaak EE, Schols AM. Obesity and the lung: 5. Obesity and COPD. Thorax. 2008;63:1110-17.
- Clerkin, EM, Newcomb, ME, Mustanski, B (2011) Unpacking the racial disparity in HIV rates: the effect of race on risky sexual behavior among Black young men who have sex with men (YMSM). J Behav Med 34: pp. 237-243 CrossRef
- Kaiser Family Foundation. 2013. http://kff.org/global-health-policy/fact-sheet/the-global-hivaids-epidemic/. Accessed 12 Mar 2014.
- Feldman, MB (2010) A critical literature review to identify possible causes of higher rates of HIV infection among young Black and Latino men who have sex with men. J Natl Med Assoc 102: pp. 1206-1221
- Magnus, M, Kuo, I, Phillips, G, Shelley, K, Rawls, A, Montanez, L (2010) Elevated HIV prevalence despite lower rates of sexual risk behaviors among black men in the District of Columbia who have sex with men. AIDS Patient Care STDS 24: pp. 615-622 CrossRef
- Maulsby, C, Millett, G, Lindsey, K, Kelley, R, Johnson, K, Montoya, D (2014) HIV among black men who have sex with men (MSM) in the United States: a review of the literature. AIDS Behav 18: pp. 10-25 CrossRef
- Earl, TR, Saha, S, Lombe, M, Korthuis, PT, Sharp, V, Cohn, J (2013) Race, relationships, and trust in providers among black patients with HIV/AIDS. Soc Work Res 37: pp. 219-226 CrossRef
- Bureau of Justice Statistics. 2011. http://www.bjs.gov/content/pub/press/p12acpr.cfm. Accessed 22 Apr 2014.
- Harris, CT, Steffensmeier, D, Ulmer, JT, Painter-Davis, N (2009) Are Blacks and Hispanics disproportionately incarcerated relative to their arrests? Racial and ethnic disproportionality between arrest and incarceration. Race Soc Probl 1: pp. 187-199 CrossRef
- Brown, GR (2010) Autocastration and autopenectomy as surgical self-treatment in incarcerated persons with gender identity disorder. Int J Transgenderism 12: pp. 31-39 CrossRef
- Balsa, AI, McGuire, TG (2003) Prejudice, clinical uncertainty, and stereotyping as sources of health disparities. J Health Econ 22: pp. 89-116 CrossRef
- Ryn, M, Burke, J (2000) The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med 50: pp. 813-828 CrossRef
- Burgess, DJ, Fu, SS, Ryn, M (2004) Why do providers contribute to disparities and what can be done about it?. J Gen Int Med 19: pp. 1154-1159 CrossRef
- Smedley, BD, Stith, AY, Nelson, AR (2003) Unequal treatment: confronting racial and ethnic disparities in health care. National Academies Press, Washington, DC
- Plant, EA, Devine, PG (2003) The antecedents and implications of interracial anxiety. Pers Soc Psychol B 29: pp. 790-801 CrossRef
- Brooks, VR The theory of minority stress. In: Brooks, VR eds. (1981) Minority stress and lesbian women. Lexington Books, Lexington, pp. 71-90
- Meyer, IH (2003) Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull 129: pp. 674-697 CrossRef
- Jones, KT, Wilton, L, Millett, GA, Johnson, WD Formulating the stress and severity model of minority social stress for black men who have sex with men. In: McCree, DH, Jones, KT, O’Leary, A eds. (2010) African Americans and HIV/AIDS: understanding and addressing the epidemic. Springer, New York
- Harrison-Quintana, J, Herman, JL (2012) Still serving in silence: transgender service members and veterans in the National Transgender Discrimination Survey. LGBTQ Policy J 13: pp. 1-13
- Gates, G (2011) How many people are lesbian, gay, bisexual and transgender?. Williams Institute, Los Angeles
- Racial Health Disparities in a Cohort of 5,135 Transgender Veterans
Journal of Racial and Ethnic Health Disparities
Volume 1, Issue 4 , pp 257-266
- Cover Date
- Print ISSN
- Online ISSN
- Springer International Publishing
- Additional Links
- MSC Codes: 62,65