Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

Health Services Research & Development

Go to the ORD website
Go to the QUERI website
HSRD Conference Logo



2023 HSR&D/QUERI National Conference Abstract

Printable View

4106 — Patient Characteristics Associated with Receipt of Gender-Affirming Hormone Therapy in the Veterans Health Administration

Lead/Presenter: Hill Wolfe
All Authors: Wolfe HL (Center for Healthcare Organization & Implementation Research, Boston University School of Public Health), Vimalananda VG (Center for Healthcare Organization & Implementation Research, Boston University School of Medicine) Wong DH (Center for Healthcare Organization & Implementation Research, Boston University School of Medicine) Reisman JI (Center for Healthcare Organization & Implementation Research) Rao SR (Boston University School of Public Health) Shipherd JC (National Center for PTSD, LGBTQ+ Health Program, Boston University School of Medicine) Blosnich JR (Center for Health Equity Research and Promotion, University of Southern California) Livingston NA (National Center for PTSD, Boston University School of Medicine) Jasuja GK (Center for Healthcare Organization & Implementation Research, Boston University School of Medicine)

Objectives:
Many transgender and gender diverse (TGD) individuals experience gender dysphoria, which is defined as psychological distress due to an incongruence between gender identity and assigned birth sex. Gender-affirming hormone therapy is a common evidence-based gender-affirming treatment for reducing gender dysphoria among TGD individuals who need or desire these treatments. This study aimed to examine patient-level characteristics associated with receipt of gender-affirming hormone therapy among TGD Veterans in the Veterans Health Administration (VHA).

Methods:
This cross-sectional study included a national cohort of 9,555 TGD patients with documentation of a gender identity disorder (GID) diagnosis who received care in the VHA from 2006-2018. The date of the earliest GID diagnosis was selected as the index date for the study cohort. To ensure that the Veterans in our study cohort were engaged in care post-GID diagnosis, we required patients to have at least 1 outpatient visit in VHA post-GID diagnosis. Adjusted odds ratio (aOR) and associated 95% Confidence Intervals (CI) were obtained from multivariable logistic regression models, which evaluated the association of patient characteristics with the receipt of gender-affirming hormone therapy. These models also included clustering by site.

Results:
Of the 9,555 TGD patients in our study cohort, 57.4% received gender-affirming hormone therapy in the VHA. Fully adjusted models indicated a lower likelihood of gender-affirming hormone therapy receipt among patients who were Black, non-Hispanic (aOR: 0.61; 95% CI: 0.52-0.72), living in the Northeast (0.72; 0.62-0.84) and South (0.83; 0.74-0.93), with documentation of drug use disorder (0.56; 0.47 - 0.68), with >3 comorbidities (0.44; 0.34-0.57), and with >3 social stressors (0.42; 0.30-0.58) as compared to white, non-Hispanic patients, those living in the West, with no documentation of drug use disorder, having no co-morbidity, and no social stressors (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+ (2.98; 2.55-3.47; p < 0.001).

Implications:
TGD individuals who are older, Black, non-Hispanic, and with higher number of comorbidities and documented social stressors are less likely to receive gender-affirming hormone therapy in the VHA. Subsequent efforts should focus on gaining an understanding of the directionality of the patient-level associations reported and the reasons behind these associations. Further, an examination of clinician- and site-level determinants of this therapy are also warranted, while recognizing that an assessment of each patient’s treatment goals remain essential.

Impacts:
In the VHA, quality improvement efforts should focus on: 1) improving accessibility to gender-affirming hormone therapy for Black TGD populations; 2) educating clinicians on the absolute and relative contraindications to gender-affirming hormone therapy, which will ensure that clinicians are comfortable initiating this therapy appropriately in the presence of relative contraindications; and 3) investigating TGD patients’ access and utilization of VHA services for social stressors.