Spotlight: Gender Differences in Healthcare

July 2015

Men and women have different health and healthcare concerns, illustrated by results of the 2013 Kaiser Men's Health Survey and Women's Health Survey of a nationally representative sample of men and women ages 18 to 64. Findings show that 68% of men compared to 81% of women identified a clinician they see for routine care, and women were more likely than men to have seen a provider in the past two years (91% vs. 75%). Men and women reported fair and poor health at similar rates (17% vs. 15%); however, significantly more women reported having an ongoing condition that requires regular monitoring (43% vs. 30%), and more women than men (26% vs. 20%) reported having to delay or forgo care in the past year due to cost.¹

In 2008, VA began a national initiative to eliminate gender gaps in preventive care, and in 2011, VA asked its healthcare regions across the country to review gender disparity data and to create and implement an improvement plan. A subsequent report released by VA's Office of Informatics and Analytics shows that VA has improved gender disparities in several key areas, including screening for PTSD, depression, and colorectal cancer, as well as improving chronic disease management for women Veterans with hypertension, diabetes, and hyperlipidemia, all risk factors for heart disease. In addition, the Women Veterans Health Strategic Health Care Group leads an initiative to improve care for women Veterans, and issued a report identifying best practices for eliminating gender gaps based on success in VA networks.

Gender differences in healthcare also apply to the transgender community. The umbrella term "transgender" has been used as a descriptor (not a diagnosis) for those who experience incongruity between birth sex and subjective sense of gender, and who may or may not meet the diagnostic criteria for a disorder. In 2011, the Veterans Health Administration Transgender Healthcare Directive was issued to all of its facilities establishing a policy of respectful delivery of healthcare to transgender and intersex Veterans enrolled in VA healthcare.

HSR&D and Research on Gender Differences in Healthcare

Following are descriptions of just a few select studies that HSR&D and QUERI investigators conduct on gender, including transgender, differences in healthcare.

Gender Differences in Chronic Pain among Veterans

Pain and its impact on physical and emotional functioning have been associated with prior traumatic experiences, low levels of social support, and higher levels of conflict. Notably, gender differences in traumatic exposure, social support, and interpersonal conflict have been observed among Veterans. Thus, this study examined a) gender differences in trauma, social support, and family conflict among Veterans with chronic pain, and b) whether these variables were differentially associated with pain severity, functioning, and depressive symptom severity as a function of gender. Using data from the Women Veterans Cohort Study survey, investigators studied male and female Veterans who served in Iraq and/or Afghanistan, who were enrolled in VA healthcare between 9/01 and 9/12 - and who endorsed having pain for three months or longer. Self-report measures included: pain severity, functioning, depressive symptom severity, opioid use, exposure to traumatic life events, emotional and tangible support, and family conflict. Findings show:

• Of the 662 Veterans who completed the survey, 460 (69%) reported experiencing pain for 3 months or longer (67% of men and 71% of women), and 75% stated pain had been present more than one year.
• Most problematic sites of pain: back (37%), joint (33%), headache (12%), and neck (9%).
• Men and women Veterans did not differ significantly in terms of pain severity, pain interference with function, depressive symptom severity, or use of prescription opioids.
• Relative to men, women Veterans reporting chronic pain evidenced higher rates of childhood interpersonal trauma (51% vs. 34%) and military sexual trauma (54% vs 3%), as well as lower levels of combat exposure.

Gender may be a salient target of investigation when examining development of and/or adaptation to chronic pain, and is an important consideration in tailoring treatment programs to meet the needs of Veterans with chronic pain.

Driscoll M, Higgins D, Seng E, et al. Trauma, social support, family conflict, and chronic pain in recent Veterans: What does gender matter? Pain Medicine. April 30, 2015; Epub ahead of print.

Racial Disparities in Physical and Mental Health among Transgender Veterans

Research about transgender persons and their healthcare concerns or outcomes has been limited largely to sources outside healthcare systems, and the majority of those who participate in such studies are white. As part of a comprehensive research program undertaken by VA's Office of Health Equity to assess health disparities among transgender Veterans, this study examined racial disparities in the prevalence of psychiatric and medical conditions among these Veterans. Using VA data, investigators identified 4,507 transgender Veterans: 4,120 non-Hispanic whites and 387 African Americans who sought VA healthcare between FY1996 and FY2013. Measures included: demographics; social determinants of health (e.g., rural residence, homelessness); service-related characteristics (e.g., service-connected disability, combat status); and mental health and medical illness, including alcohol and substance abuse. Findings show:

• Compared to white transgender Veterans, African American transgender Veterans had similar or worse outcomes on a variety of measures of medical and mental health, as well as on some social determinants of health.
• Compared to white transgender Veterans, African American transgender Veterans had increased odds of being diagnosed with: alcohol abuse, benign prostatic hyperplasia, congestive heart failure, HIV/AIDs, hypertension, end-stage renal disease, serious mental illness, and tobacco use.
• Compared to white transgender Veterans, African American transgender Veterans had decreased odds of being diagnosed with depression, hypercholesterolemia, and obesity.
• African American transgender Veterans were nearly three times more likely to have a history of incarceration and nearly twice as likely to experience homelessness as white transgender Veterans.

These findings may have implications for policy, prevention strategies, and healthcare delivery in VA and other healthcare systems.

Brown GR and Jones KT. Racial health disparities in a cohort of 5,135 transgender Veterans. Journal of Racial and Ethnic Health Disparities. December 2014;1(4):257-266.

Gender Differences in Attitudes and Their Relationship to VA Mental Healthcare Use

Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans are at risk for a variety of post-deployment mental health problems, including PTSD, depression, and alcohol abuse. Along with access to care issues, one of the most important factors that may drive mental health service use among Veterans is their attitude about VA healthcare and mental illness in general. This study explored gender differences in attitudinal barriers to and facilitators of care for OEF/OIF Veterans, and determined the relationship of those factors to VA mental health service use among female and male Veterans with probable mental health conditions. From a national sample, investigators identified 278 OEF/OIF Veterans (164 women and 114 men) with a probable diagnosis of PTSD, depression, or alcohol abuse, who had returned from deployment to Iraq or Afghanistan between 2007 and 2009 - and were separated from service at study time. Study measures assessed mental health symptomatology, positive perceptions of VA care, perceived fit in the VA setting, beliefs about mental illness and treatment, and use of VA mental healthcare in the past six months. Findings show:

• Female and male OEF/OIF Veterans were similar in their perceptions of VA healthcare and their perceived fit within the VA healthcare setting. Men held slightly more negative attitudes about mental illness and treatment than women.
• For both women and men, perceived entitlement to VA care was associated with increased likelihood of service use, and negative beliefs about treatment seeking (e.g., a problem would have to be really bad to seek mental health treatment) were associated with a reduced likelihood of seeking mental healthcare in the past six months.
• For female Veterans only, positive perceptions of VA healthcare were associated with increased likelihood of seeking VA mental health treatment.
• For male Veterans only, researchers found a positive relationship between VA service use and negative attitudes toward mental health treatment (e.g., mental health treatment does not work).
• For male Veterans only, perceived similarity to other VA healthcare users was also associated with increased likelihood of service use, while negative beliefs about mental illness (e.g., people with mental health problems are violent or dangerous) were associated with lower likelihood of service use.

Fox A, Meyer E, and Vogt D. Attitudes about the VA healthcare setting, mental illness, and mental health treatment and their relationship with VA mental health service use among female and male OEF/OIF Veterans. Psychological Services. February 2015;12(1):49-58.

Incidence of Care following VA Directive to Standardize Treatment Services for Transgender Veterans

Approximately 700,000 people in the U.S. identify as transgender; these individuals may experience symptoms of gender dysphoria and are at increased risk for depression, suicidal behavior, binge drinking, substance abuse, interpersonal violence, and cardiovascular disease. Starting in 2007, VA facilities enacted a range of policies regarding transgender care and, in June 2011, issued a national Directive to standardize treatment services for transgender Veterans. This study examined the incidence of an expanded set of ICD-9 encounter codes before and after the Directive was issued. Using VA data, investigators identified all VA clinical encounters from FY06 through FY13 for Veterans with an ICD-9 code of Gender Identity Disorder (GID), GID not otherwise specified, or Transsexualism. Additional transgender Veterans might be receiving VA care and not have one of these diagnoses or codes. Findings show:

• Increasingly, transgender Veterans seek care within the VA healthcare system. From FY06 to FY13, 2,662 transgender Veterans were identified, with incidence increasing since FY08.
• In the two years following the 2011 VA Directive, 985 new cases were identified; nearly 40% of all new diagnoses across the 8-year period occurred during this two-year period.
• The continuing increase in transgender-related ICD-9 codes following the Directive suggests that Veterans' awareness and clinical education efforts have been effective.

The authors suggest that transgender Veterans are increasingly likely to be identified and better able to access transgender-related care within the VA healthcare system.

Kauth M, Shipherd J, Lindsay J, et al. Access to care for transgender Veterans in VHA: 2006-2013. American Journal of Public Health. September 2014;104(Suppl 4):S532-S534.

Female Veterans with CVD Less Likely to Receive Statin and High-Intensity Statin Therapy Compared to Male Veterans with CVD

Gender disparities in the use of high-intensity statin therapy in patients with cardiovascular disease (CVD) are not known. Therefore, this study sought to identify the proportion of male (n=959,161) and female (n=13,371) Veterans with CVD who received care in any of 130 VA facilities between October 1, 2010 and September 30, 2011, and who received any statin and high-intensity statin. CVD patients were those with a history of coronary heart disease, peripheral artery disease, or ischemic stroke. Using VA pharmacy data, investigators determined whether these Veterans were prescribed a statin or a high-intensity statin within 100 days prior to - or 14 days following their index visit. Demographics and history of diabetes or hypertension also were assessed. Findings show:

• While evidence-based use of both statin and high-intensity statin therapy remains low in both genders, female Veterans with CVD were less likely to receive evidence-based statins (58% vs. 65%) and high-intensity statins (21% vs. 24%) compared with male Veterans. In fully adjusted analyses, female gender was independently associated with a 32% lower likelihood of receiving any statin therapy and a 24% lower likelihood of receiving high-intensity statin therapy.
• Mean low-density lipoprotein cholesterol levels were higher in female compared with male Veterans (99 vs. 85 mg/dl) with CVD.
• The use of statin and high-intensity statin therapy among female Veterans with CVD showed substantial facility-level variation. The median facility-level rate of statin use among female CVD patients was 57%. For high-intensity statin therapy, the median facility-level rate was 20%.

With the "statin dose-based approach" proposed by the recent cholesterol guidelines, these results highlight areas for quality improvement. It is important to note that despite the observed gender disparity in this study, statin and high-intensity statin use remain low in both genders.

Virani S, Woodard L, Ramsey D, et al. Gender differences in evidence-based statin therapy in patients with cardiovascular disease. American Journal of Cardiology. January 1, 2015;115(1):21-26.

References:

1. The Henry J. Kaiser Family Foundation. Gender Differences in Health Care, Status, and Use. March 31, 2015.

Additional Resources:

• Women Veterans Health Care.
• CREATE: Women Veterans Healthcare. Conducts research to examine factors significant to the delivery of comprehensive VA care for women Veterans.
• Center for Health Equity Research & Promotion. Conducts research that focuses on vulnerable patient populations, including but not limited to racial and ethnic minorities, women, and sexual orientation and gender minorities.
• The Lancet. Women and Health. This Commission offers one of the most comprehensive analyses to date of the evidence surrounding the complex relationships between women and health.

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