Treating Transgender and Gender-Diverse Veterans in the Veterans Health Administration: 23 Years of Findings

Abstract

Purpose: Many transgender and gender-diverse (TGD) people experience significant barriers to health care access, facing disparities in care, limited payments for gender-affirming services, or insufficient training and knowledge among providers. Given validation studies reporting increasing rates of TGD-related status, we documented health care types used by TGD veterans to signal whether engagement in Veterans Health Administration (VHA) care increased or decreased following documentation of a TGD-related diagnosis code. Methods: The cohort was defined by receipt of a TGD-related diagnosis code in the VHA Corporate Data Warehouse from October 1, 1999, through September 30, 2021 (fiscal years 2000 through 2021). Data were summarized in two 1-year periods before and after TGD-related diagnosis. Logistic regression estimated predictors of VHA care post-TGD-related diagnosis as well as filling gender-affirming prescriptions in the VHA. Results: Over the 23-year study period, 9894 transgender veterans were identified. Among the 91% using VHA both before and after TGD diagnosis, visits for primary, specialty, and mental and behavioral health care increased whereas emergency care did not change. Factors associated with discontinuing VHA care were Black/African American and another race, married status, older age, and service in recent versus earlier eras. Younger, highly disabled from military service veterans and those in the West (vs. South) were more likely to fill gender-affirming prescriptions in the VHA. Conclusion: This study established high levels of disability and apparent willingness to continue with care in the VHA following establishment of TGD status. The role of interpersonal, provider, and policy in VHA retention remains to be examined.

Keywords: gender dysphoria; gender-affirming hormone treatment; health care utilization; health outcome; veterans.