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2019 HSR&D/QUERI National Conference Abstract

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1019 — Housing Instability, Use of VHA Homeless Programs, and Challenges to Accessing Care Among Transgender Veterans

Lead/Presenter: Ann Elizabeth Montgomery,  Birmingham VAMC/National Center on Homelessness Among Veterans
All Authors: Montgomery AE (Birmingham VAMC, National Center on Homelessness Among Veterans, University of Alabama at Birmingham School of Public Health), Rodriguez, K (Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System), Klima, G (Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System) Shipherd, J (LGBT Health Program, VA Office of Patient Care Services; VA Boston Healthcare System, National Center for PTSD, Women's Health Sciences; Boston University, School of Medicine) Kauth, M (Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VAMC; Baylor College of Medicine; VA South Central MIRECC) Harris, KW (VHA Homeless Programs) Blosnich, JR (Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System; Division of General Internal Medicine, University of Pittsburgh School of Medicine)

The objectives of this study are to characterize housing instability among transgender Veterans accessing Veterans Health Administration (VHA) healthcare, their use of VHA Homeless Programs, and the unique barriers they may face when accessing the U.S. Departments of Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program.

This study employed quantitative and qualitative methods. Using VA administrative data, we assessed housing instability and VHA Homeless Programs utilization among 5,717 transgender Veterans and 17,133 non-transgender Veterans who responded to VA's universal screen for homelessness and risk during fiscal years 2013-2016. Multiple logistic regressions assessed the association of transgender identity with experience of housing instability and with VHA Homeless Programs utilization. We also conducted open-ended interviews with a random sample of 17 transgender and 17 non-transgender Veterans who were currently participating in HUD-VASH; we used rapid identification of themes from audio recordings (RITA) to analyze the interview data.

Transgender Veterans had more than double the odds of experiencing housing instability compared with non-transgender Veterans, adjusting for sociodemographic characteristics (aOR 2.32; 95% CI 2.09-2.57). Among Veterans who self-reported experience of housing instability, transgender Veterans were more likely to use at least 1 VHA Homeless Program compared with non-transgender peers (39.1% vs. 27.7%); specifically, transgender Veterans had greater odds of using HUD-VASH (aOR 2.09; 95% CI 1.34-3.26) and Supportive Services for Veteran Families (aOR 1.80; 95% CI 1.13-2.86). During qualitative interviews, transgender Veterans conveyed unique barriers to accessing services related to sex-specific shelter experiences and congruence of identification cards and gender expression.

Transgender Veterans have high risk of homelessness; however, they appear to access VHA Homeless Programs at a higher rate, suggesting that their needs may be met by at least 2 specific programs, however further research should explore transgender Veterans' experiences and acceptability of other VHA Homeless Programs.

VHA has a national directive assuring care for transgender Veterans. Because transgender Veterans have increased risk of housing instability, VHA Homeless Programs must consider ways to refine current programs and increase their flexibility to meet the unique needs of this minority population.