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Health Services Research & Development

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HSR&D In Progress

August 2019

In This Issue: Improving Care and Access for LGBTQ Veterans
» Table of Contents

Health Outcomes and Healthcare Use among Transgender Veterans

Feature Article

Despite the current Department of Defense policy effectively barring transgender individuals from joining the military, research suggests almost 20% of transgender adults have served in the US military, which is more than twice the prevalence in the general US population.1 Recognizing the need to serve transgender Veterans, VHA issued Directive 2013-003 (Providing Health Care for Transgender and Intersex Veterans) outlining expectations for VA to provide high-quality and respectful healthcare to transgender Veterans. However, limited information exists about the care transgender Veterans receive within the VA healthcare system.2

Current research about transgender individuals is helping VA understand the gaps and strengths of healthcare services for transgender Veterans. For example, the main objectives of this ongoing (2016–2021) HSR&D study are to:

  • Compare differences in patient-, system-, and community-level determinants of health among transgender and non-transgender Veterans;
  • Examine health services use, quality of care metrics, and mortality over time among transgender and non-transgender Veterans; and
  • Explore transgender Veterans' and VA health care providers' experiences with VA healthcare, barriers and facilitators to care, and strategies to engage transgender Veterans in research.

Researchers are using a mixed-methods approach of both quantitative analysis of VA administrative data, and qualitative analysis of data collected from patients and providers through interviews. Transgender Veterans are identified using a novel method developed within VA that defines patients as transgender who have a record of any four lifetime ICD-9 diagnoses related to gender identity disorder (GID).


  • In forthcoming findings, transgender Veterans are more than twice as likely to experience housing instability than their non-transgender peers, and they also are more likely to be utilizing VA Homelessness Programs.
  • Preliminary analyses of a historical cohort of 8,981 transgender Veterans and a comparison cohort of 26,924 non-transgender Veterans from FY2000-FY2016 revealed that, among the 10 leading causes of death, suicide was the 4th leading cause of death for transgender Veterans but the 10th leading cause of death for non-transgender Veterans.

In addition to findings from this ongoing study, research led by HSR&D investigators also shows that:

  • In the absence of self-identified gender identity data, the use of ICD codes is a valid alternative to identify a subset of transgender individuals receiving care in VHA.3
  • Social factors – such as violence, poverty, housing instability, and legal problems – are major covariates associated with transgender Veterans’ mental health, and social factors are changeable risk factors for targeted interventions.4
  • VA providers are using clinical education and resources to support transgender healthcare, such as e-consultation, but increased visibility of these programs is paramount to maximize reach.5


Results of this ongoing study are expected to improve quality of care through increasing visibility and awareness of transgender care in the VA healthcare system. Through partnerships with the LGBT Program in VA’s Office of Patient Care Services, results can be quickly disseminated throughout VA and added to existing transgender health resources for VA providers.

Principal Investigator: John Blosnich, PhD, MPH, is an HSR&D Career Development Awardee and part of HSR&D’s Center for Health Equity Research & Promotion (CHERP), Pittsburgh, PA.

View project abstract.


  1. Kauth M, Blosnich J, Marra, J et al. Transgender health care in the US Military and Veterans Health Administration facilities. Current Sexual Health Reports, 2017;9(3):121-127.
  2. Blosnich J, Rodriguez K, Hruska K, et al. Utilization of the Veterans Affairs’ transgender e-consultation program by health care providers: Mixed-methods study. JMIR Medical Informatics. 2019;7(1):e11695.
  3. Blosnich J, Cashy J, Gordon A, et al. Using clinician text notes in electronic medical record data to validate transgender-related diagnosis codes. Journal of the American Medical Informatics Association. July 2018;25(7):905-908.
  4. Blosnich J, Marsiglio M, Dichter M, et al. Impact of social determinants of health on medical conditions among transgender Veterans. American Journal of Preventive Medicine. April 2017;52(4):491-498.
  5. Blosnich J, Rodriguez K, Hruska K, et al. Utilization of the Veterans Affairs’ transgender e-consultation program by health care providers: Mixed-methods study. JMIR Medical Informatics. 2019;7(1):e11695.

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