August 2019

In This Issue: Improving Care and Access for LGBTQ Veterans
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Assessing Hormone Therapy Care Received by Transgender Veterans in VHA

Feature Article

The prevalence of transgender Veterans (“trans Vets”) is on the rise. Transgender individuals experience discord between their self-identified gender and biological sex, defined as gender dysphoria (GD). Untreated and/or undertreated GD is associated with increased mortality and morbidity including depression, anxiety, and suicidality. Hormone therapy is generally the first, and often the only medical intervention accessed by transgender persons with GD who seek to masculinize or feminize their body to be consistent with their gender identity. In 2012, VA Pharmacy Benefits Management (PBM) issued Criteria for Use (CFU) for hormone therapy care. In pilot work, investigators found that out of 7,944 transgender Veterans with GD from FY2005-FY2017, 4,977 were on hormone therapy, with a 7-fold variation on one quality care measure recommended by CFU across sites. In order to identify more gaps in the delivery of this care, research was needed to understand the current patterns of care, determine the degree of concordance with recommendations, and factors driving hormone care.

Therefore, the main objectives of this HSR&D study (2019–2021) are to:

• Refine methods for identifying trans Vets on hormone therapy using VHA data and validate by chart reviews.
• Examine the hormone therapy care provided to transgender Veterans in VA, which includes:
  • Describing the current state of hormone care in VA, and
  • Determining the degree that hormone care is concordant with PBM CFU and non-VA guidelines.
• Identify patient-, clinician-, and site-level predictors of guideline-concordant hormone care.

Working with VA’s Lesbian, Gay, Bisexual, and Transgender (LGBT) Health Program in the Office of Patient Care Services—and using VA data, investigators will identify a population of GD documented transgender Veterans on hormone therapy. They also will examine alternative approaches of identification, including receipt of hormones by opposite sex, and change in coded gender over time, which will be further validated by chart reviews. Investigators will then describe the study cohort in terms of demographics, proportion of those receiving each type of hormone therapy (estrogen vs. testosterone vs. none), route of administration (oral, transdermal, injectable), dosage and titration schedule, and duration of therapy. They also will identify key aspects of care recommended by PBM CFU and non-VA guidelines (e.g. adequacy of laboratory monitoring) against which the current care can be measured – and they will examine factors associated with guideline-concordant hormone therapy care at the patient- (i.e., housing instability), provider- (i.e., availability of transgender electronic consultations) and site-level (i.e., transgender specialty training offered at site).

Findings:

There are no findings to report at this time.

Impact:

This study will be the first to provide an assessment of the quality of hormone therapy care received by transgender Veterans served by VA, as well as to refine methods to identify transgender persons on hormones in VA data. In addition, study findings will lay the groundwork for a follow-up study to identify best practices associated with the delivery of guideline-concordant hormone therapy care.

Principal Investigator: Guneet Jasuja, PhD, is an investigator with HSR&D’s Center for Healthcare Organization and Implementation Research (CHOIR) in Boston and Bedford, MA.

View project abstract.