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CDA 14-408 – HSR&D Study

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CDA 14-408
Health Outcomes and Healthcare Use Among Transgender Veterans
John R. Blosnich PhD MPH
VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA
Pittsburgh, PA
Funding Period: March 2016 - February 2021

Background/Rationale. Transgender individuals bear a high burden of health disparities, and almost 20% of transgender adults have served in the military, which is more than twice the prevalence in the general US population. Recognizing the need to serve transgender Veterans, VHA promulgated Directive 2013-003 outlining expectations for transgender health care. However, limited information exists about transgender Veterans receiving VHA care.

Objectives. (1) Compare differences in patient-, system, and community-level determinants of health among transgender and non-transgender Veterans; (2) examine health services utilization, quality of care metrics, and mortality over time among transgender and non-transgender Veterans; and (3) explore transgender Veterans' and VA health care providers' experiences with VA health care, barriers and facilitators to care, and strategies to engage transgender Veterans in research.

This CDA uses a mixed-methods approach of quantitative analysis of VA administrative data (Aims 1 & 2), and qualitative analysis of data collected from patients and providers through semi-structured interviews. Transgender Veterans are defined as patients with any of 4 lifetime ICD-9 diagnoses related to gender identity disorder (GID). For each transgender Veteran, I will create a non-transgender Veteran comparison group at a ratio of 3:1. Data to be extracted for the sample include socio-demographics, social stressors (e.g., homelessness, military sexual trauma), medical conditions (e.g., HIV), and behavioral conditions (e.g., suicidal risk). System-level variables include primary medical facility and the volume of transgender patients at the facility, and community-level variables include rural status, distance to VA facility, and geographic region. Multivariable regression analyses will be used to examine how transgender status (yes/no) is associated with social stressors and medical and behavioral conditions (Aim 1). To determine changes in care over time (Aim 2), I will use mixed effects regression and Cox proportional hazards models with time-varying covariates. An advisory board will help to develop the semi-structured interview guide for Aim 3 to explore topics such as experiences with care, barriers and facilitators to care, and provider training.

Not yet available.

The anticipated impact of this project on Veterans is improving quality of care through increasing visibility and awareness of transgender health in VA. The cohort data derived from this project provides a foundation for intervention research to reduce disparities. Through operations partnerships with the LGBT Program in the Office of Patient Care Services, results can be expeditiously disseminated throughout VA and added to existing transgender health resources for VA providers.


Journal Articles

  1. Blosnich JR, Goldbach JT. Stark Findings About Sexual Assault: Implications for Sexual Minority Women and the Challenging Work Ahead. American journal of public health. 2020 Jun 1; 110(6):761-762.
  2. Blosnich JR, Henderson ER, Coulter RWS, Goldbach JT, Meyer IH. Sexual Orientation Change Efforts, Adverse Childhood Experiences, and Suicide Ideation and Attempt Among Sexual Minority Adults, United States, 2016-2018. American journal of public health. 2020 May 21; e1-e7.
  3. Blosnich JR, Monteith LL, Holliday R, Brenner LA, Montgomery AE. Differences in methods of suicide among veterans experiencing housing instability, 2013-2016. Psychiatry Research. 2020 Jun 1; 288:112947.
  4. Riggs KR, Hoge AE, DeRussy AJ, Montgomery AE, Holmes SK, Austin EL, Pollio DE, Kim YI, Varley AL, Gelberg L, Gabrielian SE, Blosnich JR, Merlin J, Gundlapalli AV, Jones AL, Gordon AJ, Kertesz SG. Prevalence of and Risk Factors Associated With Nonfatal Overdose Among Veterans Who Have Experienced Homelessness. JAMA Network Open. 2020 Mar 2; 3(3):e201190.
  5. Clark KA, Blosnich JR, Coulter RWS, Bamwine P, Bossarte RM, Cochran SD. Sexual Orientation Differences in Gun Ownership and Beliefs About Gun Safety Policy, General Social Survey 2010-2016. Violence and Gender. 2020 Mar 1; 7(1):6-10.
  6. Blosnich JR, Montgomery AE, Dichter ME, Gordon AJ, Kavalieratos D, Taylor L, Ketterer B, Bossarte RM. Social Determinants and Military Veterans' Suicide Ideation and Attempt: a Cross-sectional Analysis of Electronic Health Record Data. Journal of general internal medicine. 2019 Nov 19.
  7. Henderson ER, Jabson J, Russomanno J, Paglisotti T, Blosnich JR. Housing and food stress among transgender adults in the United States. Annals of epidemiology. 2019 Oct 1; 38:42-47.
  8. Carter SP, Montgomery AE, Henderson ER, Ketterer B, Dichter M, Gordon AJ, Shipherd JC, Kauth MR, Blosnich JR. Housing Instability Characteristics Among Transgender Veterans Cared for in the Veterans Health Administration, 2013-2016. American journal of public health. 2019 Oct 1; 109(10):1413-1418.
  9. Henderson ER, Blosnich JR, Herman JL, Meyer IH. Considerations on Sampling in Transgender Health Disparities Research. LGBT health. 2019 Aug 1; 6(6):267-270.
  10. Clark KA, Blosnich JR, Haas AP, Cochran SD. Estimate of Lesbian, Gay, Bisexual, and Transgender Youth Suicide Is Inflated. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 2019 Jun 1; 64(6):810.
  11. Blosnich JR, Shipherd JC, Kauth MR. Are There Differences in Anti-Gay Beliefs Among U.S. Veterans and Non-Veterans? Results from the General Social Survey. Journal of homosexuality. 2019 Apr 2; 1-11.
  12. Blosnich JR, Rodriguez KL, Hruska KL, Kavalieratos D, Gordon AJ, Matza A, Mejia SM, Shipherd JC, Kauth MR. Utilization of the Veterans Affairs' Transgender E-consultation Program by Health Care Providers: Mixed-Methods Study. JMIR medical informatics. 2019 Jan 14; 7(1):e11695.
  13. Haas AP, Lane AD, Blosnich JR, Butcher BA, Mortali MG. Collecting Sexual Orientation and Gender Identity Information at Death. American journal of public health. 2019 Feb 1; 109(2):255-259.
  14. Blosnich JR, Cassese EC, Friedman MR, Coulter RWS, Sang JM, Matthews DD, Mair C. Religious freedom restoration acts and sexual minority population health in the United States. The American Journal of Orthopsychiatry. 2018 Sep 24; 89(6):675-681.
  15. Bachrach RL, Blosnich JR, Williams EC. Alcohol screening and brief intervention in a representative sample of veterans receiving primary care services. Journal of substance abuse treatment. 2018 Dec 1; 95:18-25.
  16. Blosnich JR, Cashy J, Gordon AJ, Shipherd JC, Kauth MR, Brown GR, Fine MJ. Using clinician text notes in electronic medical record data to validate transgender-related diagnosis codes. Journal of the American Medical Informatics Association : JAMIA. 2018 Jul 1; 25(7):905-908.
  17. Downing J, Conron K, Herman JL, Blosnich JR. Transgender And Cisgender US Veterans Have Few Health Differences. Health affairs (Project Hope). 2018 Jul 1; 37(7):1160-1168.
  18. Williams EC, McGinnis KA, Bobb JF, Rubinsky AD, Lapham GT, Skanderson M, Catz SL, Bensley KM, Richards JE, Bryant KJ, Edelman EJ, Satre DD, Marshall BDL, Kraemer KL, Blosnich JR, Crystal S, Gordon AJ, Fiellin DA, Justice AC, Bradley KA. Changes in alcohol use associated with changes in HIV disease severity over time: A national longitudinal study in the Veterans Aging Cohort. Drug and Alcohol Dependence. 2018 Aug 1; 189:21-29.
  19. Lytle MC, Blosnich JR, De Luca SM, Brownson C. Association of Religiosity With Sexual Minority Suicide Ideation and Attempt. American journal of preventive medicine. 2018 May 1; 54(5):644-651.
  20. Blosnich JR, Lytle MC, Coulter RWS, Whitfield DL. Suicide Acceptability and Sexual Orientation: Results from the General Social Survey 2008-2014. Archives of suicide research : official journal of the International Academy for Suicide Research. 2018 Jan 24; 22(4):542-554.
  21. Tucker RP, Testa RJ, Simpson TL, Shipherd JC, Blosnich JR, Lehavot K. Hormone therapy, gender affirmation surgery, and their association with recent suicidal ideation and depression symptoms in transgender veterans. Psychological medicine. 2018 Oct 1; 48(14):2329-2336.
  22. Blosnich JR, Lehavot K, Glass JE, Williams EC. Differences in Alcohol Use and Alcohol-Related Health Care Among Transgender and Nontransgender Adults: Findings From the 2014 Behavioral Risk Factor Surveillance System. Journal of studies on alcohol and drugs. 2017 Nov 1; 78(6):861-866.
  23. Bukowski LA, Blosnich J, Shipherd JC, Kauth MR, Brown GR, Gordon AJ. Exploring Rural Disparities in Medical Diagnoses Among Veterans With Transgender-related Diagnoses Utilizing Veterans Health Administration Care. Medical care. 2017 Sep 1; 55 Suppl 9 Suppl 2:S97-S103.
  24. Ruben MA, Blosnich JR, Dichter ME, Luscri L, Shipherd JC. Will Veterans Answer Sexual Orientation and Gender Identity Questions? Medical care. 2017 Sep 1; 55 Suppl 9 Suppl 2:S85-S89.
  25. Lehavot K, Blosnich JR, Glass JE, Williams EC. Alcohol use and receipt of alcohol screening and brief intervention in a representative sample of sexual minority and heterosexual adults receiving health care. Drug and Alcohol Dependence. 2017 Oct 1; 179:240-246.
  26. Coulter RWS, Mair C, Miller E, Blosnich JR, Matthews DD, McCauley HL. Prevalence of Past-Year Sexual Assault Victimization Among Undergraduate Students: Exploring Differences by and Intersections of Gender Identity, Sexual Identity, and Race/Ethnicity. Prevention Science : The Official Journal of The Society For Prevention Research. 2017 Aug 1; 18(6):726-736.
  27. Riley NC, Blosnich JR, Bear TM, Reisner SL. Vocal Timbre and the Classification of Respondent Sex in US Phone-Based Surveys. American journal of public health. 2017 Aug 1; 107(8):1290-1294.
  28. Blosnich JR, Bossarte RM. Premilitary Trauma as a Correlate of Suicidal Ideation Among Veterans. Psychiatric services (Washington, D.C.). 2017 Aug 1; 68(8):755.
  29. Blosnich JR, Marsiglio MC, Dichter ME, Gao S, Gordon AJ, Shipherd JC, Kauth MR, Brown GR, Fine MJ. Impact of Social Determinants of Health on Medical Conditions Among Transgender Veterans. American journal of preventive medicine. 2017 Apr 1; 52(4):491-498.
  30. Blosnich JR. Sexual Orientation Differences in Satisfaction with Healthcare: Findings from the Behavioral Risk Factor Surveillance System, 2014. LGBT health. 2017 Jun 1; 4(3):227-231.
  31. Lytle MC, Blosnich JR, Kamen C. The Association of Multiple Identities with Self-Directed Violence and Depression among Transgender Individuals. Suicide & Life-Threatening Behavior. 2016 Oct 1; 46(5):535-544.
  32. Blosnich JR, Brenner LA, Bossarte RM. Population mental health among U.S. military veterans: results of the Veterans Health Module of the Behavioral Risk Factor Surveillance System, 2011-2012. Annals of epidemiology. 2016 Aug 1; 26(8):592-596.
  33. Blosnich JR, Hanmer J, Yu L, Matthews DD, Kavalieratos D. Health Care Use, Health Behaviors, and Medical Conditions Among Individuals in Same-Sex and Opposite-Sex Partnerships: A Cross-Sectional Observational Analysis of the Medical Expenditures Panel Survey (MEPS), 2003-2011. Medical care. 2016 Jun 1; 54(6):547-54.
  34. Farmer GW, Blosnich JR, Jabson JM, Matthews DD. Gay Acres: Sexual Orientation Differences in Health Indicators Among Rural and Nonrural Individuals. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2016 Jun 1; 32(3):321-31.
  35. Blosnich JR, Marsiglio MC, Gao S, Gordon AJ, Shipherd JC, Kauth M, Brown GR, Fine MJ. Mental Health of Transgender Veterans in US States With and Without Discrimination and Hate Crime Legal Protection. American journal of public health. 2016 Mar 1; 106(3):534-40.
Journal Other

  1. Blosnich JR, Friedman MR, Ho K. Remembering Patient Gender in Sexual Orientation-Based Research. JAMA internal medicine. 2018 Jan 1; 178(1):151.
  2. Stall R, Matthews DD, Friedman MR, Kinsky S, Egan JE, Coulter RW, Blosnich JR, Markovic N. The Continuing Development of Health Disparities Research on Lesbian, Gay, Bisexual, and Transgender Individuals. [Editorial]. American journal of public health. 2016 May 1; 106(5):787-9.
  3. Blosnich JR, Bossarte RM. Childhood Abuse and Military Experience-Important Information to Better Serve Those Who Have Served. [Editorial]. JAMA psychiatry (Chicago, Ill.). 2016 Mar 1; 73(3):195-6.
Center Products

  1. Blosnich JR, Marsiglio MC, Gao S, Gordon AJ, Shipherd JC, Kauth M, Brown GR, Fine MJ. Mental Health of Transgender Veterans in US States with and without Discrimination and Hate Crime Legal Protection [Institute for Veterans and Military Families Research Brief]. 2016 Jun 24.
VA Cyberseminars

  1. Blosnich JR, Montgomery AE. Housing Instability, Housing Services Utilization, and Suicide Morbidity Among Transgender Veterans. Connecting Research to Practice [Cyberseminar]. The National Center on Homelessness Among Veterans. 2019 Jan 8.
  2. Blosnich JR. Suicide Risk among LGBT Veterans and Service Members. VA/DOD Suicide Prevention Webinar Series [Cyberseminar]. VA and DOD. 2017 Jun 13.
  3. Blosnich JR. Exploring Self-Directed Violence Among Sexual and Gender Minority Veterans. SoSP (Suicide Prevention Series) [Cyberseminar]. Health Services Research and Development. 2017 May 8.
Conference Presentations

  1. Blosnich JR, Marsiglio MC, Dichter ME, Gao S, Gordon AJ, Shipherd JC, Kauth MR, Fine MJ. Impact of Social Determinants of Health on Medical Conditions among Transgender Veterans. Paper presented at: VA HSR&D Field-Based Meeting to Engage Diverse Stakeholders and Operational Partners in Advancing Health Equity in the VA Healthcare System; 2016 Sep 21; Philadelphia, PA.
  2. Blosnich JR. Questions of Life and Death: Pursuing Information About Suicide Deaths Among Lesbian, Gay, Bisexual, and Transgender People. Paper presented at: American Foundation for Suicide Prevention San Francisco Bay Area Chapter Conference; 2016 Apr 10; College Park, MD.
  3. Blosnich JR. Suicide Prevention in the Department of Veterans Affairs. Paper presented at: American Foundation for Suicide Prevention Research to Practice: Suicide Prevention for LGBT Communities Conference; 2016 Apr 9; College Park, MD.

DRA: Mental, Cognitive and Behavioral Disorders
DRE: Technology Development and Assessment
Keywords: none
MeSH Terms: none

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