Using self-identified gender identity data to advance health equity among transgender and gender diverse Veterans in the Veterans Health Administration

Abstract: BACKGROUND: Identification of transgender and gender diverse (TGD) people has been limited to diagnoses and text rather than self-identified gender identity (SIGI), representing a subset of TGD people. In 2017, the Veterans Health Administration (VHA) implemented SIGI, allowing for precise identification of TGD veterans, including subgroups (transgender man, transgender woman, and nonbinary). OBJECTIVES: Health conditions, adverse social determinants of health (SDOH), and health care utilization were compared among veterans (1) identified by SIGI only, both SIGI and diagnosis/text, diagnosis/text only (ie, without SIGI), and (2) SIGI subgroups. RESEARCH DESIGN: Cross-sectional. SUBJECTS: Twenty thousand seventy-nine TGD VHA patients from 2019 to 2023; SIGI only (n=5523), both SIGI and diagnosis/text (n=4066), and without SIGI (n=10,490). MEASURES: Health conditions, adverse SODH and health care utilization. RESULTS: In adjusted models, SIGI only veterans were less likely to have documentation of depression (32.4% vs. 60.7% vs. 54.8%), post-traumatic stress disorder (PTSD; 23.5% vs. 41.4% vs. 37.5%), housing instability (8.8% vs. 21.5% vs. 16.1%), unemployment/financial problems (10.5% vs. 23.8% vs. 19.0%), and mental health visits (72.5% vs. 97.7% vs. 95.2%) compared with those with both SIGI and diagnosis/text and without SIGI. Health conditions were more similar across the diagnosis groups (i.e. both SIGI and diagnosis/text and without SIGI). Among veterans with SIGI data, we identified 49% transgender women, 38% transgender men, and 14% nonbinary veterans without many differences across subgroups. In adjusted models, more nonbinary veterans than transgender women and transgender men had documentation of alcohol use disorder (10.1% vs. 6.1% vs. 7.5%), depression (62.3% vs. 42.6% vs. 47.0%), PTSD (45.9% vs. 27.4% vs. 33.5%), mental health visits (96.7% vs. 89.1% vs. 91.9%), and experienced unemployment/financial problems (21.3% vs. 16.9% vs. 14.7%). CONCLUSIONS: Without diagnosis, SIGI enables the identification of healthier TGD veterans. Regardless of SIGI, diagnosis signals much higher rates of health concerns. SIGI data facilitates understanding veteran subgroups, informing TGD policy and practice.