Patient Characteristics Associated With the Receipt of Hormone Therapy Among Transgender Patients in the Veterans Health Administration

Background: Many transgender patients experience gender dysphoria as a result of an incongruence between their gender identity and sex assigned at birth. Gender-affirming hormone therapy improves the quality of life for transgender patients seeking to increase alignment of their secondary sex characteristics and gender identity. However, little is known about the patient factors that are associated with receipt of this therapy which is critical to identifying areas for improvement in care for transgender patients. Objective: To evaluate patient characteristics associated with transgender patients’ receipt of hormone therapy from the Veterans Health Administration (VHA). Methods: Inpatient and outpatient data were reviewed for transgender patients, identified through ICD-9/ICD-10 diagnosis codes for gender identity disorder (GID), receiving VHA health care from January 2006 to December 2018. We evaluated receipt of hormone therapy (testosterone or estrogen +/- spironolactone) from the VHA, socio-demographics, comorbidities, social stressors, military sexual trauma, and documented suicide attempts. Adjusted Odds Ratios (aOR) and 95% Confidence Intervals (CI) were obtained from a multivariable logistic regression model used to ascertain the relationship between patient characteristics and hormone therapy. Results: Of 9,406 patients with documented GID, 5,487 (58.3%) received hormone therapy from the VHA. Compared to patients not receiving hormone therapy, a higher proportion of patients receiving hormone therapy were younger (21-29 years: 18.1% vs. 11.6%; 30-39 years: 20.0% vs. 14.6%; 40-49 years: 16.2% vs. 13.6%), had documentation of a positive military sexual trauma screening (22.2% vs. 16.2%; p<0.0001), and a suicide attempt (11.4% vs. 9.9%; p=0.0067). There were significant associations between receipt of hormone therapy and: 1) younger age (aOR: 1.33; 95% CI: 1.29-1.36; p<0.0001); 2) Black non-Hispanic patients (aOR: 0.58; 95% CI: 050-0.68; p<0.0001); 3) increasing number of comorbidities (aOR: 0.86; 95% CI: 0.84-0.88; p<0.0001); and 4) increasing number of social stressors (aOR: 0.86; 95% CI: 0.83-0.90; p<0.0001). Conclusions: Age, race/ethnicity, comorbidities, and social stressors among other factors are associated with receipt of hormone therapy among transgender patients in the VHA. Subsequent efforts should focus on understanding clinician- and site-level determinants to facilitate the design of effective quality improvement measures that optimize gender affirming hormone therapy through VHA for transgender patients.