Research Article
Impact of Social Determinants of Health on Medical Conditions Among Transgender Veterans

https://doi.org/10.1016/j.amepre.2016.12.019Get rights and content

Introduction

Transgender individuals experience pronounced disparities in health (e.g., mood disorders, suicide risk) and in the prevalence of social determinants of housing instability, financial strain, and violence. The objectives of this study were to understand the prevalence of social determinants among transgender veterans and assess their associations with medical conditions.

Methods

This project was a records review using administrative data from the U.S. Department of Veterans Affairs databases for 1997–2014. Transgender veterans (N=6,308) were defined as patients with any of four ICD-9 diagnosis codes associated with transgender status. Social determinants were operationalized using ICD-9 codes and Department of Veterans Affairs clinical screens indicating violence, housing instability, or financial strain. Multiple logistic regression was used to assess the associations of social determinants with medical conditions: mood disorder, post-traumatic stress disorder, alcohol abuse disorder, illicit drug abuse disorder, tobacco use disorder, suicidal risk, HIV, and hepatitis C.

Results

After adjusting for sociodemographic variables, housing instability and financial strain were significantly associated with all medical conditions except for HIV, and violence was significantly associated with all medical conditions except for tobacco use disorder and HIV. There was a dose response–like relationship between the increasing number of forms of social determinants being associated with increasing odds for medical conditions.

Conclusions

Social determinants are prevalent factors in transgender patients’ lives, exhibiting strong associations with medical conditions. Documenting social determinants in electronic health records can help providers to identify and address these factors in treatment goals.

Introduction

Social determinants of health, “the conditions in which people are born, grow, live, work, and age,”1 are crucial for understanding health and health care for marginalized patient populations,2 and they undergird the social-ecological model, which maintains health and behavior are shaped by the continuous interplay of individual biology and environment.3 Social determinants are especially salient for transgender individuals, who have high risks for stressors that negatively impact their health, such as homelessness, unemployment, and violence.4, 5, 6 Because social determinants are associated with the development and persistence of mental illness for transgender individuals seeking mental health treatment, clinical practice guidelines emphasize using an ecological approach, such as acknowledging and facilitating open discussion about sociocultural (e.g., discrimination) factors that may interfere with treatment goals.7

The Department of Veterans Affairs (VA) is an ideal environment to study the impact of social determinants on the health of vulnerable patient populations. The VA operates the largest integrated healthcare system in the U.S., uses a unified electronic health record (EHR), and is designed as a medical safety net system ensuring access to health care for enrolled veterans nationwide.

Prior research on transgender veterans documented several health disparities. For example, VA veterans with a diagnosis of gender identity disorder experienced suicide-related events at a rate 20-fold higher than the overall enrolled VA veteran population.8 Compared with non-transgender veterans, transgender veterans have a much greater prevalence of mental health diagnoses, including mood disorders and post-traumatic stress disorder (PTSD).9 Additionally, transgender populations, in general, have high rates of HIV and hepatitis C.10, 11 However, the extent to which social determinants contribute to health problems among transgender individuals is unclear.

The objectives of this project were to understand the prevalence of social determinants among transgender veterans and examine their associations with medical conditions in this vulnerable patient population. The authors aimed to:

  • 1

    assess the prevalence of three social determinants (i.e., housing instability, financial strain, and violence) using VA administrative data; and

  • 2

    investigate the independent associations of these determinants with medical conditions prevalent among transgender populations (e.g., HIV).

It was hypothesized that each individual social determinant would be independently associated with medical conditions and that an increasing cumulative number of types of social determinants would be associated with an increased prevalence of each medical condition.

Section snippets

Study Sample

This project was a secondary analysis of existing VA administrative data. Patient-level information was obtained from VA Medical SAS data sets, which contain administrative data on all veteran healthcare encounters in the VA Healthcare System nationwide.12 The VA EHR currently includes one field for the sex of the patient, with response options of male and female only; there is no field for gender identity. Veterans are able to change this field with a letter of support from a physician. To

Results

Among the 6,308 identified transgender veterans, 77.3% were white, 29.5% were coded as female at their last visit, and 76.2% were unmarried (46.9% formerly married and 29.3% never married) (Table 1). Overall, 48.1% of the study population had one or more social determinants and 6.5% had three determinants (Table 1 and Appendix Figure 1, available online); the most prevalent of these were financial strain (30.8%) and housing instability (28.3%), which co-occurred in 12.9% of the sample. Nearly

Discussion

The Institute of Medicine issued a report calling for EHR systems to collect information about patients’ social determinants,29 which could assist providers in addressing these factors in treatment goals. To the authors’ knowledge, this investigation is among the first to utilize ICD-9 codes in VA administrative data to operationalize three key social determinants among patients, and it is the first study to use EHR to examine the association of social determinants with medical conditions among

Conclusions

Health is as much a function of social factors as it is of biological factors, and the interactions of these factors are perhaps clearest among the most vulnerable populations, such as transgender veterans. The principles of patient-centered medical homes,42 which include coordination of care and ways EHR data impact coordination, broaden the concept of healthcare delivery in the U.S. Although individual-level interventions (e.g., psychotherapy, pharmaceuticals) are critical for treating

Acknowledgments

This work was also supported by a locally initiated project award (LIP 72-080) and Career Development Award (CDA 14-408) to John R. Blosnich from the Department of Veterans Affairs, Health Service Research & Development.

The authors thank Maria Mor, PhD at the Center for Health Equity Research and Promotion for her assistance with data management and statistical consultation.

The opinions expressed in this work do not necessarily reflect those of the funders, institutions, the Department of

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      We were able to measure eight facets of social and economic hardship using multiple dimensions of administrative data in a large, non-recruited, national sample, while previous studies of substance use and social and economic stressors among transgender persons have largely been limited to survey data (Grant et al., 2010; Keuroghlian et al., 2015). Our overall prevalence estimates of social and economic stressors for transgender Veterans regardless of substance use are generally consistent with previous estimates (Blosnich, Marsiglio, et al., 2017; Brown and Jones, 2016; Grant et al., 2010; Shipherd, Mizock, Maguen, & Green, 2012), with slight differences, likely reflecting different study windows, as we limited ascertainment of most stressors (except MST) to a two-year time period. Additionally, aligning with Kilbourne et al.‘s stages of disparities research (Kilbourne, Switzer, Hyman, Crowley-Matoka, & Fine, 2006), this study represents an important formative step in detecting the extent to which the sociodemographic status and/or the social experience of these groups (those with AUD/DUD and transgender persons) may increase likelihood of SUDs.

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