Approximately 1.4 million people in the Unites States identify as transgender,1 meaning their sex identity (ie, the innate sense of being male, female, both, or neither) differs from the biological sex they were assigned at birth. Because transgender identities can transcend the traditional socially constructed binary of sex, transgender individuals are particularly vulnerable to stigma and marginalization2 which can lead to negative health outcomes.3 For example, compared with their nontransgender counterparts, transgender individuals are significantly more likely to experience physical assault and discrimination4 which contributes to worse health outcomes.5 Research shows pronounced health disparities between transgender individuals and their nontransgender peers, including rates of depression,3 anxiety,3 human immunodeficiency virus (HIV),6 suicide ideation and attempt,7 and problems with alcohol8 and drug use.9 Because of these disparities, the National Academy of Medicine has called for more research focused on how sociodemographic factors influence the health of transgender individuals.10 Yet, there remains insufficient research about health differences among transgender populations.
Some evidence supports that sociodemographic factors impact health outcomes among transgender people.11 For example, black and/or African American transgender women are more likely than their white peers to experience physical assault12 and report depression symptoms.13 Another understudied sociodemographic factor that could impact the health of transgender individuals is place of residence (ie, whether a transgender individual lives in an urban or a rural area). Previous research conducted within nontransgender populations shows urban/rural differences in individual health,14 social and environmental stressors,15 and illustrates how the addition sociodemographic factors, such as race, compound these disparities.16 Yet, little is known regarding if and how these patterns may occur among transgender individuals. Beyond one recent cross-sectional study that found rural transgender men reported significantly greater symptoms of somatization and depression compared with their nonrural peers,17 urban/rural differences have not been explored in this population. This paucity of research is due largely to a lack of data sources that include large numbers of transgender individuals and/or sex identity indicators.
The Department of Veterans Affairs (VA) electronic health records have proven a useful data source for exploring the health of transgender individuals.18 The rate of transgenderism is higher in the VA than in the general population.19 Estimates project military service prevalence of 19.0% among transgender individuals20 compared with 8.7% of US persons over the age of 17.21 One theory for this increased military service among transgender individuals is “flight into hypermasculinity” which asserts that young men with sex identity disorder may enlist in the military to “become real men” by purging their inner sex conflict through the strict rigor and focus on masculine activities.19 Although the exact number of transgender Veterans who access VA care is unknown, it is possible to identify a subpopulation of transgender individuals through VA’s administrative data using 4 International Classification of Diseases (ICD)-9 codes that identify persons who are likely to self-identify as transgender.7 These data source thereby allow exploration of rural/urban differences among veterans with transgender-related diagnoses.
Rurality may be particularly stressful for veterans with transgender-related diagnoses. On top of the relatively traditional cultural milieu of the rural US, veterans with a transgender-related diagnoses living in rural areas must also contend with cultural factors associated with their veteran status and transgender-related diagnoses. According to the theory of intersectionality, these 3 sociodemographic factors intersect to create an individual experience that is unique from the experience created by the combination of any fewer of these factors.22 Stigma associated with the intersection of these factors may be internalized at the individual level, disrupting health. The minority stress model outlines how stigma projected onto minority identities and concomitant negative social impacts (eg, violence, harassment, discrimination) create excess distress among sexual and sex minority individuals.5 Given this, negative health outcomes experienced by rural individuals, veterans, and transgender individuals may be amplified among rural veterans with transgender-related diagnoses.
Although health disparities that rural veterans with a transgender-related diagnoses face cannot be deduced from those reported by rural individuals, veterans, or transgender individuals,22 existing research in these populations points to health outcomes that should be explored. Given the significant urban/rural health differences in tobacco use15 and mood disorders23 experienced in the general population, exploring how these health outcomes differ between rural and urban veterans with transgender-related diagnoses is needed. In addition, because transgender individuals are more likely to report symptomology of mood disorders,3 alcohol8 and illicit drug problems,9 and are at increased risk for suicidal ideation7 and HIV6 compared with their nontransgender counterparts, these outcomes should also be explored. Finally, rural/urban differences in prevalence of posttraumatic stress disorder (PTSD) should be explored as PTSD is common among veterans.24
Although veterans with transgender-related diagnoses are a relatively newly identified vulnerable population to VA health equity research,7 achieving equity in health and health care irrespective of sex is a priority of VA. In 2013, the VA reissued a national directive about providing high-quality care for transgender veterans.25 However, very scant research exists to characterize specific health disparities and correlates of disparities among veterans with transgender-related diagnoses that could advance health equity in this population. The existing health disparities research about this population tends to be “first generation” descriptive studies to fulfill the critical steps of characterizing the population and gathering the necessary information to inform second and third generation disparities research.26 This study seeks to add to this literature by exploring how current urban/rural status is associated with lifetime diagnoses of the following outcomes among veterans with transgender-related diagnoses: mood disorders, alcohol dependence disorder, illicit drug abuse disorder, tobacco use, PTSD, HIV, and suicidal ideation or attempt. We hypothesized transgender patients residing in rural areas will experience significantly greater prevalence of medical conditions than transgender patients residing in urban areas.
This study used a retrospective review of VA administrative data for transgender patients who received VA care from 1997 through 2014. These data include patient sociodemographic information diagnosis data from inpatient and outpatient encounters.27 These data do not currently include a field in which patients can indicate if they self-identify as transgender. Consistent with prior research,7,28 transgender patients were defined as individuals that had a lifetime diagnosis of any of 4 ICD-9 diagnosis codes associated with transgender status: 302.6 sex identity disorder—not otherwise specified, 302.5 transsexualism, 302.3 transvestic fetishism, or 302.85 sex identity disorder in adolescents or adults. The institutional review board of (institution name masked for review) approved this study.
Following methodology from previous rural health research with VA administrative data, we defined rural status by cross referencing current zip code of residence for patients with Rural-Urban Commuter Area codes,29,30 which were recoded into a 3-category variable of urban, large rural city/town, small/isolated rural town.31 VA administrative data do not include historical zip code data for patients; only current address and zip code. Other sociodemographic information extracted from the last VA patient encounter included age coded into 3 groups of 18–39, 40–59, and 60 or above; marital status that was coded as married, never married, or formerly married (which included separate, divorced, or widowed individuals); sex (coded as male or female); and race/ethnicity (coded as racial/ethnic minority or white). Two additional sociodemographic variables, housing instability, and military sexual trauma were added as covariates based on of their documented associations with the main outcomes of interest.32,33 Housing instability was defined as any notation in a patient’s record of ICD-9 diagnosis codes of V60.0 lack of housing or V60.1 inadequate housing or a positive notation to a VA clinical screen for housing instability.34 Military sexual trauma was defined as a positive notation to a VA clinical screen for sexual assault or harassment experienced during active duty service.32
The main outcomes of interest were lifetime prevalence of 7 medical conditions, which were based on ICD-9 diagnosis codes indicating: mood disorders (296 episodic mood disorders or 311 depressive disorder, not elsewhere classified), alcohol dependence disorder (303 alcohol dependence syndrome), illicit drug abuse disorder (304 drug dependence), tobacco use (305.1 tobacco use disorder or V15.82 history of tobacco use), PTSD (309.81 posttraumatic stress disorder), HIV (042 HIV), and suicidal ideation or attempt (E950–E959) including various forms of self-inflicted injuries or V62.84 suicidal ideation.
We conducted 2 sets of analyses. First, we characterized and compared the crude prevalence of all sociodemographic and medical condition variables across the 3 categories of rural status using χ2 (and the Fishers exact tests where cell sizes were <5 observations). Because of the number of statistical tests comparing the prevalence of sociodemographics and prevalence of medical conditions, we report the exact P-values for each test. Second, to assess the independent associations of rural status with medical conditions, we conducted seven individual, multivariable logistic regression analyses adjusted for sociodemographic characteristics. We set urban status as the reference category in all analyses. We report all regression estimates as adjusted odds ratios (aOR) with 95% confidence intervals (CI) and assessed statistical significance for all multivariable analyses at P<0.05. Because of the exploratory nature of the analyses, we also denoted covariates that were significant at P<0.10 in the multivariable analyses. All analyses were conducted using Stata SE Version 13 (College Station, TX).
A total of 6308 veterans with transgender-related diagnoses were identified, of whom 179 (2.8%) could not be assigned a Rural-Urban Commuter Area designation to define rural status and were subsequently omitted from analysis. The largest portion of missing data occurred in race [n=642 (10.2%)] and in ethnicity [n=792 (12.5%)], with 377 (6.0%) of patients missing both race and ethnicity data. Rural status was not significantly related to the proportion of patients missing data on their race (χ2=2.24, P=0.33) or the proportion of patients missing data on their ethnicity (χ2=5.33, P=0.07). Consequently, we omitted individuals who were missing racial and ethnic data, leaving an analytic sample of 5072 veterans with transgender-related diagnoses.
Most veterans with transgender-related diagnoses were classified as residing in an urban area (88.1%), followed by large rural city/town (6.2%), and small/isolated rural town (5.6%). Table 1 shows differences in sociodemographic characteristics and health conditions by place of residence. Veterans with transgender-related diagnoses residing in a small/isolated rural town were older than their urban counterparts. For example, 51.4% of veterans with transgender-related diagnoses residing in a small/isolated rural town were 60 years of age or older compared with 45.1% of veterans with transgender-related diagnoses residing in an urban area (P=0.05). Compared with their urban peers, veterans with transgender-related diagnoses residing in large rural city/towns or small/isolated rural towns were significantly more likely to be white (91.7% and 90.9% vs. 83.4%) and married (29.4% and 27.6% vs. 22.6%) and significantly less likely to have ever experienced housing instability (23.4% and 23.1% vs. 29.4%). Finally, 51.4% of veterans with transgender-related diagnoses residing in a small/isolated rural town had ever received a tobacco use disorder diagnosis compared with 44.3% of veterans with a transgender-related diagnoses residing in an urban area (P=0.03).
Table 2 illustrates associations of rural residence with lifetime diagnosis of medical conditions. After adjusting for age, sex, race, ethnicity, military sexual trauma, housing instability, and marital status, veterans with transgender-related diagnoses residing in small/isolated rural towns had increased odds of lifetime diagnosis of tobacco use disorder (aOR=1.39; 95% CI, 1.09–1.78) and lifetime diagnosis of PTSD (aOR=1.33; 95% CI, 1.03–1.71) compared with their urban peers. Urban/rural status was not significantly associated with lifetime diagnosis of mood disorder, alcohol abuse disorder, illicit drug abuse disorder, suicidal ideation or attempt, or HIV diagnoses. Finally, the sociodemographic covariates of housing instability and military sexual trauma were significantly associated with all outcomes except HIV-positivity when controlling for place of residence.
Our study addresses gaps identified in the National Academy of Medicine report10 and helps advance the VA’s goal of achieving equity in health and health care irrespective of gender25 by exploring how current rural status was associated with lifetime diagnoses of mood disorders, PTSD, alcohol abuse disorder, illicit drug abuse disorder, tobacco use disorder, HIV, or suicidal risk among veterans with transgender-related diagnoses. Primary findings include: (1) significant differences in prevalence of lifetime diagnosis of PTSD and tobacco use disorder exist between veterans with transgender-related diagnoses who currently reside in urban areas and those who currently reside in a small/isolated rural town; (2) the data did not support the hypotheses that urban/rural status would be significantly associated with lifetime diagnosis of mood disorder, alcohol abuse disorder, illicit drug abuse disorder, suicidal ideation or attempt, and HIV prevalence among veterans with transgender-related diagnoses; and (3) housing instability and military sexual trauma were significantly associated with all outcomes except HIV-positivity when controlling for place of residence.
Veterans with transgender-related diagnoses living in small/isolated rural towns were significantly more likely to have been diagnosed with PTSD in their lifetime than their urban counterparts, which aligns with previous research showing that, generally, PTSD diagnoses are more common among rural than urban veterans.35 However, the etiology of these differences is unclear. On one hand, veterans with transgender-related diagnoses living in rural areas may be more exposed to stressors/traumas related to social stigma against transgender identities while simultaneously having decreased access to protective factors (eg, transgender community involvement, friendships with other transgender people).36 However, qualitative evidence among a sample of transgender men suggests that transgender individuals residing in rural areas are not as isolated or shunned as conventional lore may suggest, and, in fact, may experience some degree of acceptance through a shared experience of being from a specific community or strong close ties to kinship or families of choice.37 Therefore, another interpretation is that trauma exposures and associated PTSD may have occurred outside of the rural setting (eg, during military service), and veterans with PTSD, regardless of their transgender status, may move to rural settings to avoid PTSD triggers. Even so, veterans with transgender-related diagnoses may face increased social stressors and decreased access to protective factors after relocating to rural areas which could further compound their PTSD.36 Further research is needed with more nuanced and detailed inquiry to operationalize these constructs as mediators or moderators of health outcomes among transgender populations.
In addition to PTSD, lifetime diagnosis of tobacco use disorder appeared to be more prevalent among rural than urban veterans with transgender-related diagnoses. Given the high prevalence of tobacco use disorder among veterans with transgender-related diagnoses living in small/isolated rural towns (51.4%), the development of accessible, culturally tailored tobacco cessation programs should be a top priority in this population. Because of their place of residence, veterans with transgender-related diagnoses residing in small/isolated rural towns may have difficulty accessing tobacco cessation resources,38,39 and if resources are available, they may need to be tailored to transgender consumers in ways analogous to how tobacco cessation has been tailored for sexual minority populations.40,41 Although the VA has undertaken national efforts around smoking cessation that could address rural smoking for interested veterans,42 to our knowledge no studies have examined if and how veterans with transgender-related diagnoses receive tobacco cessation treatment through their VA service utilization.
The lack of significant rural-based differences among our sample is a notable finding itself as previous research of VA patients in general have shown rural patients have a lower likelihood of substance use disorder diagnoses but higher likelihood of depression and anxiety diagnoses compared with urban patients.35 It is unclear if the lack of statistically significant associations of rural status with lifetime diagnosis of most medical diagnoses reflects a “true” equivalence of lifetime diagnosis of medical conditions among urban and rural veterans with transgender-related diagnoses, suggesting that some disparities among transgender Veterans are evident across rural-urban strata. Or, if the lack of urban-rural differences may have resulted from limited statistical power due to the relatively scarce number of veterans with transgender-related diagnoses residing in rural areas.
The small number of rural veterans with transgender-related diagnoses is a challenge for future research for at least 2 reasons. First, it is unclear if the scarcity of rural veterans with transgender-related diagnoses is due to systemic underdiagnosis in rural areas because of lack of awareness among providers, or to veterans with transgender-related diagnoses choosing to live in urban areas instead of rural areas, or to both scenarios. Second, the VA Electronic Health Records (EHR) does not contain data fields in which patients can self-report their sex identity, thus transgender veterans without Gender Identify Disorder related diagnosis codes cannot be identified and counted. Systematic collection of sex identity from patients willing to provide such information is one way to help overcome these problems.43 The addition of self-reported sex identity data with VA EHR would not only help epidemiologic investigations, but it would also facilitate development of intervention and implementation research efforts by producing greater and more robust samples of transgender veterans. For example, the VA has recently implemented systems-level programs to improve transgender health care delivery,44,45 which may provide serendipitous “natural experiment” opportunities for health services researchers to further examine the impact of rural and urban settings. However, these research opportunities will continue to be hampered by the lack of self-reported sex identity data from patients.
Finally, it is important to note that, irrespective of rural/urban status, housing instability and military sexual trauma were associated with increased odds of all health outcomes except HIV-positivity among veterans with transgender-related diagnoses. These findings may suggest the VA could advance health equity in this population by targeting existing interventions aimed at reducing these health outcomes among veterans with transgender-related diagnoses to those unstably housed and/or with a history of military sexual trauma. In addition, the VA may need to tailor existing programs aimed at reducing housing instability and experiences of military sexual trauma among veterans to meet the unique needs of veterans with transgender-related diagnoses. For example, the VA’s Housing and Urban Development-VA Supportive Housing (HUD-VASH) Program, which provides VA veterans experiencing homelessness with rental vouchers for privately owned housing, may be ineffective for veterans with transgender-related diagnoses.46 Because the Fair Housing Act does not specifically prohibit housing discrimination based on sex identity,47 veterans with transgender-related diagnoses can be evicted from privately owned housing due to their transgender status. Courts have only recently ruled that the Fair Housing Act includes protection for lesbian gay bisexual transgender individuals,48 but locally or regionally litigated cases do not equate general, nationally accepted protection.
Several study limitations must be noted. First, because of the study design, we are unable to assess the etiology of health outcomes. Therefore, it is unclear whether urban/rural status precede or follow diagnosis of our health outcomes of interest. Relatedly, because VA does not retain historical addresses we were unable to assess whether veterans may have moved between urban and rural areas over the course of their receipt of VA health care. Moreover, these results are not generalizable to all rural veterans with transgender-related diagnoses as our cohort consisted of only those veterans who utilized VA health care. Although the use of ICD-9 codes for medical conditions is a strength of the study, because they are provider-based diagnoses, sole reliance on the presence or absence of ICD-9 diagnosis codes does not allow for more nuanced examination of indicators of health (eg, depressive symptoms that may not meet the diagnostic threshold for depression). Also, our study focused on the rural designation of the veteran’s place of residence which may differ from the rural designation of the VA medical facility through which they receive their care. Future research is needed to explore whether differences may occur based on the facility location (eg, rural veterans who travel to urban centers vs. rural veterans who receive care from rural centers).
Transgender status was assessed using lifetime diagnosis of any of 4 ICD-9 diagnosis codes associated with transgender status because self-identified transgender status is not yet available in VA administrative data. This could cause misclassification bias as not all persons with and ICD-9 diagnosis code may self-identify as transgender and not all transgender-identified people have ICD-9 diagnosis codes in their medical records. Also, without self-identity, we could not ascertain or examine the heterogeneity among the transgender population, for example, the differences between transgender men and transgender women. Because previous research has found rural/urban differences vary for transgender women and transgender men,17 grouping all veterans with transgender-related diagnoses may generalize differences seen in one group to all veterans with transgender-related diagnoses. Therefore, future research should explore whether rural/urban differences are concentrated within one of these groups or are experienced by all veterans with transgender-related diagnoses.
This study contributes one of the first empirical investigations of how place of residence is associated with health among veterans with transgender-related diagnoses. The importance of place as a determinant of health is increasingly clear,49 but for transgender individuals, this research is currently very limited. Our findings suggest that rural veterans with transgender-related diagnoses are more likely to have been diagnosed with tobacco use disorder and PTSD. However, given the limitations of our study, future research with more nuanced and detailed inquiry to operationalize these constructs as mediators or moderators of health outcomes among transgender populations is needed. The addition of self-reported sex identity data within VA EHR is one way to advance this future research agenda and health equity among transgender veterans by facilitating epidemiologic and intervention research.
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