Mental Health of Transgender Veterans in US States with and without Discrimination and Hate Crime Legal Protection

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Original Publication

American Journal of Public Health (2016); 106(3), 534-540.

Publication Date – June 24, 2016

Publication Type – Peer-Reviewed Journal Article


Adam J. Gordon, M.D., M.P.H. – Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
George R. Brown, M.D. – Mountain Home VA Medical Center
Jillian C. Shipherd, Ph.D. – VA Boston Healthcare System
John Blosnich, Ph.D., M.P.H. – Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
Mary C. Marsiglio, Ph.D. – Mental Illness Research Education and Clinical Center, Portland VA Medical Center
Michael J. Fine, M.D. – Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
Michael Kauth, Ph.D. – VA Office of Patient Care Services, Department of Veterans Affairs
Sasha Gao, Ph.D. – Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System


Research Highlights

• Transgender individuals represent one of the most marginalized populations in both civilian and military communities. The VA has a higher prevalence of transgender individuals than the U.S. general population, and this study examines whether indicators of community- and state-level lesbian, gay, bisexual, and transgender (LGBT) equality are associated with mental health-related diagnoses among transgender veterans using Veterans Affairs (VA) care.

• There were no differences in the prevalence of mental health diagnoses between transgender patients who did and did not live in states with hate crime laws that included transgender status or gender identity. However, transgender patients who lived in states with employment nondiscrimination protection had a significantly lower prevalence of mood disorders (54% vs 46%; p<.01) and of self-directed violence (6.3% vs 4%; p=.04) than did transgender patients who lived in states without employment nondiscrimination protection.

• This study suggests that policies that protect transgender individuals from employment discrimination are associated with better mental health. Providers and healthcare systems serving transgender veterans should be cognizant of social environmental factors (e.g., discriminatory laws) that may affect mental health, particularly suicidal risk.


Objectives: To examine whether indicators of community- and state-level lesbian, gay, bisexual, and transgender equality are associated with transgender veterans’ mental health. Methods: We extracted Veterans Administration data for patients who were diagnosed with gender identity disorder, had at least 1 visit in 2013, and lived in a zip code with a Municipality Equality Index score (n = 1640). We examined the associations of whether a state included transgender status in employment nondiscrimination laws and in hate crimes laws with mood disorders; alcohol, illicit drug, and tobacco use disorders; posttraumatic stress disorder; and suicidal ideation or attempt. Results: Nearly half (47.3%) of the sample lived in states with employment discrimination protection, and 44.8% lived in states with hate crimes protection. Employment nondiscrimination protection was associated with 26% decreased odds of mood disorders (adjusted odds ratio [AOR] = 0.74; 95% confidence interval [CI] = 0.59, 0.93) and 43% decreased odds of self-directed violence (AOR = 0.57; 95% CI = 0.34, 0.95). Conclusions: Understanding lesbian, gay, bisexual, and transgender social stressors can inform treatment and care coordination for transgender populations.”


For Practice

Given that transgender veterans can experience unique stress from discrimination, medical providers serving transgender veterans should consider evaluating their patients’ mental health. If the medical provider finds that a transgender veteran exhibits signs of a mental health illness, such as a mood disorder or depressive symptoms, the provider should recommend further medical services, including therapy or counseling. Employers should continue encouraging a safe and welcoming environment for all employees, including individuals who identify as transgender. Family members of transgender individuals should remain supportive.

For Policy

Because U.S. military veterans experience higher risks for health disparities than civilians, the VA might continuing making strides to address the healthcare-related needs of veterans. Given that transgender individuals represent one of the most marginalized populations, the VA should continue and bolster its system-wide approaches to clinical education and training programs about transgender health care. Policymakers might continue efforts to reduce discrimination based on sexual orientation and gender identity. Policymakers residing in states without discrimination and hate crime protection laws might consider introducing bills to protect LGBT persons.

For Future Research

Despite the contributions of this study, there are several limitations. Since the data was cross-sectional, variables associated with mental health outcomes cannot be interpreted as causal. Future researchers should use longitudinal data to test causality. A limitation of this study is that it might not be generalizable to patients with gender identity disorder (GID) who live in rural areas. In addition to capturing transgender veterans who reside in cities, future studies should sample transgender veterans who live in rural and suburban areas. Another limitation of this study is that the sample was solely from the VA. Future researchers should include veterans who do not utilize the VA health system. This study is limited by the VA data not containing self-identified transgender status, and transgender status on the basis of an ICD-9 diagnosis code of GID. The lack of self-identifiable transgender status and ICD-9 diagnosis could have led to potential misclassification bias and them being excluded in this study. To reduce this potential bias and exclusion in future studies, researchers should use data that includes self-identified transgender status. In this study mental health outcomes were determined by a patient being treated in either an inpatient or outpatient visit. To ensure a more nuanced mental health status is detected, future researchers should include self-reported data on mental health. Another limitation of this study is that it only included diagnosis codes for depression and mood disorders. Future research is needed to explore additional mental health diagnoses, such as anxiety.

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