Purpose: The aims of this project were to document all-cause and suicide mortality among Veteran Healthcare Administration (VHA) utilizers with The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis consistent with transgender status. Methods: The study population consisted of VHA patients identified as having any one of four diagnosis codes indicating transgender status (n=5,117) gathered from the VA National Patient Care Database. Mortality data were gathered from the National Death Index from 2000-2009 for 1,277 veterans with transgender-related ICD-9-CM diagnoses. The remaining 3,840 were not searched because they had VHA utilization after 2009 (indicating they were alive). Person-time at risk (person-years) for crude rates were calculated based on the time from an individual's index diagnosis to either death or the end of FY 2009. Causes of death were categorized using ICD-10 code groups. Results: Approximately 9.3% (n=309) veterans with transgender-related ICD-9-CM diagnoses died across the study period. Although diseases of the circulatory system and neoplasms were the first and second leading causes of death, respectively, the other ranked causes of mortality differed somewhat from patterns for the US during the same time span. The crude suicide rate among veterans with transgender-related ICD-9-CM diagnoses across the 10-year period was approximately 82/100,000 person-years, which approximated the crude suicide death rates for other serious mental illness in VHA (e.g., depression, schizophrenia). The average age of suicide decedents was 49.4 years. Conclusion: The crude suicide rate among veterans with transgender-related ICD-9-CM diagnoses is higher than in the general population, and they may be dying by suicide at younger ages than their veteran peers without transgender-related ICD-9-CM diagnoses. Future research, such as age-adjusted rates or accounting for psychiatric co-morbidities, will help to better clarify if the all-cause and suicide mortality rates are elevated for veterans with transgender-related ICD-9-CM diagnoses.

Claims of inadequate health care and safety afforded to transgender inmates have become the subject of litigation. This article reviews 129 unsolicited letters from transgender inmates writing from 24 states and the Federal Bureau of Prisons to identify their concerns. Among the letters reviewed were reports from 10 inmates who had filed lawsuits naming departments of correction (DOCs) as defendants, claiming inadequate access to transgender health care. Five of these lawsuits have gone to trial. In all of those cases, the defendant settled the matter or was found liable as of the time of this report. Claims of inadequate care for transgendered patients that have sufficient merit to be fully litigated in U.S. courts appear likely to produce verdicts in favor of plaintiff inmates. The information gleaned from reviewing letters from transgendered inmates may alert staffs of DOCs to concerns worth addressing proactively to avoid the costs associated with transgender-related lawsuits.

The objective of this study was to examine the voices of male-to-female (MtF) transgender veterans and biological females that can result in identification or misidentification of biological gender. Twenty-one MtF transgender veterans and 9 cis-gender females were enrolled. The interaction of speaking fundamental frequency (SFo) and formant (resonatory) frequencies in gender discrimination was investigated. The results indicated that an average SFo above 180 Hz and maintaining a speaking pitch range of approximately 140 to 300 Hz appear to be the most powerful acoustic features or markers in the perception of a female voice in a biological male (M. L. Brown & Rounsley, 1996). An SFo of approximately 170 Hz appears to be the lower limit that would result in a biological male being perceived as having a female voice by most listeners. A slight elevation in the second (F2) and third (F3) formants was noted but does not appear to have a significant influence in the perception of a female voice in biological males. Female voices appear to be perceived as male by most listeners if average SFo is at or below 165 Hz, the low SFo is below 130 Hz, and a low F3 is exhibited. No evidence was found that jitter (frequency perturbation) and shimmer (amplitude perturbation) affect the perception of a female or male voice in a biological male. The results support previous research that elevated pitch is the strongest acoustic marker in the perception of a female voice in biological males.

Mental health professionals who work with transgender clients often report feeling unsupported by colleagues and/or the institutions that employ them. Moreover, family members of transgendered clientsmay aggress against the therapist, whom they see as assisting their family member in this shame-producing gender transition. To test the prevalence of direct and indirect acts of aggression against therapists who work with transgendered clients, a questionnaire was sent to members who work with this population. Results show that while threats and/or assaults from families of transgendered patients do occur, they are no more frequent than assaults perpetuated by relatives of non-transgendered clients. However, health care providers who work with this population are more likely to experience prejudice or administrative aggression from within mental health systems.

This study describes the largest population of veterans referred for a gender identity disorder (GID) evaluation. Most were self-referred, others were referred by their commanding officer. A search of the English language literature revealed no similar studies on veterans other than a pilot project by the second author. Methods: Retrospective descriptive data were obtained from chart reviews of 70 U.S. veterans who were evaluated by the second author for gender disturbances over a 20-year period (1987 to 2007). The modal veteran with gender identity disturbance was a natal male (91%) identifying as female, >40 years old, Caucasian, employed, with more than 12 years of education. Fifty-seven percent were parents with a history of sexual involvement with opposite sex individuals. Histories of autogynephilia were not elicited in vets interviewed since 1997. Classic "flight into hypermasculinity" was described by a majority of the natal male vets as a retrospective understanding of why they joined the military. Psychiatric comorbidities (43%) included post traumatic stress disorder (PTSD), depression, schizophrenia (N = 1), substance use disorders (17%), dissociative identity disorder (N = 1), and personality disorders (11%). Ninety-three percent met criteria for diagnosis of GID or GID not otherwise specified; suicidal ideation was reported by 61% with one or more suicide attempts by 11% of 56 responding; and 4% reported genital self-harm. Although 11% expressed active thoughts of surgical self-treatment, most expressed a desire for physician-performed sex reassignment surgery (SRS). Cross-dressing behaviors were common, and currently reported arousal with cross-dressing was reported by 13%, 63% of whom were not diagnosed with GID. Conclusion: Veterans often reported that they joined the military in an attempt to purge their transgender feelings, believing the military environment would "make men" of them. Most were discharged before completing a 20-year career. More than half received health care at veterans affairs medical centers, often due to medical or psychiatric disabilities incurred during service. Comorbid Axis I diagnoses were common, as were suicidal thoughts and behaviors.

It is well known that clients occasionally threaten or assault their therapists. No studies to date have attempted to systematically measure client aggression by transgender patients towards clinicians. One of the major questions of this study was to determine if clients with gender dysphoria have greater levels of aggression towards therapists than non-gender dysphoric clients. One hundred and fourteen professional therapists who are members of the Harry Benjamin International Gender Dysphoria Association responded to a questionnaire that addressed aggression by both transgender and non-transgender clients. Transgender clients were shown to commit significantly less acts of aggression than did non-transgendered clients (p = 0.0094). Within the relatively small subgroup of transgender clients that did commit acts of aggression, male-to-female transgender clients were significantly more likely to do so than female-to-male clients (p = 0.002). While the transgendered client undergoes significant suffering in violating inviolable gender boundaries, this suffering, in general, does not translate into acting out behaviors directed towards their therapists.

Background: The association between early childhood abuse and the course of illness, including psychiatric comorbidities, in adults with bipolar disorder has not been examined in a predominantly male or veteran population. Methods: As part of the VA Cooperative Study 430, "Reducing the Efficacy-Effectiveness Gap in Bipolar Disorder," 330 veterans (91% male) with bipolar I or II disorder who were enrolled in a 3-year prospective study were examined for baseline data obtained at study entry. Diagnoses were determined by the use of the SCID. A semistructured interview designed to elicit data about exposure to childhood physical, sexual, or combined abuse was conducted as part of baseline demographic and clinical information. Other reports from this data set have not addressed the issues of childhood adversity. Results: Childhood abuse was reported by 48.3% of the subjects (47.3% of men). Any abuse (AA) was reported by 48.3%; sexual abuse without physical abuse (SA) was reported by 8%, physical abuse without sexual abuse (PA) by 20.7%, and both types of abuse (combined abuse, CA) by 18.7% of the male subjects. Female veterans reported more SA (27%) and less PA (6.7%). AA subjects were more likely to have current PTSD and lifetime diagnoses of panic disorder and alcohol use disorders. CA was associated with lower SF-36 Mental scores, higher likelihood of current PTSD and lifetime diagnoses of alcohol use disorders, as well as more lifetime episodes of major depression and higher likelihood of at least one suicide attempt. Younger age at study entry was associated with AA and PA. Limitations: Potential limitations include generalizability beyond the male, veteran population of patients with bipolar disorder and the methodology used to elicit abuse histories. Conclusions: Similar to studies of predominantly female nonveteran samples, this study extends the finding that a history of childhood abuse acts as a disease course modifier in male veterans with bipolar disorder. Clinicians should routinely seek information regarding abuse and be aware that these patients may be more difficult to treat than bipolar patients who have no abuse histories.

Purpose: This study examines the differences in suicide, homicide, and all-cause mortality between transgender and cisgender Veterans Health Administration (VHA) patients. Methods: VHA electronic medical record data from October 1, 1999 to December 31, 2016 were used to create a sample of transgender and cisgender patients (n = 32,441). Cox proportional hazard regression was used to evaluate differences in survival time (date of birth to death date/study end). Death data were from the National Death Index. Results: Transgender patients had more than twofold greater hazard of suicide than cisgender patients (adjusted hazard ratio [aHR] = 2.77, 95% confidence interval [CI] = 1.88-4.09), especially among younger (18-39 years) (aHR = 3.35, 95% CI = 1.30-8.60) and older (‡65 years) patients (aHR = 9.48, 95% CI = 3.88-23.19). Alternatively, transgender patients had an overall lower hazard of all-cause mortality (aHR = 0.90, 95% CI = 0.84-0.97) compared with cisgender patients, which was driven by patients 40-64 years old (aHR = 0.78, 95% CI = 0.72-0.86) and reversed by those 65 years and older (aHR = 1.17, 95% CI = 1.03-1.33). Conclusion: Transgender patients' hazard of suicide mortality was significantly greater than that of cisgender VHA patients.

Objectives: Research shows transgender individuals experience pronounced health disparities compared with their nontransgender peers. Yet, there remains insufficient research about health differences within transgender populations. This study seeks to fill this gap by exploring how current urban/rural status is associated with lifetime diagnosis of mood disorder, alcohol dependence disorder, illicit drug abuse disorder, tobacco use, posttraumatic stress disorder, human immunodeficiency virus, and suicidal ideation or attempt among veterans with transgender-related diagnoses. Methods: This study used a retrospective review of The Department of Veterans Affairs (VA) administrative data for transgender patients who received VA care from 1997 through 2014. Transgender patients were defined as individuals that had a lifetime diagnosis of any of 4 International Classification of Diseases-9 diagnosis codes associated with transgender status. Independent multivariable logistic regression models were used to explore associations of rural status with medical conditions. Results: Veterans with transgender-related diagnoses residing in small/isolated rural towns had increased odds of tobacco use disorder (adjusted odds ratio=1.39; 95% confidence intervals, 1.09-1.78) and posttraumatic stress disorder (adjusted odds ratio=1.33; 95% confidence intervals, 1.03-1.71) compared with their urban transgender peers. Urban/rural status was not significantly associated with other medical conditions of interest. Conclusions: This study contributes the first empirical investigations of how place of residence is associated with medical diagnoses among veterans with transgender-related diagnoses. The importance of place as a determinant of health is increasingly clear, but for veterans with transgender-related diagnoses this line of research is currently limited. The addition of self-reported sex identity data within VA electronic health records is one way to advance this line of research.

No description available.