Kerry B. O’Leary, MD, MPHa; Marco Marcelli, MDa,b Correspondence: Kerry O’Leary (kerry.o’leary@bcm.edu)
aBaylor College of Medicine, Houston, Texas bMichael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
Author disclosures
The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Most of the studies included reported that transgender veterans have statistically significant worse mental health outcomes compared with cisgender veterans.28-30 In addition, transgender active-duty service members were found to have worse mental health outcomes than cisgender active-duty service members.31 MST and discrimination were associated with worse mental health outcomes among transgender veterans.32,33 One study showed a different result than others and found that transgender older adults with prior military service had higher psychological health-related quality of life and lower depressive symptoms than those without prior military service (P = .02 and .04, respectively).34 Another study compared transgender veterans with active-duty service members and found that transgender veterans reported higher rates of depression (64.6% vs 30.9%; χ2 = 11.68; P = .001) and anxiety (41.3% vs 18.2%; χ2 = 6.54; P = .01) compared with transgender service members.35
Suicidality and Self-harm
Eleven of the 19 studies included measured suicidality and/or self-harm as an outcome. Transgender veterans and active-duty service members were found to have higher odds of suicidality than their cisgender counterparts.16,28,29,31 In addition, transgender veterans may die by suicide at a younger age than cisgender veterans.36 Stigma and gender-related discrimination were found to be associated with suicidal ideation.33,37-39 Transgender veterans were less likely than transgender nonveterans to report nonsuicidal self-injury (NSSI).40
Substance Use
Two studies focused on substance use, while 5 other studies included substance use in their measures. One of these 2 studies that focused only on substance use outcomes found that transgender veterans were more likely than cisgender veterans to have any SUD (7.2% vs 3.9%; P < .001), in addition to specifically cannabis (3.4% vs 1.5%; P < .001), amphetamine (1.1% vs 0.3%; P < .001), and cocaine use disorders (1.5% vs 1.1%; P < .001).41
Another study reported that transgender veterans had lower odds of self-reported alcohol use but had greater odds of having alcohol-related diagnoses compared with cisgender veterans.42 Of the other studies, it was found that a higher percentage of transgender veterans were diagnosed with an SUD compared with transgender active-duty service members, and transgender veterans were more likely than cisgender veterans to be diagnosed with alcohol use disorder.29,31 Additionally, rural transgender veterans had increased odds of tobacco use disorder compared with transgender veterans who lived in urban areas.43
Military Sexual Trauma
Five of the studies included examined MST, defined as sexual assault or sexual harassment that is experienced during military service.44 Studies found that 15% to 17% of transgender veterans experienced MST.32,45 Transgender veterans were more likely to report MST than cisgender veterans.28,29 MST was found to be consistently associated with depression and PTSD.32,45 A high percentage (83.9%) of transgender active-duty service members reported experiencing sexual harassment and almost one-third experienced sexual assault.46
Discussion
Outcomes examined in this review included MST, substance use, suicidality, and symptoms of depression, anxiety, and PTSD among transgender active-duty service members and veterans. To our knowledge, no other review on this topic exists. There is a review of the health and well-being of LGBTQ veterans and service members, but a majority of the included studies did not separate transgender individuals from LGB persons.17 This review of transgender individuals showed similar results to the review of LGBTQ individuals.17 This review also presented similar results to previous studies that indicated that transgender individuals in the general population have worse mental health outcomes compared with their cisgender counterparts, in addition to studies that showed that veterans and active-duty service members have worse mental health outcomes compared with civilians and nonveterans.1-5 The population of focus in this review faced a unique set of challenges, being that they belonged to both of these subsets of the population, both of which experienced worse mental health outcomes, according to the literature.
Studies included in our review found that transgender veterans and service members have worse mental health outcomes than cisgender veterans and service members.28-31 This outcome was predicted based on previous data collection among transgender individuals, veterans, and active-duty service members. One of the studies included found different results and concluded that prior military service was a protective factor against poorer mental health outcomes.34 This could be, in part, due to veterans’ access to care through the US Department of Veterans Affairs (VA) system. It has been found that transgender veterans use VA services at higher rates than the general population of veterans and that barriers to care were found more for medical treatment than for mental health treatment.47 One study found that almost 70% of transgender veterans who used VA services were satisfied with their mental health care.48 In contrast, another study included in our review found that transgender veterans had worse mental health outcomes than transgender service members, possibly showing that even with access to care, the burden of stigma and discrimination worsens mental health over time.31 Although it has been shown that transgender veterans may feel comfortable disclosing their gender identity to their health care professional, many barriers to care have been identified, such as insensitivity and lack of knowledge about transgender care among clinicians.49-51 With this information, it would be useful to ensure proper training for health care professionals on providing gender-affirming care.
Most of the studies also found that transgender veterans and service members had greater odds of suicidal thoughts and events than cisgender veterans and service members.16,28,29,35 On the contrary, transgender veterans were less likely than transgender nonveterans to report NSSI, which could be for various reasons.40 Transgender veterans may report less NSSI but experience it at similar rates, or veteran status may be a protective factor for NSSI.
