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Final Research Report PATIENT-CENTERED OUTCOMES RESEARCH INSTITUTE FINAL RESEARCH REPORT Examining Health Outcomes for People Who Are Transgender Michael Goodman, MD, MPH; Rebecca Nash, MPH AFFILIATION: Emory University School of Public Health, Atlanta, Georgia Original Project Title: Comparative Risks and Benefits of Gender Reassignment Therapies PCORI ID: AD-12-11-4532 HSRProj ID: 20143115 _______________________________ To cite this document, please use: Goodman M, Nash R. (2019). Examining Health Outcomes for People Who Are Transgender. Patient-Centered Outcomes Research Institute (PCORI). https://doi.org/10.25302/2.2019.AD.12114532 TABLE OF CONTENTS ABSTRACT .............................................................................................................................. 6 BACKGROUND ........................................................................................................................ 8 Transgender Health Issues and Knowledge Gaps ...................................................................... 8 Methodological Challenges Facing Transgender Health Studies ............................................. 10 Introducing Study of Transition, Outcomes, and Gender ........................................................ 11 Table 1. STRONG Project Timeline .................................................................................... 12 STAKEHOLDER INVOLVEMENT ............................................................................................... 13 Preliminary Survey ................................................................................................................... 13 Stakeholder Advisory Group .................................................................................................... 14 Table 2. Composition of the STRONG Stakeholders Advisory Group ............................... 15 Online Focus Groups ................................................................................................................ 16 METHODS .............................................................................................................................. 19 Overall Study Structure and Objectives ................................................................................... 19 EMR-Based Study at Kaiser Permanente ................................................................................. 21 Figure 1. STRONG Transgender Cohort Ascertainment Flow Diagram ............................. 23 Table 3. ICD-9 Codes and Keywords Used to Identify Potentially Eligible STRONG Transgender Cohort Members Among Kaiser Permanente Members in Georgia, Northern California, and Southern California ................................................................... 24 Table 4. Keywords Used for STRONG Transgender Cohort Natal Sex Assignment ........... 26 Survey of Kaiser Permanente Cohort Participants ................................................................... 33 Figure 2. Results of STRONG Survey Recruitment Among Kaiser Permanente Participants ....................................................................................................................... 36 Methods of the VA Study ......................................................................................................... 39 RESULTS ................................................................................................................................ 42 Results of Kaiser Permanente EMR Cohort Analyses ............................................................... 42 Figure 3. Results of STRONG Transgender Cohort Ascertainment and Validation ........... 43 Figure 4. Prevalence of Transgender Status by Site and Year of Kaiser Permanente Health Plan Enrollment ..................................................................................................... 44 Table 5. Characteristics of the STRONG Kaiser Permanente Transgender Cohort ............. 46 Table 6. Gender Affirmation Status of the STRONG Kaiser Permanente Transgender Cohort Members .......................................................................................... 48 2 Figure 5. Incidence of VTE, IS, and MI Among TF Cohort Members Overall (A-C) and TF Members Who Initiated Estrogen Therapy After the Index Date (D-F) Compared With Matched Reference Cohorts ................................................................... 49 Table 7. Incidence Rates and Adjusted Hazard Ratios for Acute Cardiovascular Events Among TF STRONG Kaiser Permanente Cohort Members Compared With Matched Reference Cohorts (2006-2016) ......................................................................... 51 Figure 6. Incidence of VTE, IS, and MI Among TM Cohort Members Overall (A-C) Compared With Matched Reference Cohorts .................................................................. 52 Table 8. Incidence Rates and Adjusted Hazard Ratios for Acute Cardiovascular Events Among TM STRONG Kaiser Permanente Cohort Members to Matched Reference Cohortsa (2006-2016) ....................................................................................... 53 Table 9. Cancer Incidence Rates and Adjusted Hazard Ratios for TF and TM STRONG Kaiser Permanente Cohort Participants Aged ≥18 Years at Index Date Compared With Matched Referent Males and Femalesa ................................................. 55 Table 10. Prevalence of Mental Health Conditions in TF Children Aged 3 to 9 Years Relative to Referent Groups in the STRONG Kaiser Permanente Cohort ............... 56 Table 11. Prevalence of Mental Health Conditions in TM Children Aged 3 to 9 Relative to Referent Groups in the STRONG Kaiser Permanente Cohort ......................... 57 Table 12. Prevalence of Mental Health Conditions in TF Children Aged 10 to 17 Years Relative to Referent Groups in the STRONG Kaiser Permanente Cohort ................. 59 Table 13. Prevalence of Mental Health Conditions in TM Children Aged 10 to 17 Years Relative to Referent Groups in the STRONG Kaiser Permanente Cohort ............... 61 Table 14. Prevalence of Hospitalizations for Mental Health Conditions Among TF Children Aged 10 to 17 Years Relative to Referent Groups in the STRONG Kaiser Permanente Cohort .......................................................................................................... 63 Table 15. Prevalence of Hospitalizations for Mental Health Conditions Among TM Children Ages 10 to 17 Years Relative to Referent Groups in the STRONG Kaiser Permanente Cohort .......................................................................................................... 65 Table 16. Prevalence of Mental Health Conditions Among TF Adults (≥18 Years of Age) Relative to Referent Groups in the Kaiser Permanente STRONG Cohort .................. 68 Table 17. Prevalence of Mental Health Conditions Among TM Adults (≥18 Years of Age) Relative to Referent Groups in the STRONG Kaiser Permanente Cohort ................. 70 Table 18. Prevalence of Hospitalization for Mental Health Conditions Among TF Adults (≥18 Years of Age) Relative to Referent Groups in the STRONG Kaiser Permanente Cohort .......................................................................................................... 72 Table 19. Prevalence of Hospitalization for Mental Health Conditions Among TM Adults (≥18 Years of Age) Relative to Referent Groups in the STRONG Kaiser Permanente Cohort .......................................................................................................... 74 3 Table 20. Prevalence of Most Common Mental Health Conditions Among TF With Keyword Evidence Only Relative to Referent Groups in the STRONG Kaiser Permanente Cohort by Age Group .................................................................................... 76 Table 21. Prevalence of Most Common Mental Health Conditions Among TF With Keyword Evidence Only Relative to Referent Groups in the STRONG Kaiser Permanente Cohort by Age Group .................................................................................... 78 Figure 7. Corrgram Correlation Matrices of Mental Health Conditions Before the Index Date in TF (A) and TM (B) Children, Aged 3-17 Years .............................................. 80 Gender Affirmation and Self-Reported Outcomes in the Kaiser Permanente Survey ............. 81 Figure 8. Corrgram Correlation Matrices of Mental Health Conditions Before the Index Date in TF (A) and TM (B) Adults (Aged ≥ 18) ......................................................... 82 Table 22. Characteristics of the STRONG Survey Participants .......................................... 83 Figure 9. Extent to Which Survey Respondents Perceived Themselves as Male/Female (A, B) and Masculine/Feminine (C, D) Among TF (A, C) and TM (B, C) Individuals (Assuming Gender and Gender Expression Represent a Continuum, Where Would You Place Yourself on the Scales Below at the Present Time?) ................. 85 Figure 10. Extent to Which Survey Respondents Want to Be Male/Female (A, B) and Masculine/Feminine (C, D) Among TF (A, C) and TM (B, D) Individuals (Assuming Gender and Gender Expression Represent a Continuum, Where Do You Want to Be on the Scales Below?) ............................................................................. 86 Figure 11. Extent to Which Survey Respondents Believe Others Perceive Them as a Male/Female (A, B) and Masculine/Feminine (C, D) Among TF (A, C) and TM (B, D) Individuals (Assuming Gender and Gender Expression Represent a Continuum, How Do You Think Others Perceive You on the Scales Below?) ......................................
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