The Health of Gender Minorities. Mark A Schmidt, PhD, MPH HCSRN 2019 Annual Meeting April 9, 2019
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1 The Health of Gender Minorities Mark A Schmidt, PhD, MPH HCSRN 2019 Annual Meeting April 9, Copyright 2018 Kaiser Permanente Center for Health Research
2 SOGI Concepts Gender Identity Innate/internal sense of being male, female, neither, or something else Cisgender Transgender Gender non-conforming/non-binary Estimated US Gender Minority (GM) population size 0.6% (CI 0.36, 0.95); 1.4 million Source: Flores, 2016 Sexual Orientation Relational/external sense of sexual or emotional attraction to members of the same sex, opposite sex, or both sexes. Straight or heterosexual Gay/Lesbian or homosexual Bisexual 2 Copyright 2018 Kaiser Permanente Center for Health Research
3 Background GM thought to exhibit significant health disparities compared to cisgender counterparts; LARGE gaps in the literature remain. 3 Copyright 2018 Kaiser Permanente Center for Health Research
4 Goal and Aims Better characterize the magnitude and breadth of health disparities faced by GM individuals Identify a cohort of GM individuals using the EHR-recorded data elements; Compare a broad spectrum of demographic, clinical, and health care utilization metrics between GM and cisgender individuals 4 Copyright 2018 Kaiser Permanente Center for Health Research
5 Methods Study Population KPNW member or OCHIN patient, years 1 in-person encounter, 1/1/ /31/2017 GM Definition ICD-9/10 code for gender dysphoria; OR Referral for transgender-specific services or 2+ GPC visits (KPNW); OR Self-reported GM identity or discordant sex and GM-related text string (OCHIN). Outcomes Demographic characteristics (race, ethnicity, age) Insurance status, health care utilization, screenings, and vaccinations CMS Chronic Conditions Data Warehouse; all-cause mortality; suicidality; BMI, Tobacco Use 5 Copyright 2018 Kaiser Permanente Center for Health Research
6 Demographic Characteristics Histogram of Age for the combined cohort Race Cisgender n=2,741,293 N (%) GM n=7,297 N (%) White 1,833,295 (66.9) 5,401 (74.0) Black 376,320 (13.7) 578 (7.9) 5 4 COHORT_STATUS = Cis Gender Mean: 37.9 Median: 36 IQR: 23, 52 COHORT_STATUS = Gender M inority Mean: 28.8 Median: 26 IQR: 19, 35 Asian 121,078 (4.4) 170 (2.3) AI/AN 21,325 (0.8) 102 (1.4) NH/PI 17,636 (0.6) 37 (0.5) Multiple 26,719 (1.0) 270 (3.7) Percent 3 2 Ethnicity Other/Unknown 344,920 (12.6) 739 (10.1) Non-Hispanic 1,491,764 (54.4) 4,701 (64.4) 1 Hispanic 573,874 (20.9) 904 (12.4) Unknown 675,655 (24.7) 1,693 (23.2) 6 Copyright 2018 Kaiser Permanente Center for Health Research AGE
7 Proportion of population identified as GM, by index date and site 0.50% 0.49% 0.40% 0.40% 0.35% 0.34% 0.30% 0.26% 0.29% 0.29% 0.20% 0.16% 0.21% 0.20% 0.19% 0.22% 0.20% 0.22% 0.10% 0.00% Total 7 Copyright 2018 Kaiser Permanente Center for Health Research KPNW OCHIN
8 Conditions with higher occurrence among gender minority individuals 1 age- and site-adjusted Odds Ratio 8 Copyright 2018 Kaiser Permanente Center for Health Research aor 1 Suicidal Ideation 7.5 (6.7, 8.4) HIV/AIDS 7.2 (6.4, 8.1) Suicide Attempt (Self-harm) 6.1 (4.9, 7.5) Personality disorders 5.8 (5.2, 6.3) PTSD 5.0 (4.7, 5.4) Autism spectrum 5.0 (4.3, 5.8) Depression 4.6 (4.4, 4.8) Anxiety disorders 4.6 (4.4, 4.8) Schizophrenia & other psychotic disorders 3.7 (3.3, 4.1) ADHD 2.6 (2.4, 2.9) Hepatitis C (acute) 2.4 (1.2, 4.8) Asthma 2.4 (2.2, 2.6) Acute myocardial infarction 2.0 (1.2, 3.3) Fibromyalgia & Chronic Pain 1.9 (1.8, 2.1) Drug use disorder 1.9 (1.8, 2.1) Other developmental delays 1.9 (1.5, 2.4) aor 1 Hepatitis C (chronic) 1.8 (1.5, 2.1) Alcohol use disorder 1.8 (1.6, 1.9) Migraine 1.6 (1.5, 1.8) Learning disabilities 1.6 (1.3, 1.9) Pressure/chronic ulcers 1.6 (1.2, 2.2) Tobacco Use Disorder 1.6 (1.4, 1.7) Sensory impairment, deafness/auditory 1.5 (1.3, 1.8) Epilepsy 1.5 (1.8, 1.9) Ischemic Heart Disease 1.3 (1.1, 1.7) Acquired hypothyroidism 1.3 (1.1, 1.5) Hyperlipidemia 1.2 (1.1, 1.3) Obesity (ICD) 1.1 (1.0, 1.2) Anemia 1.1 (1.0, 1.2) Charlson co-morbidity 1 vs (2.6, 3.0) 2 vs (2.2, 2.7) 3+ vs (2.8, 3.2)
9 Health Care Utilization Health Care Utilization 9 Copyright 2018 Kaiser Permanente Center for Health Research aor 1 Outpatient Visits per Year 1.0 (1.0, 1.0) Emergency Department Visits per Year 1.0 (1.0, 1.1) 2 Inpatient Hospitalizations per Year 1.0 (0.8, 1.1) 2 Health Screenings Blood Pressure 1.3 (1.2, 1.5) Cholesterol 2.7 (2.6, 2.8) Colorectal Cancer 1.0 (0.9, 1.1) HbA1c 1.5 (1.4, 1.6) PHQ (2.9, 3.3) (3.8, 4.3) 1 Age- and site-adjusted Odds Ratio 2 Age-adjusted Odds Ratio, KPNW aor 1 Vaccinations Hepatitis A 4.4 (3.8, 5.1) Hepatitis B 2.7 (2.3, 3.1) Human Papillomavirus 1.1 (1.1, 1.2) Influenza 1.4 (1.3, 1.5) Pneumococcal 2.1 (1.9, 2.2) TD/Tdap 1.2 (1.1, 1.3) Meningococcal 0.9 (0.8, 0.9) Herpes zoster 0.9 (0.8, 1.1) Health Status Metrics BMI (0.9, 1.2) (1.0, 1.2) Tobacco Use Yes 1.8 (1.6, 1.9) Quit 1.6 (1.5, 1.8)
10 Discussion Increasing numbers of GM individuals in care or at least disclosing GI status especially since 2015 Identified health disparities are consistent with, but more extensive than, previous literature GM individuals have increased interaction with the health care delivery system and use of preventative health services 10 Copyright 2018 Kaiser Permanente Center for Health Research
11 Limitations Cross-sectional study design GM cohort includes those in care for / disclosing GI status Effect of multiple confounders has not yet been assessed Health care utilization and screening differences ASAB, GI, receipt and duration of hormone therapy 11 Copyright 2018 Kaiser Permanente Center for Health Research
12 Conclusion / Impacts The GM population is small, though with a disproportionate interaction with and impact on the health care delivery system Gender-affirming care involves more than transition-related procedures Need for clinically-competent and appropriate gender-affirming care across the clinical spectrum 12 Copyright 2018 Kaiser Permanente Center for Health Research
13 SOGI data and HCSRN VDW Enrollment and Demographics Short Term Gender Identity Assigned Sex at Birth Administrative/Demographic Sex Longer Term Sexual orientation 13 Copyright 2018 Kaiser Permanente Center for Health Research
14 Acknowledgements KPNW CHR Denis Nyongesa A Gabriela Rosales Tamara Lischka Morgan Fuoco KPNW GPC Erin Waters OCHIN Dagan Wright Allison O Neill Molly Krancari Questions? Mark Schmidt Mark.A.Schmidt@kpchr.org 14 Copyright 2018 Kaiser Permanente Center for Health Research
15 Resources Genderbread person (no copyright) National LGBT Health Education Center NIH SGM Resources Sexual and Gender Minority Research Office: Notice of Special Interest in Research on the Health of Sexual and Gender Minority (SGM) Populations: 15 Copyright 2018 Kaiser Permanente Center for Health Research
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