DESCRIPTION (provided by applicant): Approximately 1 million Veterans identify as lesbian, gay, bisexual, or transgender (LGBT), and health equity - irrespective of gender or sexual orientation - is a specific objective in the first goal of the Veteran Health Administration (VHA) Strategic Plan 2013-2018. LGBT individuals have high prevalence of health risk factors, (e.g., substance use, violence, barriers to care), and they experience disparities in several physical and mental conditions (e.g., mental illnesses, certain cancers, hepatitis C (HCV), HIV, and suicide). Recognizing the need to serve Veterans who are LGBT, VA promulgated Directive 2013-003, outlining healthcare provision for a subpopulation of LGBT individuals: transgender Veterans. Yet, VA knows little about the socio-demographics, health conditions, and healthcare utilization of this minority population. My prior work began addressing VA's gaps in LGBT health equity research by identifying a sub-population of transgender Veterans: those diagnosed with Gender Identity Disorder (GID). My long-term career goal is to become an independent VA health services investigator focused on improving the quality and equity of health and health care for LGBT Veterans. My immediate goals for the CDA-2 period are (1) to acquire the health services research skills to map the landscape of health disparities among transgender Veterans, (2) to create the evidence base from which to develop intervention and implementation research initiatives to address transgender health disparities, (3) to collaborate with operational partners to address LGBT health issues within VA, and (4) to develop a health equity research infrastructure with transgender Veterans that can expand to include research on LGB Veterans. The four key elements of my career plan to achieve my CDA-2 goals are (1) learn the formulation, administration, and dissemination of health services research; using electronic medical record data and complex longitudinal statistical analysis and data management; (2) improve quantitative skills with longitudinal data management, analysis, and collection; (3) acquire advanced skills in qualitative research methodology, including semi-structured interview protocols, coding, and analysis; and (4) gain knowledge in the development of intervention and implementation science initiatives for transgender Veterans' health care. For Aim 1, I will compare differences in patient-level (e.g., demographics, medical, psychiatric, and behavioral conditions), system-level (e.g., Medical Center teaching status), and community-level (e.g., rural status) determinants of health among transgender (n=6,308) Veterans and comparison group of non-transgender Veterans (n=18,924). In Aim 2, I will examine health services utilization, quality of care metrics, and mortality over time among transgender and non-transgender Veterans. For Aim 3, I will conduct semi-structured interviews with transgender Veterans and VA clinicians who provide transgender health services to explore transgender Veterans' and VA providers' experiences with VA health care, areas of improvement in care, and strategies to engage transgender Veterans in research. To guide recommendation for specific analyses, development of interventions, and policy implications based on study findings, I will develop a 6-member advisory board of methodology experts and VA operational partners with expertise in VHA LGBT issues. As a postdoctoral fellow with the Center for Health Equity Research and Promotion (CHERP-HSR&D COIN), I am in an ideal environment for health services research mentorship and training, and I have strong relationships with operational partners in the VA Office of Patient Care Services and VA Office of Public Health. This CDA will produce the first- and second-generation disparities research to provide the foundation for next steps of future quality improvement projects and future HSR&D Merit Review research to develop and test patient- level interventions (e.g., programs tailored to reduce suicide risk) or provider- or system-level interventions (e.g., clinical education and training) to improve the health and health care for transgender Veterans.

The Joint Commission, Institute of Medicine, and the Agency for Healthcare Research and Quality all note that lesbian, gay, bisexual, and transgender (LGBT) people are vulnerable to several health problems, such as HIV, mental illness, and suicide. The VA is committed to health equity for all Veterans, regardless of sexual orientation or gender. Recently the VA issued a national Directive about providing health care to transgender Veterans. This HSR&D Career Development Award application provides me with the training necessary (1) to examine differences in health outcomes and health care utilization between transgender and non-transgender Veterans, and (2) to explore delivery and quality of care through interviews with transgender patients and providers who care for them. Detecting and understanding the unique differences in health conditions and health care needs of transgender Veterans are the first steps for future quality improvement projects and intervention research to improve the equity of health and health care of this vulnerable Veteran population.