Identifying Posttraumatic Stress Disorder and Disparity Among Transgender Veterans Using Nationwide Veterans Health Administration Electronic Health Record Data Nicholas A. Livingston, PhD, 1,2 Kristine E. Lynch, PhD, 3,4 Zig Hinds, 1 Elise Gatsby, MPH, 3 Scott L. DuVall, PhD, 3,4 and Jillian C. Shipherd, PhD 2,5,6 Abstract Purpose: The prevalence of posttraumatic stress disorder (PTSD) and other psychiatric disorders is high among military veterans and even higher among transgender veterans. Prior prevalence estimates have become outdated, and novel methods of estimation have since been developed but not used to estimate PTSD prevalence among transgender veterans. This study provides updated estimates of PTSD prevalence among transgender and cisgender veterans. Methods: We examined Veterans Health Administration (VHA) medical record data from October 1, 1999 to April 1, 2021 for 9995 transgender veterans and 29,985 cisgender veteran comparisons (1:3). We matched on age group at first VHA health care visit, sex assigned at birth, and year of first VHA visit. We employed both probabilistic and rule-based algorithms to estimate the prevalence of PTSD for transgender and cisgender veterans. Results: The prevalence of PTSD was 1.5–1.8 times higher among transgender veterans. Descriptive data sug- gest that the prevalence of depression, schizophrenia, bipolar disorder, alcohol and non-alcohol substance use disorders, current/former smoking status, and military sexual trauma was also elevated among transgender veterans. Conclusion: The PTSD and overall psychiatric burden observed among transgender veterans was significantly higher than that of their cisgender peers, especially among recent users of VHA care. These PTSD findings are consistent with prior literature and minority stress theory, and they were robust across probabilistic and two rule- based methods employed in this study. As such, enhanced and careful screening, outreach, and evidence-based practices are recommended to help reduce this disparity among transgender veterans. Keywords: mental health, prevalence, PTSD, transgender, veteran Introduction T he lifetime prevalence of posttraumatic stress dis- order (PTSD) is estimated to be 6.1%–6.8% in the gen- eral population, 1,2 and it is significantly higher among military veterans (12.9%–30.9%). 3–5 Transgender individuals— individuals who identify as a gender that differs from their sex assigned at birth (e.g., trans masculine, trans femi- nine, nonbinary, gender queer)—experience higher rates of psychiatric disorders, including PTSD, relative to their non-transgender (i.e., cisgender) counterparts. 6 The PTSD prevalence estimates among transgender individuals vary depending on the specific subpopulation but include rates of 42%–44% in the general U.S. population 7,8 and 24%– 41% among transgender veterans. 9–11 According to the minority stress model, psychiatric disor- der among transgender individuals is explained by the added distal (e.g., victimization, discrimination) and proximal mi- nority stressors (e.g., concealment, gender dysphoria) that negatively impact their mental health, in addition to the 1 Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA. 2 Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA. 3 VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA. 4 Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA. 5 Women’s Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA. 6 LGBTQ+ Health Program, Veterans Health Administration, Washington, District of Columbia, USA. LGBT Health Volume 9, Number 2, 2022 ª Mary Ann Liebert, Inc. DOI: 10.1089/lgbt.2021.0246 94 Downloaded by 54.152.221.185 from www.liebertpub.com at 03/03/22. For personal use only.