Previous research about adverse childhood experiences (ACEs) clarifies the serious public health ramifications of early-life stressors, such as divorce, household substance abuse, and sexual abuse, on future health and wellness as children transition into adolescence and adulthood.^1,2 Examples of such adulthood health consequences include posttraumatic stress disorder,³ substance use,^4-6 attempted suicide,^7-10 physical health conditions (such as lung cancer¹¹ and liver disease¹²), and decreased life expectancy by up to 20 years.¹³ Persons with a history of military service may be a specific subpopulation of interest regarding ACEs because some may enlist to escape personal problems, such as household dysfunction or abuse,^14-16 thereby potentially elevating the prevalence of ACEs among military populations. Perhaps more important, military service may expose persons with a history of trauma to additional trauma (eg, combat and military sexual trauma), which may additively elevate risks of poor mental health and suicide.^17-19 However, the prevalence of childhood adversity among US military and veteran populations is largely unknown.

Objectives. To examine how sexual orientation change efforts (SOCE) are associated with suicide morbidity after controlling for adverse childhood experiences (ACEs). Methods. Cross-sectional survey data are from the Generations survey, a nationally representative sample of 1518 nontransgender sexual minority adults recruited between March 28, 2016, and March 30, 2018, in the United States. Self-identified transgender individuals were included in a separate, related TransPop study. We used weighted multiple logistic regression analyses to assess the independent association of SOCE with suicidal ideation and suicide attempt while controlling for demographics and ACEs. Results. Approximately 7% experienced SOCE; of them, 80.8% reported SOCE from a religious leader. After adjusting for demographics and ACEs, sexual minorities exposed to SOCE had nearly twice the odds of lifetime suicidal ideation, 75% increased odds of planning to attempt suicide, and 88% increased odds of a suicide attempt with minor injury compared with sexual minorities who did not experience SOCE. Conclusions. Over the lifetime, sexual minorities who experienced SOCE reported a higher prevalence of suicidal ideation and attempts than did sexual minorities who did not experience SOCE. Public Health Implications. Evidence supports minimizing exposure of sexual minorities to SOCE and providing affirming care with SOCE-exposed sexual minorities.

Objectives. To examine whether indicators of community- and state-level lesbian, gay, bisexual, and transgender equality are associated with transgender veterans’ mental health.Methods. We extracted Veterans Administration data for patients who were diagnosed with gender identity disorder, had at least 1 visit in 2013, and lived in a zip code with a Municipality Equality Index score (n = 1640). We examined the associations of whether a state included transgender status in employment nondiscrimination laws and in hate crimes laws with mood disorders; alcohol, illicit drug, and tobacco use disorders; posttraumatic stress disorder; and suicidal ideation or attempt.Results. Nearly half (47.3%) of the sample lived in states with employment discrimination protection, and 44.8% lived in states with hate crimes protection. Employment nondiscrimination protection was associated with 26% decreased odds of mood disorders (adjusted odds ratio [AOR] = 0.74; 95% confidence interval [CI] = 0.59, 0.93) and 43% decreased odds of self-directed violence (AOR = 0.57; 95% CI = 0.34, 0.95).Conclusions. Understanding lesbian, gay, bisexual, and transgender social stressors can inform treatment and care coordination for transgender populations.

Objective: Transgender individuals are vulnerable to negative health risks and outcomes, but research remains limited because data sources, such as electronic medical records (EMRs), lack standardized collection of gender identity information. Most EMR do not include the gold standard of self-identified gender identity, but International Classification of Diseases (ICDs) includes diagnostic codes indicating transgender-related clinical services. However, it is unclear if these codes can indicate transgender status. The objective of this study was to determine the extent to which patients’ clinician notes in EMR contained transgender-related terms that could corroborate ICD-coded transgender identity. Methods: Data are from the US Department of Veterans Affairs Corporate Data Warehouse. Transgender patients were defined by the presence of ICD9 and ICD10 codes associated with transgender-related clinical services, and a 3:1 comparison group of nontransgender patients was drawn. Patients’ clinician text notes were extracted and searched for transgender-related words and phrases. Results: Among 7560 patients defined as transgender based on ICD codes, the search algorithm identified 6753 (89.3%) with transgender-related terms. Among 22 072 patients defined as nontransgender without ICD codes, 246 (1.1%) had transgender-related terms; after review, 11 patients were identified as transgender, suggesting a 0.05% false negative rate. Conclusions: Using ICD-defined transgender status can facilitate health services research when self-identified gender identity data are not available in EMR.