Clinicians in the Veterans Health Administration initiate gender-affirming hormone therapy in concordance with clinical guideline recommendations.

Veterans receiving feminizing GAHT were demographically distinct from those receiving masculinizing GAHT in age, race/ethnicity, and comorbidity burden.

• A higher proportion of veterans receiving feminizing GAHT were aged ≥60 years (23.7% vs. 6.3%) compared to those receiving masculinizing GAHT.
• White non-Hispanic veterans comprised 83.5% of those receiving feminizing GAHT vs. 57.6% of those receiving masculinizing GAHT.
• Veterans receiving feminizing GAHT had a higher number of comorbidities (≥7: 14.0% vs. 10.6%).
• All demographic and comorbidity comparisons had p-values <0.001.

Veterans receiving masculinizing GAHT had higher rates of Black race, PTSD, and military sexual trauma compared to those receiving feminizing GAHT.

• Black non-Hispanic veterans represented 21.5% of those receiving masculinizing GAHT vs. 3.5% of those receiving feminizing GAHT.
• PTSD was documented in 43.0% of veterans receiving masculinizing GAHT vs. 33.9% of those receiving feminizing GAHT.
• Positive military sexual trauma was documented in 33.5% of masculinizing GAHT recipients vs. 16.8% of feminizing GAHT recipients.
• All p-values were <0.001.

The vast majority of veterans initiating estrogen as part of feminizing GAHT were guideline concordant due to absence of documented contraindications.

• 97.0% of veterans who started feminizing GAHT with estrogen were guideline concordant.
• Concordance was defined as no documentation of contraindications including venous thromboembolism, breast cancer, stroke, or myocardial infarction.
• The sample included 3,547 veterans receiving feminizing GAHT initiated between 2007 and 2018 in VHA.

Nearly all veterans initiating spironolactone as part of feminizing GAHT were guideline concordant.

• 98.1% of veterans who started spironolactone as part of feminizing GAHT were guideline concordant.
• Concordance was defined as no documentation of contraindications including hyperkalemia or acute renal failure.

The majority of veterans initiating masculinizing GAHT were guideline concordant with respect to contraindications.

• 90.1% of veterans starting masculinizing GAHT were guideline concordant due to no documentation of contraindications such as breast or prostate cancer.
• The sample included 1,129 veterans receiving masculinizing GAHT.

Hematocrit was measured in the majority of veterans prior to initiating masculinizing GAHT, and most did not have elevated hematocrit at baseline.

• Hematocrit had been measured in 91.8% of veterans before initiating masculinizing GAHT.
• 96.5% of those measured did not have an elevated hematocrit (>50%) prior to starting masculinizing GAHT.

Documentation of a gender identity disorder diagnosis prior to GAHT initiation was present in the large majority of veterans.

• 91.2% of veterans initiating both feminizing and masculinizing GAHT had documentation of a gender identity disorder diagnosis prior to GAHT initiation.
• This metric applied across the combined sample of 4,676 veterans.

The study sample consisted of 4,676 veterans with a gender identity disorder diagnosis who initiated GAHT in VHA between 2007 and 2018.

• 3,547 veterans initiated feminizing GAHT and 1,129 initiated masculinizing GAHT.
• Guideline concordance was assessed across six VHA guidelines on feminizing and masculinizing GAHT initiation.
• Demographics and health conditions were assessed for both groups.