Association of HIV Status and Other Minoritized Identities with Psychiatric Diagnoses Among Transgender and Gender Diverse Individuals in the All of Us Research Program
Abstract
Background: Transgender and gender diverse (TGD) people, whose gender identities or expressions differ from the sex assigned at birth, are disproportionately affected by adverse health outcomes, including various psychiatric diagnoses such as depression, anxiety, stress, and substance use disorders. The Gender Minority Stress Model emphasizes that TGD people face both proximal stressors at a personal/individual level (e.g., internalized stigma) and distal stressors at a societal level (e.g., discrimination) due to their minority status, which largely contributes to their increased risk of psychiatric diagnoses. Despite these health disparities, there is a paucity of gender identity data collected in large population-based health systems, hindering quantitative research on TGD individuals. For HIV-positive TGD, HIV infection may also significantly impact mental health due to the convergence of two marginalized social identities: HIV status and gender identity. This dissertation leverages the extensive and diverse data from the All of Us (AoU) Research Program, a national community-engaged program aiming to improve health and facilitate health equity in the United States by partnering with one million participants. The aims of this dissertation are to: 1) develop computable phenotype algorithms to identify TGD people within the AoU platform; 2) describe the prevalence of psychiatric diagnoses among TGD individuals; and 3) examine the impact of HIV status on psychiatric diagnoses and investigate the potential moderating effect of sex assigned at birth and race/ethnicity on the relationship between HIV status and psychiatric diagnoses on the mental health. Methods: This dissertation utilized the latest version of controlled tire data from the AoU program, specifically controlled tire version 7, encompassing individuals enrolled in AoU from May 31, 2017, to July 1, 2022. Suspected TGDs were identified using a three-tiered hierarchy strategy within the AoU dataset. Tier 1 identification was based on responses to two survey questions: one regarding sex at birth and another concerning gender identity. Tier 2 identification utilized gender dysphoria diagnosis codes from the condition occurrence table, where participants with at least one record of a gender dysphoria diagnosis were classified as “Suspected TGD.” Tier 3 identification combined three additional data categories, including Endocrine Disorder Not Otherwise Specified codes, ICD-9/10 or Common Procedure Terminology codes for Gender affirming surgery, and sex-discordant hormone therapy. A list of ICD-9/10-CM codes within the AoU system, validated by a research team from SUNY Downstate Health Science University, was converted to phecodes to identify four broad clusters of psychiatric disorders among gender minorities: any mood disorder, any anxiety disorder, any substance use disorder, and any stress-related disorder. Three multinomial logistic regression models were employed to investigate the association between HIV status and psychiatric diagnoses, as well as the potential moderating effects of race/ethnicity and sex assigned at birth. Results: A total of 4,899 out of 413,457 participants (1.18%) were identified as TGD individuals, among whom 4572 (93.33%) were identified in tier one, 170 (3.47%) were added in tier two, and 157 (3.20%) were added in tier three. Among the 4,899 TGD individuals identified in the AoU program, 1,439 (29.37%) had at least one type of the four clusters of psychiatric diagnoses. Significant correlations were observed across four clusters of disorders, with correlation coefficients ranging from 0.60 to 0.92. HIV-positive individuals had higher odds of having at least two psychiatric diagnoses (Adjusted Odds Ratio [aOR] = 1.50, 95%CI: 1.14~1.87)) or one type of diagnoses ( aOR = 0.86, 95%CI: 0.35~1.37) compared to HIV-negative TGD individuals. Additionally, the effect of HIV status on the likelihood of having one psychiatric diagnosis differed depending on the sex assigned at birth (aOR = -1.61, 95%CI: -3.11~-0.12). The increase in the likelihood of having one psychiatric diagnosis for HIV-positive TGD individuals than HIV-negative individuals was less pronounced for those who were assigned as male at birth than those who were assigned as female at birth. Conclusion: The AoU program could be a valuable resource for enhancing our understanding of the health disparities among TGD individuals and informing the development of targeted interventions and support services. Comprehensive healthcare support that integrates HIV treatment and psychotherapy is essential for HIV-positive TGD individuals. Additionally, gender-sensitive approaches are necessary when conducting mental health intervention for HIV-positive individuals who were assigned female at birth, giving their unique experience. Future research can leverage the extensive lifestyle, genomic, and other social data available in the AoU Research Program to investigate the causes and consequences of various psychiatric conditions among TGD people, with the aim of improving their mental health and overall well-being.