Variation in time-to-gender-affirming hormone therapy in the U.S. active duty Service Members

Abstract: Background: Beginning in July 2016, transgender service members in the US military were allowed to receive gender-affirming medical care, if so desired. Objective: This study aimed to evaluate variation in time-to-hormone therapy initiation in active duty Service members after the receipt of a diagnosis indicative of gender dysphoria in the Military Health System. Research design: This retrospective cohort study included data from those enrolled in TRICARE Prime between July 2016 and December 2021 and extracted from the Military Health System Data Repository. Participants: A population-based sample of US Service members who had an encounter with a relevant International Classification of Diseases 9/10 diagnosis code. Measures: Time-to-gender-affirming hormone initiation after diagnosis receipt. Results: A total of 2439 Service members were included (Mage 24 y; 62% white, 16% Black; 12% Latine; 65% Junior Enlisted; 37% Army, 29% Navy, 25% Air Force, 7% Marine Corps; 46% first recorded administrative assigned gender marker female). Overall, 41% and 52% initiated gender-affirming hormone therapy within 1 and 3 years of diagnosis, respectively. In the generalized additive model, time-to-gender-affirming hormone initiation was longer for Service members with a first administrative assigned gender marker of male relative to female (P<0.001), and Asian and Pacific Islander (P=0.02) and Black (P=0.047) relative to white Service members. In time-varying interactions, junior enlisted members had longer time-to-initiation, relative to senior enlisted members and junior officers, until about 2-years postinitial diagnosis. Conclusion: The significant variation and documented inequities indicate that institutional data-driven policy modifications are needed to ensure timely access for those desiring care.