Leveraging the Electronic Health Record to Characterize Health Care Utilization and Stressors Before a Suicide Attempt Among Transgender and Gender Diverse Patients.

Purpose: Transgender and gender diverse (TGD) people experience deleterious minority stress, contributing to high rates of suicide attempt. However, little is known about TGD individuals' health care engagement or documented stressors before suicide attempts. Methods: We used diagnosis codes and rapid keyword-based review of clinical notes to identify TGD patients with a suicide attempt in electronic health record data in an urban, safety net health system. We used a priori codes and open coding to thematically analyze free-text clinical notes to identify potential documented stressors up to 6 months before a suicide attempt, in four domains: medical/psychiatric history, marginalization within the health system, social determinants of mental health, and intersectionality with other identities. Results: Identified patients were an average age of 24 years. Over 60% were seen within the health system 6 months before suicide attempt (36% in primary care; 29% in the Emergency Department), and 21% were seen within 7 days. Over half had evidence of being misgendered inside or outside the health care system. A prominent theme from clinical notes analysis was that patients feared their gender-affirming care being compromised if they exhibited mental health concerns. Conclusions: More than half of TGD patients engaged with health care within 6 months before a documented suicide attempt, over a fifth did so within 7 days, and many had documented experiences of marginalization and other stressors in their health records. Health care systems may therefore have greater opportunity to identify and intervene on potential emerging suicidality in TGD populations.