By Annette M. Boyle
ST. LOUIS — In an effort to meet the healthcare needs of a traditionally underserved veteran population, VA is launching 500 initiatives to promote a welcoming and inclusive environment for lesbian, gay, bisexual and transgender (LGBT) veterans.
VA has instructed every healthcare facility to undertake at least three specific initiatives designed to meet that goal. On its SharePoint site, the VA Office of Health Equity (OHE) lists more than 500 already in the works.
Efforts to improve care for the LGBT population have become an increasingly greater priority since the 2011 repeal of Don’t Ask, Don’t Tell (DADT), which had been the official policy on alternative sexual orientations in the military for eight years. Because it prohibited any disclosure of homosexual or bisexual orientation, it limited information healthcare professionals could use to provide care to those veterans.
Recent research indicates that only one-third of LGBT veterans openly communicate about their sexual orientation with VA healthcare providers, and one-quarter avoided seeking specific services because of perceived stigma. 1,2
The programs build on the VA’s commitment to diversity and inclusion, as expressed in the Lesbian, Gay, Bisexual, and Transgender Workforce and Service Population Initiatives’ Value Statement: “VA must define diversity broadly to include all that makes us unique, including our sexual orientation and gender identity. Diversity and inclusion are more than legal or ethical imperatives, they are business imperatives to achieve high performance in public service.”
Nationally and at the local VA level, “most of the programs involve education of veterans and staff in culturally competent care and outreach to LGBT veterans,” Sarah Sanders, RN, BSN, of the St. Louis, MO, VAMC, told U.S. Medicine.
Nationally, the Transgender Education Resources SharePoint and LGB Education SharePoint, which will be available soon, provide access to resources such as VA directives, pharmacy guidelines, practice recommendations and training materials about LGBT healthcare for VA staff. Transgender Training and LGB Training Workgroups offer programs for staff that advocate culturally and clinically appropriate care for LGBT veterans, including providing cross-sex hormone therapy, primary care guidance and information on mental health in transgender care. Online training on transgender and intersex care is also under development.
The VA also encouraged all medical facilities to participate in the Human Rights Campaign Foundations’ Healthcare Equality Index in 2013, as a way to assess how well LBGT health care needs are being met. (See sidebar)
LGBT Population Survey
“In St. Louis, we’ve been putting on training for any staff at the VA who want to learn about the specific needs of LGBT veterans,” said Sanders, who said she hopes to train 200 VA employees by 2014.
“We’ve also advocated for LGBT elders,” for which the St. Louis VA received an award from Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (SAGE), she added.
Sanders and Katiuscia O’Brian, research project coordinator at the St. Louis VAMC are going beyond education and undertaking research to determine the needs of LGBT veterans and how well those needs are being met. The researchers and data analyst are working on the survey in their free time.
“It’s not a funded research project,” O’Brian noted.
“We’re starting from scratch,” Sanders said. “There’s lack of LGBT health data at large and no baseline data on the LGBT population” in the VA. As a nurse, it’s always good to begin with an assessment, so you know what the needs are before you start to develop programs.”
The researchers do not know how many veterans in the St. Louis area identify as LGBT. “Estimates based on modeling indicate that there could be 900,000 to 1 million LGBT veterans,” in the United States, O’Brian added.
The St. Louis survey instrument launched online in June, with O’Brian and Sanders also solicited response at the city’s PRIDE Fest, events celebrating occurring around the nation to celebrate lesbian, gay, bisexual and transgender (LGBT) culture.
Developed with the assistance of Diana Nurutdinova, MD, of the St. Louis VA, the survey asks about health access and overall health status of LGBT veterans. Questions specifically explore whether LGBT veterans feel comfortable disclosing and discussing their sexual orientation, sexual behaviors and/or gender identity to VA healthcare providers and staff and whether provider and staff attitudes about their sexual orientation or gender identity have affected their experiences or care at the VA.
The St. Louis researchers received 76 responses in the first week. “We’ve had nothing but support from the community,” said O’Brian, who expressed hope that more veterans will complete the survey online in the next few months.Transgender Clinics
In February, the VA released a directive regarding “Providing Health Care for Transgender and Intersex Veterans.” The directive makes the medical facility director, chief of staff and associate director for patient care services or nurse executive responsible for ensuring that “transgender patients and intersex individuals are provided all care included in VA’s medical benefits package.” The covered services include hormonal therapy, mental health care, preoperative evaluation and medically necessary post-operative and long-term care following sex reassignment surgery.
In Dallas, the VA has proposed to establish a dedicated transgender clinic, following the model of clinics already operational in Minneapolis and Boston. Currently, behavioral health specialists coordinate care for the approximately 30 self-identified transgender or intersex patients who seek care through the Dallas VAMC, said Alan Bernstein, associate director for patient care services.
“Our goal is to provide services to this population in a sensitive manner and ensure that all their health care needs are met,” Gwen Robinson, RN, associate chief nursing service for perioperative care at the Dallas VAMC, told U.S. Medicine. “With a dedicated clinic, we would have providers that are more expert in the specific needs and we could provide more services, such as peer-to-peer counseling. There may be a population we do not get to see right now but may pull in, once we offer more services and reach out to the community.”
Dallas is not waiting to expand its services or train clinicians and staff, however. “We are training all healthcare providers about the specific care of transgender and intersex individuals and cultural sensitivity,” using the nationally developed tools, Bernstein said.
Transgender and intersex employees can already participate in peer-to-peer counseling. Patients, however, are still referred to behavioral health specialists for counseling.
The Dallas VA does not know how many veterans would use the dedicated clinic, but suspects it could have significant demand. A study in the International Journal of Sexual Health found that veterans comprise 30% of the transgender community, three times the rate seen in the general population and that transgender veterans used VA services at a higher rate than other veterans. The Transgender American Veterans Association estimates that about 300,000 transgender individuals currently serve or have served in the U.S. Armed Forces. 3
- Simpson TL, Balsam K, Cochran BN, Lehavot K, Gold SD. “Veterans administration health care utilization among sexual minority veterans.” Psychol Serv. 2013;10:223–232.
- Kristin M. Mattocks, Michael R. Kauth, Theo Sandfort, Alexis R. Matza, J. Cherry Sullivan, and Jillian C. Shipherd. “Understanding health-care needs of sexual and gender minority veterans: How targeted research and policy can improve health.” LGBT Health. June 2013. Ahead of print.
- Shipherd JC, Mizock L, Maguen S, Green KE. “Male-to-Female Transgender Veterans and VA Health Care Utilization.” International Journal of Sexual Health. January 2012.