WASHINGTON — As VA conducts a department-wide assessment of how it serves its LGBT veterans, agency leaders will likely discover what Jillian Shipherd, PhD, and Michael Kauth, PhD, have understood for years: that sexual and gender identity play a significant role in a veteran’s health and that healthcare systems everywhere need to incorporate this lesson into their care.
Shipherd and Kauth serve as co-directors of VA’s LGBT Veteran Care Program. The program, in place since 2012, provides policy recommendations, provider education, and clinical services to support LGBT veterans. The program exists, and Shipherd and Kauth find themselves leading it, in part because they were in the right place at the right time.
Shipherd came to VA more than 20 years ago, drawn to the National Center for PTSD’s Women’s Health Sciences Division because it was a leader in examining gender and trauma recovery. She soon began working with the transgender women who were being seen in the trauma clinic, and eventually became chair of the Diversity Committee at VA Boston. Shipherd wrote a transgender veteran policy for that facility. It would eventually become the template for VA’s national policy, adopted in 2011.
She was paired with Kauth to lead the committee whose job it was to disseminate information on that policy to VA providers nationwide.
“While our workgroup was helping the field adapt to this new policy for transgender health, don’t ask, don’t tell was repealed,” Shipherd explained. “While VA never had a don’t ask, don’t tell policy, all of a sudden people were starting to ask questions bout veterans who identify as lesbian, gay or bisexual. They were coming to Michael and myself because we were already working in that space with the transgender population.”
Like Shipherd, Kauth had come to VA because that’s where the best research was being done in his field—in this case, HIV. He did his internship at the New Orleans VA and was hired to work as a clinical psychologist in their HIV clinic as well as in the inpatient PTSD program. Kauth was eventually hired as education director of the South Central Mental Illness Research, Education and Clinical Center (MIRECC).
“I used that opportunity to talk with VA central office leaders about how we should focus more on sexuality and sexual health in the healthcare we provide,” he said. “We don’t do a great job at assessing sexual health, and we’re not alone in that.”
More Organized Approach
Fresh off the transgender policy roll-out, Shipherd and Kauth argued to VA that the agency needed a more organized approach to LGBT health. The result was the LGBT Veterans Care Program, and their shared role as co-directors.
The challenges they faced in the early years are not too different from the ones they face today.
A lack of data collection makes it difficult to identify LGBT veterans and get a better picture of their needs. VA’s electronic health record—as is the case with many civilian healthcare systems—does not collect sexual or transgender identity data.
“That means we can’t identify this population in VA,” Kauth explained. “We don’t know exactly what their health needs are. We don’t know what gaps exist that we need to address. And there’s been very limited research on LGBT veterans because this work hasn’t been prioritized in the past.”
Kauth is spearheading some of the policy work to ensure that those data fields are not only included in VA’s EHR but are a regular part of the questions a veteran is asked by their provider.
Another challenge is that many providers don’t have training in LGBT health or understand why sexuality and gender identity are so important to a veteran’s health needs.
“In the early days providers would say things like ‘a veteran is a veteran is a veteran. I treat all my veterans exactly the same way.’ And they were proud of that,” Shipherd explained. “I think now people have a better understanding that if you treat everyone exactly the same way, that is not good healthcare. Everyone has unique needs, and if you want to provide good healthcare you have to provide person-centered care.”
The program is trying to provide some of that LGBT health education that’s lacking elsewhere. Much of Kauth and Shipherd’s time is spent developing training materials for VA providers, including topic-focused webinars on LGBT health.
“We also spend a lot of time managing a transgender clinical consultation program,” Kauth said. “We’ve got two very experienced teams—providers who respond to facility consults from healthcare providers who can provide a second opinion or some advice about the diagnosis or treatment of an individual.”
As clinical psychologists, Kauth and Shipherd also had the toolkit necessary to create LGBT healthcare fellowships in clinical psychology at 10 VA sites nationwide. In a perfect world they said they would like to see such LGBT health fellowships available in nursing, primary, care, women’s health, and other areas.
“That may be the future,” Kauth declared. “LGBT veterans touch every part of the VA healthcare system. All of our providers need to be trained.”
And while they admit the office is deeply under-resourced, they make up for it in part through the work of volunteer Veteran Care Coordinators at every VA facility.
Volunteer Veteran Care Coordinators
“They make sure if there’s a veteran with an LGBT or related identity who comes to their facility and encounters difficulties or needs questions answered, they have someone to go to. And the staff have someone to go to as well,” Shipherd explained.
Those volunteers are also key to helping clear one of the largest hurdles VA faces—earning the trust of LGBT veterans.
“Veterans have long associated VA with the military and viewed VA as an extension of their military service, and LGBT veterans are no different from that,” Kauth explained.
Shipherd added, “They’re nervous about coming into a VA healthcare system, especially if they served under don’t ask, don’t tell or a ban under transgender military service. They worry they may be discriminated against. They worry they may lose their service-connected disability if they come out. It’s really important for us to work harder to let these veterans in particular know that not only are they welcome at VA and encouraged to talk to their healthcare team, that they are absolutely protected and not going to lose their benefits.”
Kauth and Shipherd said they would also like to see those benefits expanded to better provide for transgender veterans.
“Gender alterations is listed as an exclusion in the medical benefits package,” Shipherd explained. “It’ll take some work to remove that exclusion, but if we’re able to do that it means transgender veterans would be able to access surgical care in the future.”
Shipherd and Kauth are hopeful that the commitment by new VA Secretary Denis McDonough to provide LGBT equity will translate into more awareness and understanding of the importance of sexual and gender identity in veteran health.
“We’ve seen huge changes in this country in the last few years,” Kauth said. “That’s been remarkable, and I think it’s in some ways made it easier to do the work that we’re doing. We’re getting a lot more attention, though it makes it harder because we’re stretched more thin. But I’m delighted our Secretary has put out very strong statements about the need to provide health equity across the board.”