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WASHINGTON — With the understanding that the health of lesbian, gay, bisexual and transgender veterans is affected by how equitably they are treated, the VA is seeking to improve its services for those groups.

Last month, VA Secretary Denis McDonough ordered a department-wide review of policies to ensure that VA is a welcoming place to LGBT veterans and employees, with a particular focus on transgender veterans. The policy review is expected to be complete by March 30.

“The policy review that the secretary is mandating is far-reaching, requiring VA to examine the entire slate of services that the department provides to veterans to ensure maximum equity and inclusivity, including the delivery of medically necessary, gender affirmation care and procedures,” explained Kayla Williams, Senior Advisor for VA’s Office of Public and Intergovernmental Affairs in a post on VA’s website. “However some of the most impactful changes could also be the most basic, such as those that would afford veterans the basic dignity of being recognized for how they self-identify. To that extent, changes could include ensuring that VA systems are able to accommodate a veteran’s preferred name and pronouns when interacting with VA.” 

According to VA, LGBT veterans are more likely to report poor health conditions and suffer from multiple chronic conditions than other veterans. This is partly due to those veterans forgoing medical care to avoid stigma and discrimination.

The problem becomes more pronounced for transgender veterans, who die by suicide at six times the rate of the general population. Potentially affected are an estimated 134,000 transgender veterans and 15,000 transgender servicemembers. 

Part of improving care for LGBT veterans will likely involve a better understanding of that population’s needs. According to an October 2020 Government Accountability Office (GAO) report, VA cannot fully understand the needs of LGBT veterans because it does not consistently collect sexual orientation or veterans’ self-identified gender identity (SIGI).

No consistent field is available in the VA electronic health record (EHR) for providers to input sexual orientation. And SIGI information from administrative files are not linked to the EHR. Also, SIGI are not consistently recorded. VHA has made plans to link SIGI data across its systems, but that has been postponed several times. 

“According to VHA officials, the absence of such a standardize sexual orientation field in computerized patient record system (CPRS) is due to a system created many years ago when society greatly stigmatized lesbian, gay, and bisexual identities, and the military still had a ban on service by openly gay or lesbian personnel,” the GAO report states. “Until VHA is able to consistently collect this information, providers’ ability to deliver appropriate care may be affected, which could also affect veterans’ health outcomes.”

One example cited by the report is that, without knowing the sexual orientation of their male gay and bisexual patients, providers won’t know to conduct additional screenings for anxiety and depression, which affects that population at higher rates.

Also, because VHA does not know which of its veterans are LGBT or even the total number of those veterans in its system, it’s not possible to fully track health outcomes for those cohorts 

“VHA researchers have conducted research that identified health disparities for lesbian, gay, and bisexual veterans, such as a higher likelihood of suicide ideation compared to their heterosexual peers,” GAO investigators wrote. “However, researchers we spoke with reported that without consistent sexual orientation data their work was limited to small, convenience samples. Without the ability to assess health outcomes for the entire population…VHA maybe be limited in its ability to make informed decisions about addressing health disparities or improving outcomes.”

Researchers told GAO investigators that until there is sufficient SIGI and sexual orientation data to analyze, they would continue to look for workarounds in assessing the health of this population. For example, VA’s Office of Health Equity has been conducting a review to determine how, if at all, non-VA researchers and other health systems identify this population, such as searching the EHR for common keywords such as “transgender, “his husband,” or “her wife.” 

VA officials agreed with the GAO investigator’s findings and said that the agency would be forming a workgroup to “establish goals, plans, and timelines for consistently collecting sexual orientation and SIGI data.”