Improving Healthcare for LGBTQ+ Veterans
June is PRIDE Month, and VA takes pride in striving to improve the health and healthcare for LGBTQ+ (lesbian, gay, bisexual, transgender, queer, and questioning, pansexual, etc.) Veterans. There are an estimated one million LGBTQ Veterans in the United States. Research also shows that transgender identity is about five times more common among Veterans than non-Veterans.1 Sexual and gender minority Veterans have faced stigma and discrimination, which can affect health, so VA is working to make sure that LGBTQ Veterans know they are welcome within the VA healthcare system. In addition, there is an LGBTQ+ Veteran Care Coordinator (LGBTQ+ VCC) at every facility to help Veterans get the care they need. For more information about health services provided for LGBTQ+ Veterans, see the VHA LGBTQ+ Health Program, part of VA’s Patient Care Services.
HSR&D continues to contribute to VA’s mission to provide optimal care to all Veterans, including Veterans with LGBTQ identities. The following studies represent a few of the HSR&D-funded research projects dedicated to the health and care of LGBTQ Veterans.
Lesbian, gay, bisexual, and transgender (LGBT) individuals have been identified as being at risk for health disparities. Compared to their heterosexual and cisgender (gender identity corresponds to birth gender) counterparts, they are especially likely to have higher rates of depression, PTSD, suicide ideation and attempt, alcohol misuse, and smoking. The available data also suggest that LGBT Veterans experience a high burden of mental health problems and health risk behaviors, though studies have most often failed to examine differences by gender (combining women and men) or sexual identity (combining gay/lesbian and bisexual), and data on some sub-populations (e.g., gay and bisexual men, and transgender men) are extremely limited. Further, few studies have examined the risk and protective factors that may explain these disparities, or LGBT Veterans’ experiences with and preferences for treatment. This ongoing study (April 2019 – September 2023) aims to:
- Identify the extent of sexual orientation and gender identity disparities in mental health problems (depression, PTSD, anxiety, suicide ideation/attempt) and health risk behaviors (alcohol misuse, smoking) among Veterans over time and across geographic regions;
- Examine risk and protective factors associated with these outcomes; and
- Assess LGBT Veterans’ experiences with and preferences for treatment, including VA utilization, barriers to care, and preferences for tailored interventions.
With approximately 1,000 Veterans in the study cohort, investigators will address these objectives in each of the following groups: cisgender heterosexual women, cisgender lesbian women, cisgender bisexual women, cisgender heterosexual men, cisgender gay men, cisgender bisexual men, transgender women, and transgender men.
Results of this study should improve knowledge about the extent of existing health disparities, the risk and protective factors associated with them, and treatment preferences of LGBT Veterans. They also will provide critical information for future prevention and intervention efforts for this minoritized group.
Principal Investigators: Keren Lehavot, PhD, with HSR&D’s Center of Innovation for Veteran-Centered and Value-Driven Care in Seattle, WA, and Tracy Simpson, PhD, part of the VA Puget Sound Healthcare System.
The prevalence of transgender Veterans is on the rise. Transgender individuals experience discord between their self-identified gender and biological sex, defined as gender dysphoria (GD). Untreated and/or undertreated GD is associated with increased mortality and morbidity including depression, anxiety, and suicidality. Hormone therapy is generally the first, medical intervention accessed by trans persons with GD who seek to masculinize or feminize their body to be consistent with their gender identity. In 2012, Pharmacy Benefits Management (PBM) issued Criteria for Use (CFU) for transgender Veteran hormone therapy care. In pilot work, this study’s investigators identified that from FY 2005-17, of nearly 8,000 trans Veterans with GD, approximately 5,000 were on hormone therapy, with 7-fold variation on one key quality measure recommended by the PBM CFU across sites. To identify more such gaps in delivery of this care, investigators determined three specific aims:
- Refine methods for identifying trans Veterans on hormone therapy using VA data and validate by chart reviews.
- Examine the hormone therapy care provided to transgender Veterans in VA, describing its current state and determining the degree that hormone care is concordant with PBM CFU and non-VA guidelines.
- Identify patient-, clinician-, and site-level predictors of guideline-concordant hormone therapy care for transgender Veterans.
Investigators in this ongoing study (April 2019 – September 2022) identified a population of gender identity disorder (GID) documented transgender Veterans receiving hormone therapy using national VA data. Additional non-GID criteria of identification were employed, including receipt of hormones by opposite sex, endocrine disorder, not otherwise specified codes, and change in coded gender over time. Both GID and non-GID criteria were validated by chart reviews. Investigators then characterized the study cohort in terms of demographics, proportion of those receiving each type of hormone therapy (estrogen vs. testosterone vs. none), route of administration (oral, transdermal, injectable), dosage, and duration of therapy. Investigators also examined factors associated with both receipt of hormone therapy and guideline-concordant hormone therapy at the patient- (e.g., housing instability), provider- (e.g., availability of transgender electronic consultations) and site-level (e.g., transgender specialty training offered at site). Preliminary findings show:
- Both GID and non-GID approaches were applied to identify transgender status. However, after chart review validation investigators concluded that non-GID approaches were not reliable in detecting transgender identity in VA though they might be useful in other settings. This would require separate validation in each setting. In the absence of self-identified gender identity in VA, findings suggest that relying entirely on GID diagnosis codes is the most reliable approach to identify transgender individuals in the VA setting.
- Data also suggest that age, race, comorbidities, and social stressors, among other factors, can affect the receipt of hormone therapy among transgender patients in VA. Patients who were younger with fewer comorbidities and social stressors were more likely to receive hormone therapy in VA.
This study is the first to provide an assessment of the quality of hormone therapy care received by transgender Veterans served by VA, as well as to refine methods to identify transgender persons on hormones in VA data. In addition, this study lays the groundwork for a follow-up qualitative study to identify best practices associated with the delivery of guideline-concordant hormone therapy care in transgender Veterans.
Guneet Jasuja, PhD, is with HSR&D’s Center for Healthcare Organization and Implementation Research (CHOIR) in Bedford and Boston, MA.
Wolfe H, Reisman J, Yoon S, et al., and Jasuja G. Validating data-driven methods to identify transgender individuals in the Veterans Affairs. American Journal of Epidemiology. April 12, 2021. Epub ahead of print.
Despite literature on suicidality among lesbian, gay, bisexual, and transgender (LGBT) persons, little research has examined LGBT Veterans. In addition, little is known about how race/ethnicity, gender, morbidity, and treatment intersect with sexual orientation/gender identity to impact suicidality risk.
Using VA electronic health record data, investigators in this ongoing study will identify LGBT Veterans to ascertain pathways to suicidal behavior – and will assess both risk and protective factors related to LGBT individuals in all gender, age, and racial and ethnic groups. Because suicide attempts might not be captured if a Veteran presents at a non-VA hospital, investigators also will integrate data from the Centers for Medicare & Medicaid Services. Specific aims of this study include:
- Developing informatics tools to identify LGBT Veterans and suicide attempts and event,
- Characterizing suicide risk factors in a national sample of Veterans, and
- Examining the differential effect of risk factors on suicide by LGBT status.
This area of VA health services research is in its infancy. Next steps will include an examination of service(s) use after policy changes and VHA directives, such as repeal of DADT (Don’t Ask, Don’t Tell; 2010) and DOMA (Defense of Marriage Act; 2013), and VHA Directives 1340 and 2011-024; using SHEP (VA Survey of Healthcare Experiences of Patients) data to examine differences in satisfaction with care, as well as data on differences in outcomes of care for LGBT Veterans.
Kessler R, Bauer M, Bishop T, et al. Using administrative data to predict suicide after psychiatric hospitalization in the Veterans Health Administration System. Frontiers in Psychiatry, May 6, 2020;11,390.
Joseph Goulet, PhD, MS, is part of HSR&D’s Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center in West New Haven, CT.
Transgender individuals bear a high burden of health disparities, and almost 20% of transgender adults have served in the military, which is more than twice the prevalence in the general US population. Recognizing the need to serve transgender Veterans, VA disseminated expectations for transgender healthcare. However, limited information exists about transgender Veterans receiving VA care.
Thus, this HSR&D-funded study (2016-2021) sought to:
- Compare differences in determinants of health among transgender and non-transgender Veterans;
- Examine health services utilization and mortality over time among transgender and non-transgender Veterans; and
- Explore transgender Veterans' and VA health care providers' experiences with VA healthcare, barriers and facilitators to care, and strategies to engage transgender Veterans in research.
Study findings are expected to increase visibility and awareness of transgender health in the VA healthcare system. For example, findings of a recent study by Blosnich and colleagues found that differences in methods of suicide death suggest that firearms and self-poisoning may be specific areas of concern for transgender individuals experiencing suicidal crisis, which underscore the need to examine effective delivery of evidence-based care to this population of Veterans.
Further, through an operations partnership with the VA LGBT Health Program in the Office of Patient Care Services, results can be shared throughout VA and added to existing transgender health resources for VA providers, VA’s Suicide Prevention Coordinators, and Veterans’ Crisis Line responders.
Principal Investigator: John Blosnich, PhD, MPH, is part of HSR&D’s Center for Health Equity Research & Promotion (CHERP) in Pittsburgh and Philadelphia, PA.
Blosnich J, Boyer T, Brown G, et al. Differences in methods of suicide death among transgender and non-transgender patients in the Veterans Health Administration, 1991-2016. Medical Care. February 2021;59:S31-S35.
- LGBT Veteran Health Care. Male Veterans: Transgender Male Healthcare.