An estimated one million U.S. Veterans identify as lesbian or gay.1 In honor of National Pride Month, VA celebrates the opportunity to provide the best care for all members of the LGBTQ+ community.
Recognizing that stigma and discrimination can affect emotional as well as physical health, and that LGBTQ+ individuals are vulnerable to certain mental and physical health conditions, such as substance misuse, anxiety, and depression,2 VA is dedicated to being a leader in providing high-quality healthcare for LGBTQ+ Veterans by offering an LGBTQ+ Veteran Care Coordinator at every VA facility, healthcare services that include gender-affirming care, substance use treatment, suicide prevention, and virtual mental healthcare, and more.
In addition, VA’s HSR&D and Quality Enhancement Research Initiative (QUERI) support a range of research and implementation initiatives to address and improve LGBTQ+ health, including the following:
“All Veterans, all people, have a basic right to be identified as they define themselves. This is essential for their general well-being and overall health. Knowing the gender identity of our patients helps us better understand the population we serve.”—VA Secretary Denis McDonough
Following are some recent HSR&D studies on LGBTQ+ health:
“I am beyond grateful to the many, many Veterans from all walks of life who participated in this longitudinal survey. The data are rich and offer an unprecedented opportunity to examine how stress, trauma, mental health burden, and protective factors unfold over time and inform engagement in health risk behaviors for Veterans who do and do not identify as sexual and/or gender minorities, information that will undoubtedly help VA better meet our mission of providing top-notch care to all who served.”— Tracy Simpson, PhD
Compared to their heterosexual and non-transgender counterparts, lesbian, gay, bisexual, and transgender (LGBT) Veterans are more likely to experience depression, posttraumatic stress disorder (PTSD), suicide ideation and attempt, and health risk behaviors such as alcohol misuse and smoking. However, studies have often failed to examine differences by gender or sexual identity (combining gay/lesbian and bisexual), and data on some subpopulations, such as gay and bisexual men, are extremely limited. In addition, few studies have examined the risk and protective factors that might explain these disparities, or LGBT Veterans’ experiences with and preferences for treatment.
About This Study
The objectives of this study are 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, guided by a conceptual model that is informed by minority stress theory and the self-medication hypothesis.
- Assess LGBT Veterans’ experiences with and preferences for treatment, including their use of VA healthcare, barriers to care, and preferences for tailored interventions.
This ongoing (April 2019–September 2023) study used social media advertising, community organizations, and listservs to recruit 1,062 Veterans, with up to 200 individuals in each of the following groups: heterosexual women, lesbian women, bisexual women, heterosexual men, gay men, bisexual men, transgender women, and transgender men. Study assessments were conducted online every nine months for 27 months, for a total of four assessments.
Longitudinal findings are pending. Baseline data findings include:
- Transgender men and women had a significantly higher prevalence of lifetime suicide plans and attempts compared to all other subgroups within their respective genders.
- The prevalence of health and mental health conditions and substance use varied markedly among the LGBT subgroups.
- LGBT Veterans reported using VA services at high rates despite frequently encountering verbal harassment.
- Bisexual women and gender diverse participants consistently report the highest prevalence of past-year and lifetime interpersonal violence when compared to other subgroups.
Baseline findings are largely in line with previous literature but add nuance due to this study’s examination of differences and similarities among LGBT subgroups. In addition to providing subgroup information pertaining to health and mental health conditions and treatment use, future analyses of baseline and longitudinal data will examine coping, social support, and resilience among and between the groups and identify patterns of change over time. Ultimately, findings from this study will yield critical information for VA as it strives to provide uniformly respectful and accepting services for LGBT Veterans and achieve health equity for these Veterans.
Tracy Simpson, PhD, is part of VA’s Center of Excellence in Substance Addiction, Treatment, and Education in Seattle, WA. She became the study PI upon the departure of Keren Lehavot, PhD, from VA in July 2022.
Related research by this investigator
Lehavot K, Beaver K, Simpson T, et al. Disparities in mental health and health risk behaviors for LGBT Veteran subgroups in a national U.S. survey. LGBT Health. November 2022;9(8):543–554.
“Gender-affirming hormone therapy, one of the most common gender-affirming treatments, has been shown to improve health and quality of life in transgender individuals. However, little is known about gender-affirming therapy care received by transgender Veterans in VA. Understanding gender-affirming hormone therapy care received by transgender Veterans in VA is key to improving the quality of this care and ultimately the health of transgender Veterans who desire this treatment.”—Guneet Jasuja, PhD
The prevalence of transgender Veterans is on the rise. Transgender individuals experience gender dysphoria—discord between their self-identified gender and biological sex. Untreated and/or undertreated gender dysphoria is associated with increased mortality and morbidity including depression, anxiety, and suicidality. Gender-affirming hormone therapy (hereafter referred to as hormone therapy) is generally the primary medical intervention sought by trans individuals with gender dysphoria who wish to masculinize or feminize their body to be consistent with their gender identity.
About This Study
To identify gaps in delivery of hormone therapy care in VA among transgender Veterans, this study’s investigators sought to:
- Refine methods for identifying transgender 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 to which hormone care aligns with guidelines.
- Identify patient-, clinician-, and site-level predictors of guideline-concordant hormone therapy care for transgender Veterans.
After using VA data to identify gender identity disorder (GID) documented transgender Veterans, researchers used non-GID identification criteria, including receipt of hormones by opposite sex, endocrine disorder, and change in coded gender over time, to identify additional potential trans Veterans. GID and non-GID criteria were validated by chart reviews. Investigators then described the transgender Veteran study cohort in terms of demographics, the proportion of those receiving hormone therapy (estrogen vs. testosterone vs. none), route of administration (oral, transdermal, injectable), and other hormone therapy-related characteristics. Investigators also examined factors associated with the receipt of hormone therapy at the patient (e.g., comorbidities), provider (e.g., availability of transgender electronic consultations), and site level (e.g., transgender specialty training offered at site).
- Non-GID approaches were not reliable in detecting transgender identity in VA, though they might be useful in other settings.
- In the absence of complete data on self-identified gender identity in VA, findings suggest that relying primarily on GID diagnosis codes is the most reliable way to identify transgender individuals in VA.
- Transgender Veterans who were younger with fewer comorbidities and social stressors were more likely to receive hormone therapy compared to transgender Veterans who were older, with more comorbidities and more social stressors.
VA has an imperative to provide high-quality care to trans Veterans. This study—the first to assess the quality of hormone therapy care received by transgender Veterans served by VA, as well as to refine methods using VA data to identify transgender individuals—lays the groundwork for a follow-up 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 in Bedford and Boston, MA.
Related research by this investigator
Jasuja GK, Reisman JI, Rao SR, et al. Social stressors and health among older transgender and gender diverse Veterans. LGBT Health. February-March 2023;10(2):148–157.
Wolfe HL, Vimalananda VG, Jasuja GK, et al. Patient characteristics associated with receiving gender-affirming hormone therapy in the Veterans Health Administration. Transgender Health. December 19, 2022. Published online.
Wolfe HL, Reisman JI, Jasuja GK, et al. Validating data-driven methods for identifying transgender individuals in the Veterans Health Administration of the U.S. Department of Veterans Affairs. American Journal of Epidemiology. September 1, 2021;190(9):1928–1934.
“The disproportionate burden of mental illness among transgender people is startling and demands action! With the help and leadership of collaborating scientist Joy Lee, this study is generating needed evidence about the magnitude of the problem in the VA, as well as potential pathways to better outcomes.”— Michael Weiner, MD, MPH
Transgender Veterans die by suicide at twice the rate of cisgender (non-transgender) Veterans. Depression is a risk factor for suicide, but neither the mental healthcare use patterns of transgender Veterans with depression nor the barriers to care experienced by these Veterans is well understood.
About This Study
This ongoing (September 2021â€“September 2023) study is the first to use VA data to describe the mental healthcare use patterns of transgender Veterans with depression, and is innovative in its examination of the potential of communication technology to address barriers to care. The study aims to:
- Characterize mental healthcare use patterns of transgender Veterans diagnosed with depression.
- Identify and compare the mental healthcare use rates of transgender Veterans with depression to a matched cohort of cisgender Veterans with depression.
- Identify and describe the facilitators and barriers for transgender Veterans in accessing depression treatment, and their experiences using communication technology to access or coordinate related care.
- Interview transgender patients to understand their care experiences, and the role that communication technology plays, if any, in those experiences.
- Design an intervention strategy to overcome mental healthcare barriers for transgender Veterans with depression.
- Elicit iterative feedback from key stakeholders.
Findings are not yet available.
This pilot will produce an intervention strategy to address barriers to depression care for transgender Veterans. Results will inform efforts to meet the goals of the 2018 VA directive, Providing Health Care for Transgender Veterans, and will affirm VA’s commitment to address health disparities among transgender Veterans.
Michael Weiner, MD, MPH, is director of HSR&D’s Center for Health Information and Communication in Indianapolis, IN.
Related research by this investigator
Lee JL, Huffman M, Weiner M, et al. “I don’t want to spend the rest of my life only going to a gender wellness clinic”: Healthcare experiences of patients of a comprehensive transgender clinic. Journal of General Internal Medicine. October 2022;37(13):3396–3403.
“The hardest part of research is recruiting participants, and we were afraid that we’d have trouble reaching transgender and gender diverse Veterans or that they would not want to participate. We found the exact opposite. Our recruitment goal was filled in just 30 days. Veterans expressed thanks for having their voices heard and being able to share their experiences and recommendations.”—John R. Blosnich, PhD, MPH
People who identify as transgender or gender diverse bear a high burden of health disparities. Several research studies suggest that, compared to the general U.S. population, transgender people are more likely to have served in the military. To serve transgender Veterans, VA has outlined expectations for high-quality, respectful transgender healthcare. However, limited information exists about the care transgender Veterans receive within the VA healthcare system.
About This Study
The main objectives of this study were to:
- Compare differences in patient-, system-, and community-level determinants of health among transgender and non-transgender Veterans.
- Examine health services use and mortality over time among transgender and non-transgender Veterans.
- Explore transgender Veterans’ and VA healthcare providers’ experiences with VA healthcare, barriers and facilitators to care, and strategies to engage transgender Veterans in research.
Researchers analyzed VA administrative data and data collected from patients and providers through interviews. For administrative data, transgender Veterans were defined as those who had a record of ICD-9 diagnoses related to gender identity disorder. When this study began, there was no self-identified gender identity data available in VA electronic health records. For interviews, researchers worked with LGBTQ+ Veteran Care Coordinators to share recruitment information about the study with eligible Veterans.
- Transgender Veterans had twice the prevalence of experiencing housing instability compared to their non-transgender peers, and they were more likely to use VA supportive housing programs.
- Analysis of a historical cohort of 8,981 transgender Veterans and a comparison cohort of 26,924 non-transgender Veterans from FY 2000–FY 2016 revealed that suicide was the fourth leading cause of death for transgender Veterans but the tenth leading cause of death for non-transgender Veterans.
- On average, transgender Veterans died from suicide at a younger age than their non-transgender peers (52 vs. 64 years of age).
- Transgender and gender diverse (TGD) Veterans participate in VA research to serve the TGD community and fellow Veterans but were concerned about being “outed” and any potential impact on VA benefits. Mental health and gender-affirming hormone therapy were the most important research priorities for TGD Veterans.
Results of this study are expected to improve quality of care by increasing visibility and awareness of transgender care in VA healthcare and provide a foundation for intervention research to reduce disparities. Through partnerships with the LGBTQ+ Health Program in VA’s Office of Patient Care Services, results can be quickly disseminated throughout VA and added to existing transgender health resources for VA providers at the LGBTQ+ Program’s Sharepoint site.
John R. Blosnich, PhD, MPH, is part of HSR&D’s Center for Health Equity Research & Promotion (CHERP) in Pittsburgh, PA. Taylor L. Boyer, MPH, also of CHERP, was research coordinator.
Related research by this investigator
Hahn H, Burkitt KH, Blosnich JR, et al. Primary sources of healthcare among LGBTQ+ Veterans: Findings from the Behavioral Risk Factor Surveillance System. Health Services Research. April 1, 2023;58(2):392–401.
Blosnich JR, Boyer TL. Concordance of data about sex from electronic health records and the National Death Index: Implications for transgender populations. Epidemiology. May 1, 2022;33(3):383–385.
Wolfe HL, Boyer TL, Blosnich JR, et al. Exploring research engagement and priorities of transgender and gender diverse Veterans. Military Medicine. November 26, 2021;published online.
Boyer TL, Youk AO, Blosnich JR, et al. Suicide, homicide, and all-cause mortality among transgender and non-transgender patients in the Veterans Health Administration. LGBT Health. April 13, 2021;8(3):173–180.
1 VA CPT - Lesbian, gay, bisexual (LGB) Veterans | VA Community Provider Toolkit
2 Mental-Health-Facts-for-LGBTQ.pdf (psychiatry.org)