Multi-Level VA System Improvements are Needed to Ensure Equitable and Accessible Gender-Affirming Hormone Therapy
BACKGROUND:
In 2011, VA established a national directive on policy for delivering healthcare to transgender and intersex Veterans, including that all 171 VA medical centers provide gender-affirming hormone therapy (GAHT). GAHT induces physiological effects and physical changes in secondary sex characteristics, which can improve psychological well-being and overall life satisfaction among transgender and gender diverse (TGD) patients by more closely aligning their physical self with their internal sense of self. Investigators conducted interviews with TGD patients (n=30) and VA healthcare providers (n=22) to determine barriers and facilitators to GAHT at the individual (i.e., knowledge, coping mechanisms), interpersonal (i.e., interactions with other individuals or groups), and structural (i.e., societal gender norms, institutional policies) level and also asked participants for recommendations for overcoming perceived barriers. Transgender, non-binary, and gender diverse patients were recruited using convenience sampling through VA’s national LGBTQ+ Veteran Care Coordinator (VCC) network. VA providers were recruited from a variety of specialties that may be involved in the provision of GAHT, including primary care, pharmacology, mental health, and social work. Interviews were conducted between August 2019 and January 2020. Patients were offered $40 for a 30- to 60-minute interview.
FINDINGS:
- Multi-level system improvements are needed within and outside VA to ensure equitable and efficient access to GAHT.
- Facilitators included having GAHT offered through primary care or TGD specialty clinics—as opposed to only through endocrinology— and having knowledgeable VA providers. Patients also noted the importance of supportive social networks (i.e., Veteran peers sharing their experiences accessing GAHT) and self advocacy.
- Barriers included a lack of providers trained or willing to prescribe GAHT, patient dissatisfaction with prescribing practices, and anticipated or enacted stigma from providers or Veteran peers.
- To overcome barriers, study participants recommended increasing provider capacity and support, providing opportunities for continual provider education in GAHT, and enhancing communication to both patients and providers around VA policy and training regarding GAHT.
IMPLICATIONS:
- Authors recommend continued efforts to enforce non-discrimination policies to eradicate barriers and sustain facilitators for this important evidence-based treatment across all VHA systems.
LIMITATIONS:
- Although participants were recruited nationwide, the patient sample was predominantly White, non-Hispanic, and transfeminine; providers primarily worked in mental or behavioral health.
AUTHOR/FUNDING INFORMATION:
This study was supported through an HSR&D Career Development Award (CDA 14-408) to Dr. Blosnich. Drs. Wolfe and Blosnich and Mr. Boyer are part of HSR&D’s Center for Health Equity Research and Promotion; Drs. Shipherd and Kauth are part of VA’s LGBTQ+ Health Program; and Dr. Jasuja is part of HSR&D’s Center for Healthcare Organization and Implementation Research.
Wolfe HL, Boyer TL, Shipherd JC, Kauth MR, Jasuja GK, Blosnich JB. Barriers and Facilitators to Gender-Affirming Hormone Therapy in the Veterans Health Administration. Annals of Behavioral Medicine. July 12, 2023; online ahead of print.
