The United States Veterans Health Administration (VHA) has a lesbian, gay, bisexual, transgender, and queer (LGBTQ+) Program through the Office of Patient Care Services. The “+” sign captures identities beyond LGBTQ, including but not limited to questioning, pansexual, asexual, agender, gender diverse, nonbinary, gender-neutral, and other identities. VHA began collecting data on veteran’s sexual orientation and gender identity in 2022 to inform policy and improve clinical care. There are estimated to be more than one million LGBTQ+ Americans who are military veterans. If LGBTQ+ veterans use VHA at the same rate as non-LGBTQ+ veterans, there could be more than 250,000 LGBTQ+ veterans served by VHA. Using diagnostic codes in medical record data, Blosnich and colleagues found that the prevalence of transgender veterans in VHA (22.9/100,000) is five times higher than reported prevalence of transgender-related diagnoses in the general population (4.3/100,000). Brown and Jones identified 5,135 transgender veterans receiving care in VHA using a broader set of diagnostic codes. Brown also notes that this methodology fails to identify transgender veterans who have not disclosed their gender identity to providers, those who don’t meet criteria for a diagnosis, or veterans who get their transition-related care outside of the VHA.
History
In 2011, the Department of Defense repealed its Don’t Ask, Don’t Tell policy, allowing openly gay, lesbian and bisexual military personnel to serve in the armed forces. However, ending Don’t Ask, Don’t Tell did not change the military’s policy toward transgender people who continued to be banned from military service. Department of Defense’s policy on transgender service has fluctuated over the years, but as of 2023 there are no restrictions on transgender individuals’ military service. Although VHA, as a separate entity from Department of Defense, did not ever exclude LGBTQ+ veterans from accessing VHA resources, the repeal of Don’t Ask, Don’t Tell and the transgender military ban was expected to increase the numbers of LGB military personnel and consequently increase the number of LGB veterans who seek care at the VHA after service.
Concerns from LGBTQ+ veterans
Some researchers have raised concerns that LGBTQ+ veterans may not feel welcome at the VHA. Sherman and coauthors found that 24% of a sample of 58 LGBT veterans had not disclosed their sexual orientation to any VHA provider. The researchers noted that LGBT veterans may be uncomfortable disclosing their sexual orientation or gender identity because when they were in the military this information could lead to their discharge from service. Although VHA never had a policy prohibiting care to LGBTQ+ veterans, former military personnel often associate military policy with VHA policy. Sherman and colleagues also found that some LGBTQ+ veterans worried that disclosing their sexual or gender minority status would lead to losing VA medical benefits, even though there is a Patient’s Rights and Responsibilities Policy that prevents this type of discrimination.
In the same study, Sherman and colleagues examined attitudes and practices of 202 VHA providers at two mid-western hospitals and found that only half of providers had asked their patients about sexual orientation in the past year, despite it being relevant to health care. Mental health providers were more likely to ask patients about sexual orientation than medical providers, perhaps due to an awareness of the stress associated with being a member of a minority group. Less than half of the VHA providers overall (43%) had received any kind of training in LGBTQ+ health issues since they began practicing.
A later study by Kauth and colleagues found improvements in some areas related to LGBTQ+ veterans’ experiences with VHA care. For example, nearly two-thirds of a sample of LGBTQ+ veterans rated their primary care and mental health care providers at VHA as “somewhat” or “very welcoming.” Similarly, 64% of LGBTQ+ veterans endorsed feeling “somewhat” or “very comfortable” disclosing their sexual orientation to their VHA providers, and 67.5% of transgender participants reported feeling comfortable disclosing their gender identity.
LGBTQ+ people who disclose their sexual orientation to healthcare providers and feel comfortable talking to their providers about sexuality and sexual health also report greater satisfaction with their healthcare. LGBTQ+ people, including LGBTQ+ veterans, have unique health needs that need screening and follow up, which require healthcare providers initiate conversations about sexuality and gender identity and expression with patients.