Transgender Veterans Are Inadequately Understood by Health Care Providers

Transgender individuals face challenges dealing with health care providers. For reasons that are poorly understood, the prevalence of gender dysphoria (GD) in veterans is higher than in the general population. LGBT (lesbian, gay, bisexual, transgender) health issues, particularly those of the transgender community, are inadequately covered in recent medical publications and most training programs, and previous negative experiences in health care settings have created barriers for appropriate care of transgender veterans resulting in decreased preventive services, continuity of care, and life expectancy.

Future research must focus on the unique needs of transgender veterans so that health care providers have greater understanding and are better prepared to render appropriate care.

The Department of Veterans Affairs (VA) is committed to providing sensitive, evidenced-based care and has made significant progress in achieving this goal although much remains to be done.

Transgender individuals, including those who meet Diagnostic and Statistical Manual-5 (DSM-5; APA, 2013) criteria for the diagnosis of GD, are inadequately understood by health care providers. For reasons that are unclear, the prevalence of GD in veterans is higher than in the general population, even though individuals with GD cannot serve openly in the military.^1,2 VA is committed to caring for transgender veterans who require sensitive, evidence-based care and has made significant progress in achieving this goal although much remains to be done.^2,3

MULTIPLE CHALLENGES FACED BY TRANSGENDER PEOPLE

Societal stigmatization of transgender individuals results in poor self-esteem, lack of confidence, and difficulties in forming close friendships and embracing advanced employment opportunities. The stresses experienced by this population include increased risk of cardiovascular disease, drug abuse, cigarette smoking, and an unhealthy diet contributing to poor health outcomes including increased rates of depression, anxiety, trauma exposure, suicidal ideation, and somatization.^3,14

The Lambda Legal Health Care Fairness Survey (2010) reported that 73% of transgender individuals avoided health care because of a history or fear of stigma in health care settings, whereas 89% perceived providers as not being aware of their unique needs. The avoidance of care and perception that health care providers are unaware of their needs result in inadequate preventive services, continuity of care, and decreased life expectancy.¹⁵

Some publications fail to differentiate unique needs of the separate populations represented under the umbrella of LGBT. LGBT health issues, particularly those of the transgender community, are inadequately covered in recent medical publications and most training programs.^16,24

PROGRESS MADE AND FUTURE GOALS OF VA

VA goals are to ensure evidence-based health care of transgender veterans including increasing sensitivity, expanding knowledge of specific needs, bolstering mental health services, partnering with non-VA facilities, forming transgender support groups at more VA facilities, and instituting local dialogues to correct misconceptions and reduce stigmatization.^{7,8,12,13,19,25,28}

The VA has created national LGBT educational programs and policies targeted to ensure uniform, respectful, and compassionate care of transgender veterans. Online archived national transgender health care presentations are available to VA providers and at least 15 facilities have established transgender support groups. In addition, VA established 7 postdoctoral psychology fellowships in interprofessional LGBT health care, and the program will expand to include 9 fellows in the 2014 fiscal year. Although VA cannot provide sex reassignment surgery or transition-related cosmetic procedures, it provides all other medically necessary care including mental health care, hormonal therapy, preoperative evaluation, and postoperative care.²⁹

Following the lead of establishing interprofessional VA psychology fellowships, similar interprofessional LGBT training programs have been launched that include a wide array of disciplines being trained in the treatment of transgender veterans by national experts over videoconferencing. In this way, the VA is working toward integrating mental health and primary care by creating interdisciplinary teams that should reduce barriers to accessing appropriate care. This approach should ensure that psychiatric symptoms are addressed early before progressing to serious mental illness or suicidality. Thus, prevention and wellness care delivered by integrated primary care teams are being promoted at VA centers, including teams specializing in transgender veteran care.^27,29

In addition, an E-consultation program is being developed to respond to specific inquiries on a case-by-case basis (scheduled to launch Spring of 2014). Public health experts must also advocate strongly for transgender individuals so that their health care issues are acknowledged.⁸

VA guidance to ensure staff members' sensitive and respectful behavior while interacting with veterans has been clearly delineated.²⁹ Basic behavior such as addressing transgender individuals in ways consistent with their experienced gender will contribute to greater trust, encourage compliance with preventive care, and reduce acute care needs.^13,21 Guidance for VA personnel is available online on the VA intranet (Transgender SharePoint) and elsewhere.¹⁸

Peer support has been shown to diminish the impact of minority stress in the transgender population, and support groups have been shown to enhance self-esteem, improve social relationships, decrease isolation, and build confidence.^30,33 VA should encourage support groups for transgender veterans at all VA medical facilities.

Recognizing that not all transgender veterans receive their care at the VA, programs to partner with more non-VA facilities to provide competent care is essential. Such facilities may also help family members deal with stress and difficult challenges. For example, the NYU Langone Medical Center Military Family Clinic has partnered with the VA New York Harbor Healthcare System in Manhattan to provide effective and compassionate evidence-based treatments to family members of veterans receiving care at VA.³⁴

Community participatory research and direct dialogues between members of the transgender community and VA staff could serve to build trust and provide helpful information about fears, needs, and previous negative experiences. Such “face-to-face” conversations could help to diminish prejudice, reduce stigmatization, and encourage transgender veterans to obtain needed health care.³¹ Direct “one-on-one” dialogues with transgender veterans would promote the development of cultural competency among VA providers and facilitate viewing transgender veterans as individuals.^19,30,33

NEED FOR RESEARCH

There is a small, but growing set of researchers examining the needs of transgender veterans.^3,35,36 However, little is known about the specific concerns of transgender veterans. When a group assigned female sex at birth who identified on the masculine spectrum was asked recently about priority issues, the most pressing were having culturally competent doctors to provide routine and sexual health care, accessing hormone and surgical treatment, and obtaining health insurance.¹¹ It is unclear if the concerns of veterans also mirror what is being found in the general transgender population, or if military participation alters the core concerns.

Future research must focus on the unique needs of all transgender veterans so that health care providers have greater understanding and are better prepared to render appropriate care. Questions regarding sexual orientation and behavior should be included in VA surveys to elucidate those needs and ensure they are being met nationally.³⁷

CONCLUSION

Each population within the LGBT community experiences unique health risks, barriers to health care, and health disparities. Transgender individuals, in particular, face challenges in the health care setting. For reasons that are poorly understood, the prevalence of transgender individuals among veterans is higher than in the general population. The unique needs of transgender veterans are understudied.

LGBT health issues, particularly those of the transgender community, are inadequately covered in most training programs leading health care providers and support staff ill-prepared to understand and meet their clinical needs in a culturally sensitive manner. Previous negative experiences in health care settings have created barriers to care for transgender veterans resulting in avoidance of care or delaying care as well as decreased preventive services, continuity of care, and life expectancy.

VA is committed to providing sensitive, patient-centered, and evidenced-based care to all veterans including those who are transgender. Significant progress in achieving this goal has been made, although much remains to be done.