Improving Healthcare for LGBTQ Veterans
June is PRIDE Month, and VA takes pride in striving to improve the health and healthcare for LGBTQ Veterans. There are an estimated one million lesbian, gay, and bisexual 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 2020, 64 VA medical centers (VAMCs) were designated as a Leader and 34 VAMCs were designated as a Top Performer in LGBTQ Healthcare Equality.2
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.
High Rates of Suicide among Sexual Minority Veterans
Suicide is a widespread public health concern and remains a priority for VA, and suicide disproportionally burdens certain groups. For example, people with gay, lesbian, or bisexual sexual orientations (i.e., sexual minority) have a higher prevalence of lifetime suicide attempt, and limited research suggests greater risk of suicide death than their heterosexual peers. Led by a team of investigators from the VA Informatics and Computing Infrastructure (VINCI) and HSR&D investigator, John Blosnich, PhD, MPH, this retrospective study assessed suicide mortality among Veterans from October 1, 1999 through September 30, 2017 who had documentation of sexual minority sexual orientation status recorded in VA’s electronic health record (EHR). Investigators identified 8.1 million Veterans – of which, 96,893 (68% male, 70% White) had at least one sexual minority documentation in the EHR. National Death Index (NDI) data were used to calculate death rates/causes among sexual minority Veterans. Findings show:
- Risk of death from suicide was more than four-fold higher for sexual minority Veterans compared to the general US population – and more than twice as high as what has been found among the general Veteran population.
- Though not a focus of this study, there was evidence of excess mortality across everycause of death category among sexual minority Veterans compared with the US population.
Sexual minority Veterans are uniquely affected by suicide mortality. Understanding whether and to what extent suicide prevention efforts reach this vulnerable population should be the focus of future research. Adding self-reported sexual orientation as a standard, voluntary demographic element in the EHR would facilitate this future research.
Lynch K, Gatsby E, Viernes B, Schliep K, Whitcomb B, Alba P, DuVall S, and Blosnich J. Evaluation of Suicide Mortality among Sexual Minority US Veterans, 2000-2017. JAMA Network Open. December 28, 2020.
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.
Lesbian, gay, bisexual, and transgender (LGBT) individuals have been identified as being at risk for health disparities. Compared to their heterosexual and non-transgender 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: heterosexual women, lesbian women, bisexual women, heterosexual men, gay men, bisexual men, transgender women, and transgender men.
Results of this study should improve our 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 Investigator: Keren Lehavot, PhD, is with HSR&D’s Center of Innovation for Veteran-Centered and Value-Driven Care in Seattle, WA.
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, and often the only, 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 recently completed study (April 2019 – March 2021) 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 these approaches were not reliable in detecting transgender identity. In the absence of self-identified gender identity in the 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.
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.
Principal investigator: Guneet Jasuja, PhD, is with HSR&D’s Center for Healthcare Organization and Implementation Research (CHOIR) in Bedford and Boston, MA.
- LGBT Veteran Health Care. Male Veterans: Transgender Male Healthcare.
- VA Office of Health Equity. Lesbian, Gay, Bisexual, and Transgender Veterans.