For decades, transgender individuals in the United States have faced discriminatory policies that bar them from serving openly in the U.S. military under their self-identified gender and hinder their ability to feel accepted among fellow veterans. These individuals are at an increased risk of experiencing discrimination (Harrison-Quintana & Herman, 2013), sexual trauma (Beckman et. al., 2018), and negative mental health outcomes such as suicidality, depression, and substance use (Blosnich et. al., 2013; Frost et. al., 2021). The most recent ban on transgender service members openly serving, which was lifted and reinstated several times since 2016, is representative of the vacillating support transgender individuals have encountered. Nonetheless, these individuals are two to three times more likely to serve than their cisgender counterparts (Harrison-Quintana & Herman, 2013) and the U.S. Veterans Health Administration (VHA) has become one of the larger providers of LGBTQ+ health care in the U.S. (Kauth & Shipherd, 2016) – statistics that highlight the need for transgender care that is inclusive, compassionate, and that takes into consideration the nuanced experiences of transgender veterans.
Currently, the VHA provides care for transgender individuals according to VHA Directive 1341(2), published in May 2018 and amended in May 2019 and June 2020. The directive includes descriptions of and requirements for care as well as a list of VHA covered services. In line with its mission to serve all veterans, the U.S. Department of Veterans Affairs (VA) is required to provide physical and mental health-related care or cover local community care for eligible transgender veterans. Additionally, all VA facilities are required to have at least one LGBTQ+ Veteran Care Coordinator, whose role is to help connect veterans with appropriate services. While services may vary across facilities, some VAs have also established transgender care teams, which include an array of expertise (e.g., primary care physicians, endocrinologists, social workers, psychologists, and chaplains) in an effort to provide holistic and specialized care.
While the VA offers a growing number of services to transgender veterans, it does not currently provide or cover any transition-related surgical interventions, such as gender-affirming surgeries (e.g., vaginoplasty and breast augmentation for transgender women or mastectomy and phalloplasty for transgender men) and related surgical interventions (e.g., facial surgeries on hairline, nose, jaw, or other parts of the face to make one’s physiognomy appear more feminine or masculine). That said, transgender individuals may receive pre- and/or post-operative evaluations and follow-up care through the VA. Most notably, the VA provides and covers hormone therapy for transgender veterans who are seeking to begin their transition or transfer their post-operative hormone therapy care to the VA. Following guidelines established by the World Professional Association for Transgender Health (WPATH), this process requires the veteran to undergo an evaluation to establish a diagnosis of gender dysphoria, acknowledge informed consent, and identify any medical or mental health comorbidities. Other transition-related services offered alongside of or as an alternative to hormone therapy include speech pathology, coverage of prosthetics (e.g., wigs, chest binders, dilators), and, to a lesser extent, laser hair removal (currently only provided when medically necessary, decided case-by-case). It is noteworthy that all of these services may not be available at the VA facility through which the veteran has already established care, often requiring outsourcing to a community provider. While expenses related to these services are covered, transgender veterans who seek community care often run the risk of experiencing discrimination or obtaining services from providers who are not knowledgeable of the transgender experience and military culture.
Excluding gender-affirmation surgeries and related surgical interventions from VA care has been noted to create barriers for transgender individuals, with research documenting the association between receiving transition-related medical interventions and decreased depression and suicidality (Tucker et. al., 2018) and substance use (Frost et. al., 2021). Since mid-2021, the VA has announced initiatives to modify the Code of Federal Regulations to expand VA transgender care to include gender-affirming surgery. While there is still a long way to go in order to implement this change, the announcement has instilled hope for the continuous improvement of transgender care available to U.S. veterans. By including gender-affirmation surgeries, the VA would allow transgender veterans to obtain streamlined and coordinated layered care that is most consistent with VA values, improving continuity of care. Though it seems increasingly likely that the VA will gain approval to conduct gender-affirming surgeries, in the meantime the onus is on us as providers to advocate for change where gaps in care exist for our veterans. This advocacy and support is particularly important given a historical context that has created mistrust of providers amongst transgender individuals seeking medical or mental health care (Safer et. al., 2017). The following are a few ways in which we may foster an environment that is safe, affirming, and sensitive to the needs of our transgender veterans:
- Ask about the veteran’s chosen name and pronouns and use them consistently throughout care (e.g., in the veteran’s presence, in documentation and notes, in team meetings or when coordinating care). You may also choose to disclose your own preferred name and pronouns in an effort to normalize and model this for others.
- Reinforce the zero-tolerance approach through correcting transphobic and other discriminatory language or remarks by colleagues or other veterans.
- Be aware of your biases and avoid microaggressions (see Livingston et. al., 2019; Nadal et. al., 2016).
- If you commit a microaggression, openly acknowledge the error, apologize, and take time to process the veteran’s reactions. Similarly, in the event that you misgender the veteran, promptly correct yourself and acknowledge the mistake.
- Remember the scope of treatment. Do not ask veterans questions related to their identity or transition status if it is not appropriate or related to the service you provide.
- Advocate for the development of safe spaces that foster connection and community. This advocacy can include transgender veteran support groups or establishing a specialty care team at your facility.
- Consult with your appointed LGBTQ+ Veteran Care Coordinator for resources, information, and best practices to improve the services you provide to transgender veterans.
- Assist transgender veterans in navigating the VA system by familiarizing yourself with the documentation needed to change names and self-identified genders on military service records and VA medical records (see Transgender American Veterans Association, n.d.; Trans Lifeline, 2015). Additionally, veterans can request to include their preferred name in their VA medical records by contacting the Registration and Enrollment office at their local facility.
About the Author
Antonella Bariani, MA, is a fifth-year doctoral student at Alliant International University and a current predoctoral intern at Jerry L Pettis Memorial Veterans Hospital in Loma Linda, California. Broadly, her research interests primarily include trauma, multiculturalism, and the impact of cultural identities on posttraumatic symptomology. Additionally, she has examined treatment outcomes and symptom severity in veteran survivors of military sexual trauma and combat-related trauma.
References
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