Office of Research & Development
Office of Research & Development
A scene from the 2015 Boston Pride Parade and Festival, featuring the participation of the Boston and Bedford (Massachusetts) VA medical centers. (Photos courtesy of Bedford VAMC)
September 6, 2017
By Tristan Horrom
VA Research Communications
"This is an optimistic and promising finding...and perhaps reflects the recent advances in transgender health in VA."
Most transgender Veterans who use VA health care are satisfied with their care, according to a VA Puget Sound Health Care System study.
The results were published in the September 2017 issue of the journal Medical Care.
The researchers conducted an online survey of 298 transgender Veterans living in the United States. They found that 56 percent of these Veterans have used VA medical care since their military discharge. This rate is similar to VA health care usage by all Veterans: 62 percent of Veterans from the recent conflicts in Afghanistan and Iraq, for example, have used VA health care since October 2001.
Of the transgender Veterans who use VA health care, 79 percent reported being satisfied with the medical care they received. Sixty-nine percent of those who used VA mental health care were satisfied. The results mirror satisfaction levels of all Veterans. A 2013 study found that 82 percent of Veterans Health Administration patients were satisfied with the outpatient care they received. That transgender Veterans are just as satisfied with their care as other Veterans is encouraging, according to the researchers. “This is an optimistic and promising finding for VA and perhaps reflects the recent advances in transgender health in VA,” they wrote.
The results show that transgender men – individuals who identify as men but were female at birth – were more likely to be dissatisfied with mental health care than transgender women – those who identify as women but were male at birth. However, the researchers say that it is hard to draw conclusions from this result because of a small sample size of transgender men. The study population was 85 percent transgender women. This is likely because of two reasons, explain the researchers. First, a majority of Veterans are male sex at birth. Second, gender dysphoria is three times more likely to occur among natal males than females.
Despite the good news, the study also found areas where VA needs improvement. Of the 298 Veterans surveyed, 46 percent said they delayed seeking needed medical care in the past year, while 38 percent delayed seeking mental health care. These numbers are higher than in other populations in the U.S. For example, about 19 percent of women Veterans delay seeking health care in a given year, while 23 percent of the transgender community as a whole delay seeking care.
The most common reason for delaying seeking care, according to the Veterans’ survey responses, was an inability to afford it. While VA provides medical care without cost for all service-connected disabilities and conditions, some Veterans may need to pay a copay for non-service-related care. Transgender people are more likely to have a low income compared with the general population, according to the researchers, so this barrier to care may be especially prominent for this population. Lower income was associated with more dissatisfaction with VA medical care in the study group.
Other common reasons for delaying care were fear of disrespect or discrimination, being unable to take time off work, and transportation difficulties. The results showed, not surprisingly, that Veterans who experienced harassment in medical settings were more likely to delay medical care than those who did not. The researchers believe addressing the negative experiences of transgender Veterans is an important step to take. They wrote, “Greater understanding of transgender Veterans’ experiences in health care systems … could inform future efforts to improve care.”
The transgender Veterans who delayed seeking medical care were also more likely to screen positive for depression and/or PTSD. Depression and PTSD symptoms make all Veterans, not just transgender Veterans, more likely to delay care, according to previous studies. This is an area of particular concern for the transgender population, though. Transgender Veterans are more likely than those who are not transgender to have depression or PTSD, with nearly 60 percent of the study sample screening positive for at least one of the conditions.
Transgender-related diagnoses are five times more prevalent in VA than in the general population. In 2011, VA outlined a policy to provide nonsurgical medically necessary care, including hormone therapies, to Veterans. The researchers explain that use of VA medical care by transgender Veterans likely increased since this directive. VA is now likely the largest provider of LGBT health care in the world, they say. A 2014 report estimated that there are 134,300 transgender Veterans in the country, and that approximately 15,500 transgender individuals currently serve on active duty. A 2016 study using different methods estimated between 1,320 and 6,630 transgender individuals on active duty. According to another 2016 study, 5,135 unique transgender individuals used VA medical care over an 18-year period. The authors note that it is difficult to estimate the number of transgender Veterans because not all transgender individuals are “out” to their health care providers, and because data are limited.
The results of this study reflect VA’s efforts to improve health equity in its health care system. VA Secretary David J. Shulkin, in a statement to the Times-Picayune of New Orleans on July 29, 2017, reasserted VA’s commitment to caring for all Veterans: “Our commitment will be: As long as they are Veterans, we are there for them for life, and we will continue to care for all Vets. … As long as there are Veterans who we serve who are transgender, then we will continue to provide them services.”
Although a majority of transgender Veterans was satisfied with VA medical care, the researchers explain that there is more work to be done. They point out that transgender individuals are “a health population facing widespread disparities, stigma, and discrimination.” Further, some of the most vulnerable groups – those with lower income, with a minority gender identity (transgender men), and with depression or PTSD – experienced the most dissatisfaction with care. “Interventions that target the health care setting or engage these Veterans may be a valuable step to achieving health equity and more satisfying health care experiences,” wrote the researchers.
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