Nearly two years ago, I argued that then-incoming VA Secretary Robert Wilkie should expand care to transgender veterans, removing the exclusion of gender confirmation surgery from VA’s medical benefits package. Today, on Transgender Day of Visibility, I am disappointed to report that not only has there been no progress on that front, but recent research conducted by my team at CNAS has identified other shortcomings in VA’s provision of care to transgender veterans. This is particularly concerning since transgender individuals may serve at higher rates.
The VA’s Office of Health Equity website shows that under the LGBT Healthcare Equality Index, developed by the Human Rights Campaign, less than half of VA Medical Centers nationwide were classified as “Leaders,” or “Top Performers,” the two highest designations awarded, as of 2019. This is reinforced by what we heard during interviews with stakeholders and veterans. Transgender veterans described encountering barriers in accessing high-quality health care due to their gender identity, including “dealing with medical providers that aren’t receiving necessary training to properly assess issues that you’re going through and provide unnecessary treatments.”
Each VA Medical Center has an LGBT veteran care coordinator (VCC) to serve as a patient advocate; however, their quality varies widely. In addition, our site visits identified significant variation in the LGBT-focused materials available in waiting rooms, ranging from confusion over the acronym “LGBT” to comprehensive informational material, welcoming posters, and competent staff. Additionally, other patients can contribute to VA Medical Centers being unwelcoming: One representative of a veteran-serving nonprofit reported witnessing transgender veterans being subjected to inappropriate verbal and nonverbal behavior from fellow patients because of their transgender status. Additionally, locating the VCC office on the mental health floor was perceived as likening LGBT status to a mental health condition.
Mandated training on LGBT-specific issues is one way to increase VA staff’s cultural competence to better serve this segment of the veteran population. For example, all personnel should be aware that misgendering transgender veterans is not just rude, it can lead to negative mental health outcomes.
In terms of transgender-specific health care, gender confirmation surgery remains specifically excluded from the VA medical benefits package; additionally, VA does not provide any surgery for what is considered cosmetic purposes. This is not in alignment with generally accepted standards of care for those with gender dysphoria. What is less known, however, is that because VA health care is considered “minimum essential coverage” under the Affordable Care Act, veterans who are enrolled in VA health care also do not qualify for subsidies in the Health Insurance Marketplace. This means that not only are financially vulnerable transgender veterans unable to access appropriate care within the VA system, but they are also unable to enroll in a plan that would provide this medically necessary care.
These barriers to — and deficiencies in — care are particularly concerning given that individuals with gender dysphoria attempt suicide at a substantially higher rate. [Veterans in crisis should contact the Veterans Crisis Line.] Being LGBT does not directly lead to higher risk of suicide; rather, “stigma, prejudice, and discrimination create a hostile and stressful social environment that causes mental health problems,” which is known as minority stress. Crucially, studies have shown dramatic reductions in suicide ideation, suicide attempts, and suicides among transgender individuals who receive appropriate transition-related care. Excluding this care from the VA medical benefits package while also denying transgender individuals needed support to attain plans that would cover this care does not align with suicide prevention goals.
The news is not uniformly bad. According to the 2015 U.S. Transgender Survey, of transgender veteran respondents using VA care, 72 percent were out as trans to their health care provider, 47 percent reported they were “always” treated respectfully, and 40 percent were “mostly” treated respectfully. VA should work to increase the number of VA Medical Centers classified as “Leaders” and “Top Performers” on the Healthcare Equality Index to boost those numbers and improve outcomes for transgender veterans.
In addition, since VA has proven itself unwilling to update its medical benefits package, Congress should step in and mandate change. Denying transgender veterans the ability to access medically necessary care is wrong.
NOTE: This post has been updated from the original to correct what entities were involved in creation of the LBGT Healthcare Equity Index.
Kayla Williams is a senior fellow and director of the Military, Veterans, and Society Program at the Center for a New American Security. She previously served two years as director of the Center for Women Veterans at the Department of Veterans Affairs, serving as primary adviser to the secretary on policies, programs and legislation affecting women veterans. Prior to that, she worked at the RAND Corporation, where she did research related to veteran health needs and benefits, international security and intelligence policy. She is the author of “Love My Rifle More Than You: Young and Female in the U.S. Army,” a memoir of her deployment to Iraq.