Under Secretary for Health’s Information Letter Regarding the Provision of Health Care For Lesbian, Gay and Bisexual Veterans

WASHINGTON, July 1 -- The U.S. Department of Veterans Affairs' Veterans Health Administration issued the following information letter:

1. Purpose. This Veterans Health Administration (VHA) Information Letter provides guidance for medical and administrative staff in providing high quality health care to lesbian, gay and bisexual (LGB) Veterans and in creating an environment and culture that is informed, welcoming, and empowering for the LGBT Veterans and families whom we serve. Due to differing health care needs, guidance on care for transgender Veterans can be found in VHA Directive 2013-003: Providing Health Care for Transgender and Intersex Veterans.

2. Background.

a. In keeping with the Department of Veterans Affairs (VA) mission to honor and serve America's Veterans, VA continuously strives to create and maintain a health care environment that provides high quality, equitable, Veteran-centered, and compassionate care. The VA Core Values establish an expectation that VA will advocate for Veterans and provide the best possible service to them, their families, and their caretakers, treating every Veteran with dignity and respect throughout all aspects of care delivery.

b. Throughout the health care sector, LGBT individuals, including LGBT Veterans, have been identified as an underserved and largely invisible population.

c. As part of its commitment to Veteran-centered care, VHA provides services that are designed to meet the specific care needs of all of its patients. These services include services that meet the specific care needs of LGBT Veterans.

d. VA has established that, consistent with Federal law, VA policy, and accreditation standards of The Joint Commission, Veterans and their family members "will not be subject to discrimination for any reason, including for reasons of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression."

3. Definition. Sexual orientation is defined as "a person's enduring physical, romantic, emotional, and/or spiritual attraction to another person." Sexual orientation encompasses sexual attraction, behavior, and self-identity. There are three sexual orientations commonly referred to as heterosexual or straight, homosexual or gay/lesbian, and bisexual. Women who identify as gay or lesbian are primarily attracted to other women, men who identify as gay are primarily attracted to other men, and men and women who identify as bisexual are attracted to both men and women, although their attraction to one particular gender may be stronger. Most people are consistent across sexual attraction, behavior, and self-identity, but for some individuals, self-identity may be inconsistent with attraction and behavior. For instance, a man who is attracted to, and engages in sexual behavior with, other men may not self-identify as homosexual or gay.

4. Demographics.

a. The prevalence of LGBT Veterans is unknown, but estimates based on national data suggest that there are approximately one million LGB Veterans, with another 71,000 LGB individuals among active duty military, reserves, and National Guard. Lesbian or bisexual women are more likely to have served in the military than gay or bisexual men. Because national surveys such as the U.S. Census do not include demographic questions related to sexual orientation, estimates are inferred from data on relationships within a household. Based on this information, it is conservatively estimated that among active duty personnel, 2.9 percent of active duty women are lesbian/bisexual and 0.6 percent of active duty men are gay/bisexual.

b. VA does not have a system in place that tracks the LGBT populations within the VA electronic medical records or other VHA databases, thus it is difficult to know how many LGBT Veterans are receiving VA medical care and whether these numbers are changing over time.

5. Historic Discrimination. Healthy People 2020 is a Web site that sets forth the U.S. government's science-based, 10-year national objectives for improving the health of all Americans. According to Healthy People 2020, the social determinants affecting the health of LGBT individuals largely relate to the history of oppression and discrimination that these communities have faced. Examples include historic and ongoing legal discrimination in access to health insurance, employment, housing, marriage, adoption, retirement benefits, inadequate legal protection against bullying, violence and homicide toward members of the LGBT community, and rejection of LGBT individuals by many social institutions leading to social isolation.

6. Clinical Care.

a. Social stigmatization of LGBT individuals and homosexuality has made it difficult to study LGBT health and health care. As a consequence, health information about LGB Veterans is limited. However, preliminary research suggests that when compared with heterosexual Veterans, larger numbers of LGBT Veterans have reported suicidal ideation and attempt, sexual assault, substance use disorders, and poor physical health.

b. Several health disparities have been documented in the general LGBT population as compared with non-LGBT individuals. These include a higher prevalence of interpersonal violence (e.g. harassment/victimization, bullying), smoking, and a higher prevalence of risk factors for breast cancer and cardiovascular disease among lesbian/bisexual women, anal cancer and HIV among gay men. These disparities have not yet been fully studied among LGBT Veterans.

c. LGBT Veterans are likely to experience challenges in accessing health care due to social stigma, bias, and discrimination, as well as a shortage of health care providers who are knowledgeable and culturally competent in LGBT health care.

d. A recent online survey of LGB Veteran experiences at VHA revealed that only 33 percent of the Veterans disclosed their sexual orientation to providers, and 25 percent of the Veterans reported avoiding at least one clinical service because of concerns about stigma. Due to the former Department of Defense (DoD) policy known as "Don't Ask, Don't Tell" (DADT) that barred LGB persons from serving in the military, LGB Veterans are likely to have concealed or denied their identities while in the military, experienced psychological and physical harassment, or have been discharged from military service. Currently, transgender people cannot serve openly in the U.S. Armed Forces. Although these are DoD, not VA policies, VA medical and administrative staff must be aware of the potential consequences of those policies on LGBT Veterans, such as distrust, expectations of rejection, or feeling the need to conceal information.

e. A Veteran's request to exclude information about sexual orientation in the VA medical record should be respected if this will not compromise the patient's care. Such a request requires the provider to determine whether the information is necessary and how a response to this request will influence trust with the patient and respect for the patient's preferences, privacy and autonomy. At the same time, the health care provider has a professional obligation to maintain a timely, relevant, accurate, and complete medical record. Even in circumstances where a Veteran's sexual orientation may have clinical relevance, a provider can document information about the individual's sexual behaviors or sexual risks in the medical chart without using the labels: "heterosexual," "gay/lesbian," or "bisexual."

f. If a Veteran requests that information about the Veteran's sexual orientation be removed from the record once it has been entered, VA staff must follow the procedures outlined in VHA Handbook 1907.01, Health Information Management and Health Record, available on the VHA Forms and Publications web site (see paragraph 8.i.).

g. The VA medical facility's Ethics Consultation Service is available to address ethical concerns related to the provision of respectful care for LGBT Veterans.

7. Recommendations and Initiatives to Help Build a Welcoming and Inclusive Environment for LGBT Veterans.

a. In 2011, The Joint Commission updated many of its standards in the areas of Communication, Cultural Competency, and Patient and Family-Centered Care. In addition, The Joint Commission published a "Field Guide" that "urges U.S. hospitals to create a more welcoming, safe, and inclusive environment that contributes to improved health care quality for lesbian, gay, bisexual, and transgender (LGBT) patients and their families."

b. The Joint Commission, the VHA LGBT Health Equity Workgroup, LGBT Education Workgroups, VA researchers, and others who have examined how to create an inclusive environment in health care recommend actions such as the following:

(1) Communicate to visitors and staff that equitable treatment of patients is a priority.

4 (2) Communicate clear expectations for ethical practice regarding LGBT patients.

(3) Establish an LGBT workgroup to review available resources and to recommend and coordinate the implementation of local initiatives.

(4) Ensure that images representing diverse LGBT individuals and families are included in posters and brochures.

(5) Provide employees time to participate in LGBT cultural competency training.

(6) Ensure that patients' rights documents are inclusive of LGBT patients and are posted prominently in a public area (such as the lobby or elevator bank) of the facility.

(7) Ensure that visitation policies are not based on a narrow definition of "family," but are centered on patient preferences and values, allowing patients themselves to determine and restrict whom they wish to visit them.

(8) Participate in the Healthcare Equality Index (HEI) survey.

(9) Ensure that employees are trained to treat same sex and opposite sex spouses equally.

(10) Participate in community awareness events (e.g., Pride month activities).

c. Consistent with VA's commitment to patient-centered care and The Joint Commission standards on non-discrimination, two documents, Rights and Responsibilities of VA Patients and Residents of Community Living Centers and Rights and Responsibilities of Family Members of VA Patients and Residents of Community Living Centers now include a statement that Veterans and their family members will not be discriminated against for any reason, including for reasons of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. The documents also provide a more inclusive definition of "family," specifically, defining family as "anyone related to the patient or resident in any way (for example, biologically or legally) and anyone whom the patient or resident considers to be family."

d. In December 2012, a joint Memorandum on LGBT inclusion was sent to VISN and VA medical facility Directors by the Principal Deputy Under Secretary for Health and the Deputy Under Secretary for Health for Operations and Management. That Memorandum directed VA medical facilities to undertake at least three specific initiatives in Fiscal Year 2013 to "help build a welcoming and inclusive environment for LGBT Veterans within their facility." Among the suggested initiatives was participation in the Healthcare Equality Index (HEI) survey for 2013. The HEI, a quality improvement tool created by the Human Rights Campaign (HRC) in collaboration with the Gay and Lesbian Medical Association, benchmarks best practice and policy for equal treatment of LGBT patients and families within U.S. health care systems. The Office of Health Equity (OHE) served as the VHA program coordinator for the 2013 HEI and a resource to facilities pursuing HEI endorsement. In 2013, 121 VA facilities participated in the HEI, with 92 achieving Leadership Status. Information about this achievement and the 570 projects undertaken in FY 2013 is available on the Office of Health Equity SharePoint site (see paragraph 8.d.).

8. Resources.

a. LGB SharePoint Site: http://vaww.infoshare.va.gov/sites/LGBEducation/default.aspx. NOTE: This is an internal VA website, not available to the public.

b. Poster 10-88, Rights and Responsibilities of VA Patients and Residents of Community Living Centers (CLC): http://vaww.va.gov/vhapublications/publications.cfm?Pub=8. NOTE: This is an internal VA website, not available to the public.

c. IB 10-284, Rights and Responsibilities of Family Members of VA Patients and Residents of Community Living Centers (CLC): http://vaww.va.gov/vhapublications/publications.cfm?Pub=8. NOTE: This is an internal VA website, not available to the public.

d. Office of Health Equity SharePoint: http://vaww.vha.vaco.portal.va.gov/sites/OHE/Pages/Default.aspx. NOTE: This is an internal VA website, not available to the public.

e. Healthcare Equality Index-VA Resources: http://vaww.vha.vaco.portal.va.gov/sites/OHE/Pages/LGBT.aspx . NOTE: This is an internal VA website, not available to the public.

f. VA LGBT Initiatives: http://vaww.vha.vaco.portal.va.gov/sites/OHE/Pages/LGBT.aspx. NOTE: This is an internal VA website, not available to the public.

g. Office of Diversity and Inclusion: http://www.diversity.va.gov/default.aspx.

h. The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide, 2012. http://www.jointcommission.org/lgbt.

i. VHA Forms and Publications Page (For all VHA brochures, directives, handbooks, etc.): http://vaww.va.gov/vhapublications/publications.cfm?pub=2&order=asc&orderby=pub_Number. NOTE: This is an internal VA website, not available to the public.

9. References.

a. Department of Veterans Affairs. 38 CFR Part 0 Subpart A, Core Values and Characteristics of the Department.

b. Healthy People 2020. http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=25.

c. Institute of Medicine. (March 31, 2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: Institute of Medicine.

d. Gates, G., (May, 2010). Lesbian, gay, and bisexual men and women in the US military: Updated estimates. The Williams Institute.

e. Herrell, R., Goldberg, J., True, W. R., et al. (October 1999). Sexual orientation and suicidality: A co-twin control study in adult men. Archives of General Psychiatry, 56(10), 867-874.

f. Blosnich, J., Bossarte, R., & Silenzio, V. (March 2012). Suicidal ideation among sexual minority veterans: Results from the 2005-2010 Massachusetts Behavioral Risk Factor Surveillance Survey. American Journal of Public Health, 102(S1), S44-S47.

g. Blosnich J, Foynes, M M , Shipherd, J.C. (July 2013). Health disparities among sexual minority women veterans. Journal of Women's Health, 22(7):631-636.

h. Booth, B. M., Mengeling, M., Torner, J., & Sadler, A. G. (June 2011). Rape, sex partnership, and substance use consequences in women veterans. Journal of Traumatic Stress, 24(3), 287-294.

i. Booth, B. M., Davis, T.D., Cheney, A.M., Mengeling, M.A., Torner, J.C., & Sadler, A.G. (November-December 2012). Physical health status of female veterans: Contributions of sex partnership and in-military rape. Psychosomatic Medicine, 74(9), 916-924.

j. Simpson, T. L., Balsam, K. F., Cochran, B. N., Lehavot, K., & Gold, S. D. (May 2013). Veterans Health Administration utilization among sexual minority veterans. Psychological Services, 10(2), 223-232.

k. Farmer, G. W., Jabson, J. M., Bucholz, K. K., Bowen, D. J. (October 2013). A population-based study of cardiovascular disease risk in sexual-minority women. American Journal of Public Health, 103(10)1845-1850.

l. Sherman, M., Kauth, M., Ridener, L., Shipherd, J.C. Bratkovich, K. & Beaulieu, G. (in press). Creating a welcoming environment in VA for sexual and gender minority veterans. Professional Psychology: Research and Practice.

m. Burks, D. J. (October 2011). Lesbian, gay, and bisexual victimization in the military: An unintended consequence of "Don't Ask, Don't Tell"? American Psychologist, 66(7),604-613.

n. Mattocks, K., Kauth, M. R, Sandfort, T. Matza, A. R, Sullivan, J. C. & Shipherd, J. C. (July 2013). Understanding healthcare needs of sexual and gender minority veterans: How targeted research and policy can improve health. LGBT Health,1(1) 30-37.

10. Inquiries. Questions related to this Information Letter should be directed to Dr. Jillian Shipherd ([email protected]) and Dr. Michael Kauth ([email protected]), LGBT Program Coordinators for Patient Care Services.

Robert L. Jesse, MD, PhD

Acting Under Secretary for Health

DISTRIBUTION: E-mailed to the VHA Publications Distribution List on 7/3/2014.

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