Experiences in the Veterans Health Administration and Impact on Healthcare Utilization: Comparisons Between LGBT and Non-LGBT Women Veterans

Abstract

Purpose:

This study aimed to compare experiences related to healthcare of LGBT women and non-LGBT women in a sample of routine users of Veterans Health Administration (VHA) primary care services and examine the impact of those experiences on delaying or missing appointments for VHA care.

Methods:

Women veterans (N = 1391) who had at least three primary care visits in the previous year at 12 VHA facilities were surveyed by phone in January–March 2015 in a baseline wave of a cluster-randomized quality improvement trial. The majority identified as non-LGBT (1201; 85.6%) with 190 (14.4%) women identified as LGBT, based on items measuring sexual orientation and gender identity.

Results:

In models controlling for demographics, health status, and positive trauma screens, LGBT identity was predictive of women veterans experiencing harassment from male veterans at VHA in the past 12 months, as well as feeling unwelcome or unsafe at their VHA. Compared with non-LGBT women veterans, LGBT women veterans attributed missing needed care more often in the previous 12 months to concerns about interacting with other veterans. Participant descriptions of harassment indicated that male veterans' comments and actions were distressing and influenced LGBT women's healthcare accessing behavior.

Conclusions:

Compared with non-LGBT women, LGBT women were more likely to report harassment and feeling unwelcome at VHA. Some LGBT women reported delaying or missing needed care, primarily due to concerns about interacting with other veterans. Additional work is necessary to help LGBT women veterans feel safe and welcome at VHA facilities and, thereby, reduce barriers to LGBT women veterans accessing needed care.

Introduction

The National Academy of Medicine, formerly the Institute of Medicine,¹ and the National Institutes of Health² have recognized that LGBT people experience health disparities. The minority stress model explains that chronic stress associated with being a sexual or gender minority individual partially accounts for these disparities.^3,4 The minority stress model posits that the poorer health^5–7 and earlier deaths^8–10 noted in LGBT people result from a combination of factors, including the stress of concealment, discrimination, and stigma including institutional stigma as evidenced by noninclusive policies.¹¹ Research findings support this model, with health among LGBT people living in states without laws protecting their equal rights documented as being worse than for LGBT people living in states with legal protections.^12–14

Given the documented impact of policy on health, it is important to recognize that many veterans served in the military under the Department of Defense's “Don't Ask, Don't Tell” policy and the recently revoked ban on transgender military service, which was recently considered for reinstatement.¹⁵ Under these policies, concealment of identity was a requirement to serve in the military. Many people consider the Veterans Health Administration (VHA) an extension of the military, given that VHA treats former service members. Many VHA providers and staff are also former military, and several of the policies and structures of VHA follow military culture. For example, VHA does not have a sexual orientation field in the medical record, which can perpetuate a culture of not asking about and not telling sexual orientation in routine care. In addition, similar to many healthcare organizations, there has been little emphasis historically on training in LGBT health for providers, even though VHA never had policies denying care for LGBT veterans.^16,17

It is estimated that there are more than one million LGBT veterans.^18–20 If only a minority of these veterans sought care at VHA, it would be the largest provider of LGBT healthcare in the world.^16,21 Currently, it is not known how many LGBT veterans use VHA, but it appears that LGBT veterans use VHA at elevated rates compared with non-LGBT veterans.^20,22 Thus, it is important to understand LGBT veterans' VHA experiences relative to those of non-LGBT veterans. VHA policies require that facilities create “a welcoming environment” and that veterans do not experience discrimination, including due to sexual orientation and gender identity and expression.²³ LGBT veterans' health research is growing,^{16,17,22,24–27} but information about LGBT veterans' experiences at VHA and how those experiences influence healthcare utilization is currently insufficient for addressing disparities.

Among veterans, a greater proportion of women identify as sexual minorities compared with men,¹⁸ and despite their smaller numbers (<10% in VHA), women veterans are the fastest growing group of VHA users.²⁸ In response, VHA increased availability of women's health services and use of gender-sensitive care models, and required that care be delivered with safety, dignity, and sensitivity to gender-specific needs.²⁹ Women veterans who identify as LGBT may feel the impact of minority stress even more than men, given their dual minority status at VHA (female and LGBT).²¹ Indeed, sexual minority veteran women have worse outcomes compared with both sexual minority nonveterans and with heterosexual veteran women.³⁰ Disparities include elevated mental distress, sleep problems, smoking, and poorer overall health in sexual minority women veterans compared with other groups³⁰ and greater risk for early death.³¹ LGB women veterans are also more likely to have experienced sexual violence, including during military service, compared with non-LGB women veterans.^26,32,33 In general, veterans may benefit from VHA providers' knowledge of veteran-specific issues (e.g., injuries and issues common in wars such as posttraumatic stress disorder [PTSD] and traumatic brain injury), however, LGBT veterans may not feel welcome at VHA,¹⁷ despite policies that specifically require VHA facilities and providers to be welcoming. Moreover, the relationship between feeling welcome (as required by policy) and VHA utilization has not been examined in detail.

Similar to what is seen in the civilian literature, LGBT women veterans report experiencing discrimination, rejection, and/or poor care following disclosure of their sexuality or gender identity to healthcare providers,^25,34–36 or harassment and retaliation from VHA staff and other veterans.^{17,22,26,27,37,38} Harassment is a problem for LGBT people in the civilian population,^39–45 and lesbian veterans have endorsed concerns about harassment or discrimination posing barriers to being open about their identity at VHA.²⁷ However, it is not known how these concerns compare with non-LGBT women veterans' experiences. Since VHA is a primary source of healthcare for many veterans, it is essential to know if minority stress is occurring and if it is affecting care. For example, experiencing harassment may lead to avoidance of locations where harassment has occurred.^39,46 Interactions with other veterans can be an essential component of the healthcare environment (both positive and negative), but no studies have compared LGBT women and non-LGBT women veterans' experiences.

This study aimed to examine LGBT women veterans' experiences with the VHA environment of care, and the impact that those experiences have on use of VHA care. Based on the minority stress model, we hypothesized that LGBT women veterans may feel less welcome and safe at VHA, be more likely to experience harassment, and be more concerned about interactions with other veterans than non-LGBT women veterans. We also asked about whether they delayed or missed needed care due to concern about interactions with other veterans.

Methods

Study design and sample

Data are from a cross-sectional survey of 1391 veterans who had a female gender listed in their medical record^a and at least three primary care and/or women's health medical visits from 12 VHA medical centers across nine states in the previous one-year period. We selected these inclusion criteria to be reflective of the typical female VHA user's average of 3.2 visits in one year.⁴⁷ Deceased veterans and those with incomplete contact information were excluded. The survey, conducted from January 10 to March 23, 2015, is the baseline survey in a 4-year cluster-randomized controlled trial Implementation of Women's Health Patient Aligned Care Teams Study, an evidence-based quality improvement project to address the needs of women veterans, which is described elsewhere.⁴⁸

Data collection

Survey recruitment best practices were used,⁴⁹ sending potential participants a prenotification packet, including an introductory letter, leadership endorsements, and a brochure that provided information about the survey. Up to 12 attempts to contact potential respondents occurred at varying times and days, using a Computer-Assisted Telephone Interviewing system. Survey interviewers were trained to follow an IRB-approved script to obtain verbal informed consent. The response rate among eligible participants was 45% (Fig. 1). The study was approved by the VA Greater Los Angeles Healthcare System Institutional Review Board.

FIG. 1.

CONSORT chart of participant recruitment and exclusion criteria.

Measures

LGBT identity was derived from responses to a pair of items asking (1) “…Do you consider yourself transgender,” (yes/no/not sure) and (2) “Do you think of yourself as ‘lesbian,’ or ‘gay,’ or as ‘straight’ - that is, ‘not lesbian or gay,’ or as ‘bisexual,’ or something else?” We based item wording and question order on a qualitative study of the psychometric properties of sexual and gender identity questions conducted by the Centers for Disease Control and Prevention.⁵⁰ Respondents who self-identified as transgender in the first question and/or lesbian, gay, bisexual or “something else” in the second were classified as LGBT. The option of “something else” was included to capture sexual and gender minority participants who did not identify with the labels offered (e.g., queer). We refer to respondents who did not identify as transgender and indicated that they were straight, not lesbian or gay, as “non-LGBT.” Respondents who answered only the transgender or the sexual identity question were classified according to their single response. Only four respondents could not be categorized as LGBT or non-LGBT due to missing data (e.g., they did not respond or were coded as “not sure” or “refused”) on both items. The reference period for all questions was the previous 12 months, unless otherwise noted.

Outcome variables

Feeling welcome at VHA

Participants were asked how strongly they agreed or disagreed with the statement, “As a woman, I feel welcome at the VA.”⁵¹ The response options were as follows: agree strongly, agree somewhat, neither agree nor disagree, disagree somewhat, and disagree strongly. Responses were dichotomized into those who agreed versus those who were neutral or did not feel welcome.

Feeling unsafe at VHA

Participants were asked if there were any areas at their VHA where they felt particularly unsafe, uneasy, or concerned about their safety. This item was developed based on Operation Enduring Freedom/Operation Iraqi Freedom focus groups and pilot tested for this study. The response options were as follows: Yes, within the last 12 months; Yes, before the last 12 months; or No. Responses were dichotomized into Yes at any point versus No.

Harassment

Participants were asked “How often, if ever, did you feel you experienced inappropriate or unwanted comments or behavior toward you from male veterans?” Responses were never, sometimes, usually, or always. These items were developed for the survey using cognitive interviewing and pilot tested with women Veteran VA users who were not part of the study sample. We dichotomized the responses as Never = 0 versus Any (Sometimes, Usually, Always) = 1.

Descriptions of unwanted encounters

Participants who responded affirmatively to the item about harassment were asked the open-ended question “To help us understand your experiences, please briefly describe or give an example of when you experienced unwanted comments or behavior from male veterans at VA.”

Delayed/missed care

Respondents were asked: “…did you ever delay, put off, or go without care that you felt you needed, or that was recommended to you by a provider?” Response options were as follows: Yes; No; or Not sure. If respondents answered yes, they were asked, “Did concern about having to interact with other veterans cause you to delay or put off getting care from the VA…?” Responses were as follows: Yes; No; or Not sure. Responses were dichotomized as Yes versus No.

Independent variables

Demographics

Age categories corresponding to life stages were used as follows: reproductive years (18–44), middle age (45–64), and older (65+). The two older age categories were combined for the multivariate models due to the small number of observations in cells. A standard battery of U.S. Census yes/no items⁵² was used to create a single race/ethnicity variable with categories of non-Hispanic white, non-Hispanic black, and other race (including Hispanic). Education categories were college degree (yes/no).

Health status

A widely used self-report item assessing overall health was used.⁵³ Responses were poor, fair, good, very good, and excellent. Responses were dichotomized into poor/fair health versus excellent/very good/good health.

Trauma exposure

Trauma exposure was assessed with three Deployment Risk and Resilience Inventory-2 (DRRI-2)⁵⁴ combat stressors items (e.g., combat, mortars, dead bodies) and two items asking if they had ever experienced or witnessed actual or threatened death or serious injury to themselves or someone else (e.g., accidents, rape, natural disaster). A positive response to any of these five items was coded as positive for exposure to potentially traumatic life events.

Military sexual trauma

Military sexual trauma (MST) was assessed using VHA's two-item measure assessing unwanted, threatening, or repeated sexual attention or contact during military service.⁵⁵ Responses were dichotomized as a yes response to either/both items or no to both.

PTSD screen

A PTSD screener⁵⁶ consisted of two questions asking the extent to which respondents had been bothered by stressful events from the past (not at all, a little bit, moderately, quite a bit, or extremely). A positive screen comprised moderately-to-extremely responses on either question. This measure has been validated for use with women in primary care.⁵⁷

Analytic approach

Sampling weights were created to account for the nonproportional sample design, and logistic regression was used to create nonresponse weights. For bivariate comparisons, we report unweighted frequencies and weighted percentages. We used Stata v13 (StataCorp LP, College Station, TX) survey features to account for the complex sampling design for bivariate analysis with chi-square significance tests at P < 0.05. We also used Stata survey features for the multivariate logistic regressions. We performed general linear models as sensitivity analyses. Responses of “not sure” or “refused” were excluded from multivariate analysis on that variable. Verbatim responses to the open-ended description of experiences from self-identified LGBT veteran women that illustrate LGBT-specific concerns are included.

Results

The majority of the respondents (N = 1391) were identified as non-LGBT (n = 1201, 86%). Fourteen percent (n = 190) were identified as LGBT, including 102 lesbian or gay women, 42 bisexual, 21 transgender, and 56 who reported “something else” or “not sure” for their sexual orientation or gender identity, respectively. Participants could report multiple minority identities (e.g., transgender and lesbian), but were only counted once in the final total of 190 LGBT participants. Table 1 compares demographic and health characteristics of LGBT and non-LGBT women veterans. There were no statistically significant differences between LGBT and non-LGBT women with regard to education, self-reported health, or having experienced MST. However, LGBT women veterans were younger compared with non-LGBT women veterans, and a higher proportion of LGBT women identified as nonwhite races/ethnicity, including Hispanic/Latina. Compared to non-LGBT women veterans, LGBT women veterans were more likely to screen positive for trauma exposure and for PTSD.

Table 1.

Comparison of Demographic and Health Characteristics for Self-Identified LGBT and Non-LGBT Women Veterans

	All women veterans n = 1391 n (%)	Non-LGBT n = 1201 n (%)	LGBT n = 190 n (%)	p
Dependent variables^a
Felt welcome at VHA				0.0007
Yes	1255 (89.73)	1097 (91.17)	158 (81.15)
No	125 (9.42)	94 (7.95)	31 (18.16)
Not sure or refused	11 (0.85)	10 (0.88)	1 (0.69)
Felt unsafe at VHA				0.0169
Yes	132 (9.97)	100 (8.55)	32 (18.43)
No	1250 (89.37)	1094 (90.83)	156 (80.63)
Not sure or refused	9 (0.66)	7 (0.62)	2 (0.94)
Experienced harassment				0.0030
Yes	325 (24.26)	254 (21.89)	71 (38.43)
No	1058 (75.12)	940 (77.5)	118 (60.88)
Not sure or refused	8 (0.62)	7 (0.61)	1 (0.69)
Delayed or missed care due to concern about interactions with other veterans				<0.001
Yes	66 (5.09)	41 (3.58)	25 (14.11)
No	1322 (94.69)	1157 (96.17)	165 (85.89)
N/A, not sure, or refused	3 (0.22)	3 (0.25)	0
Demographics
Age group				0.0220
18–44	370 (34.99)	311 (34.13)	59 (40.11)
45–64	754 (50.31)	645 (50.01)	109 (52.13)
65+	263 (14.4)	242 (15.59)	21 (7.3)
Missing or refused	4 (0.30)	3 (0.27)	1 (0.46)
Race/Ethnicity				0.0101
Non-Hispanic White	853 (58.3)	757 (60.06)	96 (47.75)
Non-Hispanic Black	317 (24.76)	269 (24.54)	48 (26.05)
Other race (includes Hispanic)	203 (15.57)	161 (14.21)	42 (23.75)
Not sure or refused	18 (1.37)	14 (1.19)	4 (2.45)
Education				0.3475
No college degree	859 (60.86)	751 (61.6)	108 (56.48)
College degree	529 (38.94)	447 (38.17)	82 (43.52)
Missing or refused	3 (0.2)	3 (0.23)	0
Self-reported health				0.1550
Excellent/Very Good/Good	869 (62.65)	760 (63.54)	109 (57.31)
Fair/Poor	517 (37.01)	437 (36.17)	80 (42.07)
Not sure or refused	5 (0.34)	4 (0.29)	1 (0.62)
Positive screens for:
Lifetime combat trauma exposure				0.0274
Yes	1096 (80.27)	934 (79.32)	162 (85.98)
No	295 (19.73)	267 (20.68)	28 (14.02)
Military sexual trauma (MST)				0.1120
Yes	841 (60.67)	713 (59.4)	128 (68.23)
No	527 (37.78)	468 (39.03)	59 (30.37)
Not sure/refused/does not apply	23 (1.55)	20 (1.57)	3 (1.40)
PTSD (VHA 2-item)				0.0013
Yes	557 (40.54)	455 (38.42)	102 (53.16)
No	820 (58.45)	735 (60.74)	85 (44.77)
Not sure/refused/does not apply	14 (1.01)	11 (0.84)	3 (2.07)

Included are unweighted frequencies and weighted percentage estimates.

Statistically significant p-values < 0.05 are bolded

Respondents indicating “not sure” or “refused” were excluded from the multivariate analyses.

VHA, Veterans Health Administration; PTSD, posttraumatic stress disorder

As presented in Table 2, LGBT identity was associated with different experiences with the environment of VHA care compared with non-LGBT women veterans. In models that adjusted for age, race/ethnicity, educational attainment, self-reported health, and positive screens for PTSD, MST, and other trauma, LGBT women were less likely to feel welcome at VHA (AOR 0.46, P < 0.01), more likely to feel unsafe at VHA (AOR 2.24, P < 0.05), and more likely to report experiencing harassment by male veterans (AOR 1.80, P < 0.05) than non-LGBT women. Among those who had delayed/missed care, LGBT women were more likely to attribute the missed care to concern about interactions with other veterans (AOR 3.47, P < 0.001). In general linear model sensitivity analyses, the results were unchanged.

Table 2.

LGBT Identity as a Predictor of Veterans Health Administration Experience and Utilization

	Felt welcome at VHA				Felt unsafe at VHA				Experienced harassment				Delayed/missed care—concern about interactions
	AOR	p	LB	UB	AOR	p	LB	UB	AOR	p	LB	UB	AOR	p	LB	UB
Non-LGBT	(base)
LGBT	0.46	0.006	0.27	0.76	2.24	0.033	1.08	4.63	1.80	0.048	1.01	3.23	3.47	<0.001	2.17	5.56
Age 18–44	(base)
Age 45 and older	1.25	0.284	0.89	2.25	0.83	0.349	0.91	1.86	0.89	0.246	0.72	1.1	0.85	0.656	0.38	1.90
Race/Ethnicity
Non-Hispanic White	(base)
Non-Hispanic Black	1.41	0.131	0.89	2.25	1.30	0.130	0.91	1.86	0.28	0.270	0.80	2.05	0.65	0.180	0.34	1.26
Hispanic/Other	1.27	0.567	0.52	3.06	0.95	0.847	0.55	1.66	0.24	0.338	0.78	1.97	1.13	0.733	0.52	2.48
Education
No college degree	(base)
College degree	0.63	0.016	0.44	0.90	1.31	0.322	0.74	2.31	1.23	0.066	0.98	1.54	1.04	0.903	0.51	2.11
Self-reported health
Excellent/very good/good	(base)
Fair/poor	0.52	0.011	0.32	0.84	1.15	0.163	0.94	1.41	1.78	0.001	1.32	2.40	1.53	0.110	0.89	2.61
Positive screen for trauma exposure	0.27	0.015	0.10	0.73	1.88	0.103	0.86	4.13	2.98	<0.001	1.88	4.72	1.65	0.593	0.22	12.36
Positive screen for MST	0.33	0.002	0.18	0.59	2.77	0.001	1.73	4.42	3.48	<0.001	2.21	5.50	9.76	0.002	2.82	33.73
Positive screen for PTSD	0.62	0.009	0.44	0.86	2.72	<0.001	1.85	4.00	1.22	0.172	0.90	1.64	7.22	0.002	2.40	21.70

Models controlled for age, race/ethnicity, education, self-reported health, and positive screens for PTSD, MST, and other trauma.

Statistically significant p-values < 0.05 are bolded.

Descriptions of harassment

Women veterans were asked to provide an example of unwanted interactions with male veterans at VHA when they endorsed having these experiences. Without prompting, LGBT women's descriptions included references to harassment specific to their LGBT identities. For example, “When you walk into the VA, you get stares or statements such as “Dyke” or other inappropriate lack of respect.” Or, “When in the waiting room some guys make comments about lesbians getting care at the VA.” One woman veteran characterized the harassment she experienced as “Comments about me being a boy or girl… gender comments.” A transgender woman veteran reported, “When I switched doctors I had a choice of the regular clinic or the women's clinic. I wanted the women's clinic because I am transgender. I hope that I won't have to sit in front of 50 male veterans undressing me with their eyes. I know that I am not a genetic female, but that is a terrible experience. In my case being transgender, it is so much more comfortable with women. The main number one thing that was uncomfortable is the waiting room.”

Discussion

This study is the first population-based study of routine users of VHA primary care to compare the experiences of LGBT and non-LGBT women veterans in the VHA healthcare environment, and the impact of those experiences on their use of VHA care. In line with an earlier qualitative study,²⁷ the majority of women veterans reported feeling welcome at their VHA facilities, which is a positive and important finding. However, consistent with minority stress theory, fewer LGBT women veterans reported feeling welcome at VHA compared with non-LGBT women veterans. Furthermore, LGBT women veterans endorsed feeling unsafe at VHA and experiencing harassment from male veterans at higher rates than non-LGBT women. LGBT women who reported delaying or missing needed care were more likely to attribute that missed care to concern about interacting with other veterans.

Open-ended responses describing harassment indicated that the comments and actions of male veterans made it difficult for some LGBT women veterans to feel comfortable when accessing VHA care. Therefore, it is not surprising that LGBT women reported delaying or missing needed care. However, it is concerning that more than three times as many LGBT women who missed care did so specifically out of concern about interacting with other veterans (relative to non-LGBT peers), suggesting that education efforts directed toward increasing LGBT women veterans' safety and security at VHA are critically needed. VHA is increasingly becoming the provider of choice for women veterans.⁵⁸ Thus, when LGBT veterans miss appointments, the needed care may not be attained elsewhere, and this could be one variable contributing to poorer health outcomes in this population.

Creating a safe and welcoming environment at VHA is important for women veterans generally, but these findings indicate that for LGBT women in particular, this is a serious concern. Thus, despite VHA's ongoing efforts to educate employees and change the culture toward a more inclusive environment,¹⁶ more targeted work addressing the needs of LGBT women veterans may be needed. It is possible that interventions with male veterans are needed, such as those that underscore the shared veteran identity and encourage veterans to be supportive of one another. It is unclear if LGBT women veterans have similar experiences in other healthcare environments, as LGBT studies outside the VHA generally do not report data about veteran status.⁵⁹ In addition, the volume of women veterans using VHA care is increasing, with nearly a doubling between fiscal years 2001 and 2010.⁶⁰ Women veterans also use non-VA providers for services that VHA is not able to deliver locally through the Veterans Choice Act.^60,61 Even though these women are accessing a non-VA provider, the care is considered VHA care, since VHA coordinates and pays for that care. Thus, environments of care beyond VHA facilities are salient for LGBT women veterans.

Limitations

Limitations to our study include reliance on cross-sectional telephone survey self-reports about healthcare experiences and utilization. To mitigate these effects, we followed best practices for encouraging unbiased and honest recall.⁴⁹ While response rate is an unreliable indicator of bias,⁶² with a 45% response rate there is potential for undetected bias in the sample, even after using sampling frame adjustments to correct for differential non-response. When women veterans endorsed delaying or missing care, we specifically asked if this was due to concerns about interacting with other veterans, therefore, it is possible that other reasons for delaying or missing care were more prominent, but unasked. To ensure familiarity with the VHA primary care environment, we sampled routine users with three or more visits in the past year. This cohort may differ from other women veterans in important but untested ways. Moreover, our analyses combine a heterogeneous group of LGBT veterans and did not include a two-step assessment of birth sex and gender identity, which is the current gold standard. Future work should examine if there are particular risks or resiliencies among subgroups of veterans. In addition, this study specifically asked participants about harassment and unwanted experiences with male veterans, but did not ask about interactions with other patients, VHA support, or professional staff, which could influence willingness to seek care. Finally, while our sample was drawn from routine users of 12 diverse VHA sites across nine states, some findings may not be directly generalizable to other locales or women who used VHA less frequently.

Balancing these limitations, the study also has strengths. The representative sample of women veterans with three or more visits included 190 LGBT women veterans, one of the largest samples we are aware of to date. These data are important to healthcare systems as they consider how to collect data on gender identity and sexual orientation, so they can respond to LGBT veterans' unique needs and create more welcoming environments.⁶³ To our knowledge, this is the first study directly comparing the experiences and preferences of LGBT and non-LGBT women receiving care in the same care system and clinical sites.

Conclusions

VHA is working toward creating an environment where all veterans feel supported and receive quality care. There is a focus in VHA on meeting the unique needs of women veterans, veterans with MST histories, and now also LGBT veterans. In 2012, VHA established a LGBT Health Program within the Office of Patient Care Services in Washington D.C. and improvements have occurred, including a LGBT Veteran Care Coordinator at every facility since 2016.¹⁶ However, these findings suggest that some challenges remain, including potentially lingering effects of the military culture where both women and LGBT people historically have not been welcomed. Fortunately, both the military and the VHA systems are focusing on becoming more inclusive. Culture change may require sustained educational and other initiatives directed toward employees and veteran customers. There are several such programs already underway at VHA,⁶⁴ with the safety, health, and well-being of LGBT veterans being a focus. This research supports the need for continuing such efforts and additional research on improving healthcare environments. For example, a more in-depth assessment of experiences in healthcare environments that comprehensively assesses provider, staff, and other veteran interactions, as well as their influence on veteran healthcare seeking behaviors is needed. In this work, understanding best practices for all veterans, with tailored emphasis on vulnerable populations, such as LGBT veterans, is needed.

Footnotes

Acknowledgments

The WH-PACT study (# CRE12-026) was funded by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development (HSR&D) Service through the CREATE initiative. Dr. Yano's effort was funded by a VA HSR&D Senior Research Career Scientist Award (Project # RCS 05-195), the Women's Health Research Consortium/Practice-Based Research Network (# SDR 10-012), and the VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (# CIN 13-417). The data are registered at , NCT02039856.

We thank the WH-PACT patient survey team, specifically, Ismelda Canelo, MPA for her qualitative coding assistance, Barbara Simon, MA and Alissa Simon, MA for their contributions to survey planning and instrument development, Andrew Lanto, MA for his work on sampling and analysis, and research assistant Anneka Oishi, BA for her invaluable support. We relied on the expertise of the staff of Davis Research, LLC of Calabasas, California who assisted with pretesting and training, interfaced with the VA Veterans Crisis Line to ensure participant emotional safety, and conducted the interviews. Above all, we are grateful for the participation of the women Veterans who helped with question testing and provided the information reported in this study.

Disclaimer

These data were presented, in part, (although not in their entirety) at the Annual Research Meeting and in the Gender and Health Interest Group Meeting for AcademyHealth in Boston, MA, June 2016. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Author Disclosure Statement

No competing financial interests exist.

a

The VHA record system sometimes displays this field as “sex” and sometimes displays this same field as “gender” in the record system. Furthermore, it is possible for this field to be updated by a veteran with support from a medical professional and the facility Privacy Officer. It is possible that this sample includes transgender women who had updated this field, transgender men who had not yet updated this field, and veterans with nonbinary gender identities, as the system only allows binary selections of male or female.

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