Veterans' Reported Comfort in Disclosing Sexual Orientation and Gender Identity.

BACKGROUND: The Veterans Health Administration (VHA) does not routinely collect and document sexual orientation and gender identity (SOGI) data despite research on health disparities among sexual and gender minority (SGM) veterans. Due to the legacy of previous Department of Defense policies that prohibited disclosure of sexual or gender minority identities among active-duty personnel, minority veterans may be reluctant to respond to SOGI questions on confidential VHA surveys and in discussions with their VHA providers. Veterans may generally find SOGI questions uncomfortable and may not appreciate their relevance to health care. OBJECTIVE: The purpose of this research was to examine veterans' comfort in reporting identity characteristics on confidential VHA surveys and in discussion with their VHA providers and whether comfort differed by sociodemographic characteristics. RESEARCH DESIGN: The project involves the secondary analysis of quantitative data from a quality improvement survey project. SUBJECTS: A total of 806 veterans were surveyed. RESULTS: Overall, 7.15% endorsed sexual or gender minority identity which is a higher rate than the 4.5% noted in the general US population. Cisgender and heterosexual veterans were more comfortable reporting identity characteristics both on VHA confidential surveys and in discussion with VHA providers compared with SGM veterans. CONCLUSIONS: These data suggest that the majority of veterans feel comfortable reporting their identities both on surveys and in the context of health care. Understanding these perceptions can assist VHA programs in implementing SOGI data collection and disclosure in clinical care, creating a welcoming environment of care for SGM veterans that does not make veterans from other backgrounds feel uncomfortable.

Lesbian, Gay, Bisexual, and Transgender Veterans' Experiences of Discrimination in Health Care and Their Relation to Health Outcomes: A Pilot Study Examining the Moderating Role of Provider Communication.

Purpose: Lesbian, gay, bisexual, and transgender (LGBT) veterans report discrimination in health care, which may be associated with negative health outcomes/behaviors and has implications for LGBT identity disclosure to providers. Quality provider communication may serve to offset some of the deleterious effects of discrimination; however, no research to date has examined provider communication with respect to health among LGBT patients. Methods: Participants were 47 LGBT veterans who completed measures related to past health care experiences, experiences of discrimination in health care, perceptions of provider communication, and measures of anxiety, depression, post-traumatic stress disorder symptoms, and alcohol/tobacco use. Results: The majority of LGBT veterans reported experiencing LGBT-based discrimination in health care, which was associated with higher rates of tobacco use and less comfort in disclosing their LGBT identity to providers. We also found evidence of moderation, such that high-quality provider communication appeared to buffer these associations. Conclusion: LGBT veterans face unique challenges with respect to receiving appropriate health care. The high frequencies of reported discrimination in health care is problematic and warrants further research and intervention. These results highlight the important role of provider communication, and the potential for quality communication to buffer against certain effects, particularly with respect to tobacco use and LGBT identity disclosure, which is an important protective factor.

Utilization of the Veterans Affairs' Transgender E-consultation Program by Health Care Providers: Mixed-Methods Study.

BACKGROUND: In 2015, the Department of Veterans Affairs (VA) nationally implemented a transgender e-consultation (e-consult) program with expert clinical guidance for providers. OBJECTIVE: This mixed-methods project aimed to describe providers' program experiences, reasons for nonuse of the program, and ways to improve the program use. METHODS: From January to May 2017, 15 urban and rural VA providers who submitted at least one e-consult in the last year participated in semistructured interviews about their program experiences, which were analyzed using content analysis. From November to December 2017, 53 providers who encountered transgender patients but did not utilize the program participated in a brief online survey on the reasons for nonuse of the program and the facilitators encouraging use. RESULTS: Qualitative analysis showed that providers learned of the program through email; colleagues; the electronic health record (EHR) system; and participation in the VA Lesbian, Gay, Bisexual, and Transgender committees or educational trainings. Providers used the program to establish care plans, hormone therapy recommendations, sexual and reproductive health education, surgical treatment education, patient-provider communication guidance, and second opinions. The facilitators of program use included understandable recommendations, ease of use through the EHR system, and status as the only transgender resource for rural providers. Barriers to use included time constraints, communication-related problems with the e-consult, impractical recommendations for underresourced sites, and misunderstanding of the e-consult purpose. Suggestions for improvement included addition of concise or sectioned responses, expansion of program awareness among providers or patients, designation of a follow-up contact person, and increase in provider education about transgender veterans and related care. Quantitative analysis showed that the common reasons for nonuse of the program were no knowledge of the program (54%), no need of the program (32%), and receipt of help from a colleague outside of e-consult (24%). Common suggestions to improve the program use in quantitative analyses included provision of more information about where to find e-consult in the chart, guidance on talking with patients about the program, and e-mail announcements to improve provider awareness of the program. Post hoc exploratory analyses showed no differences between urban and rural providers. CONCLUSIONS: The VA transgender e-consult program is useful for providers, but there are several barriers to implementing recommendations, some of which are especially challenging for rural providers. Addressing the identified barriers and enhancing the facilitators may improve program use and quality care for transgender veterans.

Experiences of trauma, discrimination, microaggressions, and minority stress among trauma-exposed LGBT veterans: Unexpected findings and unresolved service gaps.

OBJECTIVE: LGBT veterans experience high rates of trauma, discrimination, and minority stress. However, guidelines for case conceptualization and treatment remain limited. The aim of the current study was to examine the experiences of trauma and other high impact experiences among LGBT veterans to inform case conceptualization and treatment. METHOD: We recruited 47 LGBT veterans with a history of exposure to LGBT-related Criterion A trauma and performed semistructured interviews about their experiences in trauma treatment, barriers to engagement, and treatment needs and preferences. We used thematic analysis of qualitative codes guided by inductive and deductive approaches to characterize the variety of trauma and high impact experiences reported. RESULTS: LGBT veterans disclosed a range of clinically relevant stressors, including Criterion A traumatic events, minority stress, and microaggression experiences, including interpersonal and institutional discrimination perpetrated by fellow service members/veterans, citizens, therapy group members, and health care providers. CONCLUSION: These data provide a unique account of LGBT veteran's identity-related trauma and concomitant interpersonal and institutional discrimination, microaggression experiences, minority stress, and traumatic stress symptoms. Findings highlight existing service gaps regarding evidence-based treatments for the sequalae of trauma, discrimination, microaggressions, and minority stress. In addition, we noted past and present issues in military and health care settings that may lead to or exacerbate trauma-related distress and discourage treatment seeking among LGBT veterans. We provide suggestions for clinical work with LGBT veterans and encourage ongoing research and development to eliminate remaining service gaps. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Advancing LGBT Health Care Policies and Clinical Care Within a Large Academic Health Care System: A Case Study.

Culturally competent health care is especially important among sexual and gender minority patients because poor cultural competence contributes to health disparities. There is a need to understand how to improve health care quality and delivery for lesbian, gay, bisexual, and transgender (LGBT) veterans in particular, because they have unique physical and mental health needs as both LGBT individuals and veterans. The following article is a case study that focuses on the policy and clinical care practices related to LGBT clinical competency, professional training, and ethical provision of care for veteran patients in the VA Boston Healthcare System. We apply Betancourt et al.'s (2003) cultural competence framework to outline the steps that VA Boston Healthcare System took to increase cultural competency at the organizational, structural, and clinical level. By sharing our experiences, we aim to provide a model and steps for other health care systems and programs, including other VA health care systems, large academic health care systems, community health care systems, and mental health care systems, interested in developing LGBT health initiatives.

Intrusive Cognitive Content and Postdeployment Distress.

Although intrusive cognitions (ICs) are common posttrauma, little is known about trauma-related IC content, or associations between IC content and posttraumatic adjustment. A mixed-method cross-sectional approach was used in a secondary analysis of IC content and postdeployment distress. Participants were 1,521 U.S. Army soldiers 3-12 months postdeployment reporting their most distressing postdeployment ICs (mean number of ICs reported was 1.20). ICs were transcribed and content was categorized by 13 emergent themes. The most commonly reported ICs were of injury or death (48.2%) and combat (43.5%), and soldiers with probable posttraumatic stress disorder (PTSD; n = 187) were more likely to report the presence of these ICs, χ(2) s(1) = 35.27, ps < .001, φs < .16 than those without probable PTSD (n = 1,331). Other domains also emerged frequently, including ICs about friends (31.0%), family (15.8%), and leadership concerns (13.8%). IC content was a small, but significant correlate of distress after adjusting for combat exposure (ΔR(2) ≥ .02, ps ≤ .001). The presence of ICs of injury or death, combat, military sexual trauma, health, leadership, and family (ßs > .06, ps < .02) were unique correlates of distress. Results suggested that ICs about a wide range of topics should be addressed in postdeployment interventions.

Nationwide Interdisciplinary E-Consultation on Transgender Care in the Veterans Health Administration.

BACKGROUND: Veteran's Health Administration (VHA) requires the provision of quality transgender care for the relatively large number of transgender veterans using VHA services. INTRODUCTION: The Office of Patient Care Services has taken a multimethod approach to improving provider knowledge and skill for transgender veteran care. However, unique patient-specific questions can arise. Thus, VHA implemented a 3-year feasibility program to determine if nationwide interdisciplinary e-consultation can offer veteran-specific consultation to providers who treat transgender veterans in VHA. MATERIALS AND METHODS: Launch of this program is described along with use to date, types of questions submitted by providers, and length of time to complete a response in the veteran's electronic medical record. RESULTS: In 17 months, the program responded to 303 e-consults, with consultation provided on the care of 230 unique veterans. Nationwide coverage was achieved 1 year after the launch of the program. Common consult questions have been about medications, including hormones (n = 125); primary care concerns (n = 97); mental health evaluations (n = 63); and psychotherapy (n = 18). Consistent with the interdisciplinary model, multiple disciplines typically responded to each consult (x = 2.27). Average time to completion of a consult was 5.9 calendar days (range = 2.4-7.7 days). DISCUSSION: VHA has established a nationwide interdisciplinary e-consultation program. Additional outreach about the program will be needed if funding is continued. CONCLUSIONS: E-consultation on transgender health within VHA is feasible and complements the suite of trainings offered within VHA. Other healthcare organizations may benefit from a similar program.

System-Level Influences on the Sustainability of a Cognitive Therapy Program in a Community Behavioral Health Network.

OBJECTIVE: The purpose of this study was to examine influences on the sustainability of a program to implement an evidence-based psychotherapy in a mental health system. METHODS: Interviews with program administrators, training consultants, agency administrators, and supervisors (N=24), along with summaries of program evaluation data and program documentation, were analyzed with a directed content-analytic approach. RESULTS: Findings suggested a number of interconnected and interacting influences on sustainability, including alignment with emerging sociopolitical influences and system and organizational priorities; program-level adaptation and evolution; intervention flexibility; strong communication, collaboration, planning, and support; and perceived benefit. These individual factors appeared to mutually influence one another and contribute to the degree of program sustainability achieved at the system level. Although most influences were positive, financial planning and support emerged as potentially both facilitator and barrier, and evaluation of benefits at the patient level remained a challenge. CONCLUSIONS: Several factors appeared to contribute to the sustainability of a psychosocial intervention in a large urban mental health system and warrant further investigation. Understanding interconnections between multiple individual facilitators and barriers appears critical to advancing understanding of sustainability in dynamic systems and adds to emerging recommendations for other implementation efforts. In particular, implications of the findings include the importance of implementation strategies, such as long-term planning, coalition building, clarifying roles and expectations, planned adaptation, evaluation, diversification of financing strategies, and incentivizing implementation.

Understanding Health-Care Needs of Sexual and Gender Minority Veterans: How Targeted Research and Policy Can Improve Health.

Given the size of the patient population of the Veterans Health Administration (VHA), it is likely the largest single provider of health care for sexual and gender minority (SGM) individuals in the United States, including lesbian, gay, bisexual, and transgender persons. However, current VHA demographic data-collection strategies limit the understanding of how many SGM veterans there are, thereby making a population-based understanding of the health needs of SGM veterans receiving care in VHA difficult. In this article, we summarize the emergent research findings about SGM veterans and the first initiatives that have been implemented by VHA to promote quality care. Though the research on SGM veterans is in its infancy, it suggests that SGM veterans share some of the health risks noted in veterans generally and also risks associated with SGM status. Some promising resiliency factors have also been identified. These findings have implications for both VHA and non-VHA systems in the treatment of SGM veterans. However, more research on the unique needs of SGM veterans is needed to fully understand their health risks and resiliencies in addition to health-care utilization patterns.