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Ensuring Appropriate Care for LGBT Veterans in the Veterans Health Administration by Virginia Ashby Sharpe and Uchenna S. Uchendu
W
ithin health care systems, negative perceptions of lesbian, gay, bisexual, and transgender persons have often translated into denial of services, denial of visitation rights to same-sex partners, reluctance on the part of LGBT patients to share personal information, and failure of workers to assess and recognize the unique health care needs of these patients. Other bureaucratic forms of exclusion have included documents, forms, and policies that fail to acknowledge a patient’s valued relationships because of, for example, a narrow definition of “spouse,” “parent,” or “family.” Bureaucratic exclusion has taken a particularly prominent form in the U.S. military. Until its repeal and termination in 2011, the “Don’t Ask, Don’t Tell” policy had for eighteen years barred openly gay men and lesbians from serving in the military. (Although DADT’s repeal ended official support for discrimination against lesbian, gay, and bisexual persons in the military, it did not change the Department of Defense’s [DoD’s] exclusion of transgender individuals from serving.) Among the effects of DADT (and of the ongoing policy barring transgender individuals from military service) is a dearth of information about the number and needs of LGBT service members who transition from the DoD to the Veterans Health Administration (VHA) for health care at the end of their military service. The long-standing social stigma against LGBT persons, the silence mandated by DADT, and the often unrecognized bias built into the fabric of bureaucratic systems make the task of
creating a welcoming culture in the VHA urgent and challenging. The VHA has accepted a commitment to that task. Its Strategic Plan for fiscal years 2013 through 2018 stipulates that “[v]eterans will receive timely, high quality, personalized, safe, effective and equitable health care irrespective of geography, gender, race, age, culture or sexual orientation.”1 To achieve this goal, the VHA undertook a number of coordinated initiatives to create an environment and culture that is informed, welcoming, positive, and empowering for the LGBT veterans and families whom the agency serves. These initiatives include
Virginia Ashby Sharpe and Uchenna S. Uchendu, “Ensuring Appropriate Care for LGBT Veterans in the Veterans Health Administration,” LGBT Bioethics: Visibility, Disparities, and Dialogue, special report, Hastings Center Report 44, no. 5 (2014): S53-S55. DOI: 10.1002/hast.372
•
establishing the Office of Health Equity to address health disparities and ensure that all veterans receive appropriate, individualized, and patient-driven care in a way that reduces disparate health outcomes and assures health equity regardless of race; ethnicity; sex; age; socioeconomic status; geography; sexual orientation; mental health; physical, cognitive, or sensory disabilities; or other characteristics historically linked to discrimination or exclusion that result in health disparities;2
•
broadening standards on nondiscrimination to mandate respectful delivery of care to transgender and intersex veterans3 and LGB veterans4 and to protect these veterans from discrimination in federally funded education and training programs;5
•
revising official language to be more inclusive of nontraditional families, such as by revising hospital visitation policies to allow patients to determine and
SPECIAL REP ORT: L G B T B io et h ic s: Visib ilit y, D i s p a ri ti e s , a n d D i a l og u e
S53
One of the most complex issues Veterans Affairs has encountered in its efforts to provide equitable health care to LGBT veterans centers on the collection of sexual orientation and gender identity data. restrict whom they wish to visit them and redefining “family” to include “anyone the patient considers to be family”; •
partnering with advocacy organizations to identify outreach mechanisms and materials to improve cultural competency of the workforce and health outcomes for LGBT patients;
•
undertaking specific initiatives to create a welcoming environment for LGBT veterans, such as by providing facility booths at Gay Pride events, organizing local events to recognize National Coming Out Day, and initiating hospital-wide conferences on LGBT veteran health care;
•
developing and providing clinical education training for health care providers, such as clinical guidance criteria for cross-sex hormone therapy, and establishing regional interdisciplinary clinical consultation programs on transgender health; and
•
taking steps to enable veterans to self-identify their sexual orientation, gender identity, and relationship status so that these demographic data can be used to assess health and health equity.
The VHA’s efforts to transform its organizational culture and create a welcoming environment for LGBT veterans have been recognized beyond the agency. In 2013, 121 Veterans Affairs facilities voluntarily participated in the Human Rights Campaign’s 2013 Health Equality Index (HEI), and 76 percent were awarded HEI Equality Leader status for meeting “core leader” criteria for LGBT care— for their patient nondiscrimination policies, equal visitation policies, employment nondiscrimination policies, and training in LGBT patient-centered care.6 One of the most complex and ethically interesting issues that Veterans Affairs has encountered in its efforts to provide equitable health care to LGBT veterans centers on data collection. LGBT persons, especially those who have served in the U.S. military, are understandably reluctant to share information that could be used to adversely affect their careers. In addition, health care providers do not S54
routinely initiate discussions about a patient’s sexual orientation, and intake forms in health care systems are not typically designed to collect information about sexual orientation or gender identity. These factors often make the specific needs of LGBT patients invisible, preventing the collection, discussion, and dissemination of information that can be used to establish best practices and to assess health and health equity. Indeed, it was with the specific purposes of advancing health equity and overcoming barriers to access and quality that the Institute of Medicine recently recommended collecting sexual orientation and gender identity data in electronic health records. As the Institute of Medicine observed, it is also important to create an environment in which individuals who have historically been stigmatized and discriminated against feel safe providing this information.7 Under the current electronic health information exchange system and the planned interoperable electronic record, VHA health records are available to health care professionals in the DoD, where they may be used for both health care and nonhealth care purposes (for example, for assessing fitness for duty). By law, reservists and National Guard members are eligible to receive care as civilians through the VHA but may be recalled to active duty in the military. Although the repeal of DADT now prevents the DoD from initiating an adverse action based on information about homosexuality among reactivated reservists or National Guard members, the Veterans Affairs’s electronic health record does not provide an environment in which information about transgender status is assured confidentiality relative to DoD. Under the health equity initiatives outlined above, the VHA is actively reaching out to transgender veterans to affirm a policy of inclusion and nondiscrimination. To make good on this promise, the VHA is seeking to ensure that the goal of data collection—even for the important purpose of health equity—is mindful of a transgender patient’s legitimate desire that certain information not be shared outside of the clinician-patient relationship. With this in mind, the ethical challenge is to ensure that functionalities for collecting gender information— specifically information about transgender status—in the Veterans Affairs electronic health record September-October 2014/ H A S T I N G S CE NTE R RE P O RT
•
enable veterans to select their self-identified gender from a variety of choices, including “other” and “individual chooses not to answer”;
•
provide a dynamic self-identified field that can be updated by the veteran; and
•
provide a mechanism for the self-identified gender field to be excluded from data-sharing outside the VA.
Improving ethical practices within a large, bureaucratic, integrated health care system depends on multilevel organizational change and learning strategies. By establishing an Office of Health Equity at the highest level of the organization and including equity as a specific objective in its strategic plan, the VHA’s goal is to diminish and, where possible, eliminate health disparities in veteran populations that have historically been subject to marginalization and discrimination. Acknowledgment
We gratefully acknowledge the work of the VHA LGBT Health Equity Workgroup for its recommendations report and also the individuals, medical facilities, program offices, and leadership that have supported and promoted the initiatives described in this paper.
1. Veterans Health Administration, “VHA Strategic Plan FY 2013-2018,” http://www.va.gov/health/docs/VHA_STRATEGIC_ PLAN_FY2013-2018.pdf. 2. U. Uchendu, “VHA Office of Health Equity: What Is It All About?,” accessed July 1, 2014, http://www.hsrd.research. va.gov/for_researchers/cyber_seminars/archives/video_archive. cfm?SessionID=769. 3. U.S. Department of Veterans Affairs, Veterans Health Administration, VHA Directive 2013-003, “Providing Health Care for Transgender and Intersex Veterans,” February 8, 2013, www. va.gov/vhapublications/ViewPublication.asp?pub_ID=2863. 4. Under Secretary for Health’s Information Letter (IL 10-201414), “Guidance Regarding the Provision of Health Care for Lesbian, Gay, and Bisexual Veterans, 10P4—Office of Patient Care Services,” July 1, 2014, http://www.va.gov/vhapublications/publications. cfm?pub=3. 5. U.S. Department of Veterans Affairs, Veterans Health Administration, VHA Directive 1018, “Nondiscrimination in Federally-Conducted Education and Training Programs,” May 20, 2013, www.va.gov/vhapublications/ViewPublication.asp?pub_ ID=1733. 6. Human Rights Campaign, “Healthcare Equality Index: HEI 2O13 Leaders in LGBT Healthcare Equality,” http://www.hrc.org/ hei/about-the-hei. 7. Institute of Medicine, Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding (Washington, D.C.: National Academies Press, 2011); Institute of Medicine, Collecting Sexual Orientation and Gender Identity Data in Electronic Health Records: Workshop Summary (Washington, DC: National Academies Press, 2013).
SPECIAL REP ORT: L G B T B io et h ic s: Visib ilit y, D i s p a ri ti e s , a n d D i a l og u e
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Ensuring Appropriate Care for LGBT Veterans in the Veterans Health Administration by Virginia Ashby Sharpe and Uchenna S. Uchendu
W
ithin health care systems, negative perceptions of lesbian, gay, bisexual, and transgender persons have often translated into denial of services, denial of visitation rights to same-sex partners, reluctance on the part of LGBT patients to share personal information, and failure of workers to assess and recognize the unique health care needs of these patients. Other bureaucratic forms of exclusion have included documents, forms, and policies that fail to acknowledge a patient’s valued relationships because of, for example, a narrow definition of “spouse,” “parent,” or “family.” Bureaucratic exclusion has taken a particularly prominent form in the U.S. military. Until its repeal and termination in 2011, the “Don’t Ask, Don’t Tell” policy had for eighteen years barred openly gay men and lesbians from serving in the military. (Although DADT’s repeal ended official support for discrimination against lesbian, gay, and bisexual persons in the military, it did not change the Department of Defense’s [DoD’s] exclusion of transgender individuals from serving.) Among the effects of DADT (and of the ongoing policy barring transgender individuals from military service) is a dearth of information about the number and needs of LGBT service members who transition from the DoD to the Veterans Health Administration (VHA) for health care at the end of their military service. The long-standing social stigma against LGBT persons, the silence mandated by DADT, and the often unrecognized bias built into the fabric of bureaucratic systems make the task of
creating a welcoming culture in the VHA urgent and challenging. The VHA has accepted a commitment to that task. Its Strategic Plan for fiscal years 2013 through 2018 stipulates that “[v]eterans will receive timely, high quality, personalized, safe, effective and equitable health care irrespective of geography, gender, race, age, culture or sexual orientation.”1 To achieve this goal, the VHA undertook a number of coordinated initiatives to create an environment and culture that is informed, welcoming, positive, and empowering for the LGBT veterans and families whom the agency serves. These initiatives include
Virginia Ashby Sharpe and Uchenna S. Uchendu, “Ensuring Appropriate Care for LGBT Veterans in the Veterans Health Administration,” LGBT Bioethics: Visibility, Disparities, and Dialogue, special report, Hastings Center Report 44, no. 5 (2014): S53-S55. DOI: 10.1002/hast.372
•
establishing the Office of Health Equity to address health disparities and ensure that all veterans receive appropriate, individualized, and patient-driven care in a way that reduces disparate health outcomes and assures health equity regardless of race; ethnicity; sex; age; socioeconomic status; geography; sexual orientation; mental health; physical, cognitive, or sensory disabilities; or other characteristics historically linked to discrimination or exclusion that result in health disparities;2
•
broadening standards on nondiscrimination to mandate respectful delivery of care to transgender and intersex veterans3 and LGB veterans4 and to protect these veterans from discrimination in federally funded education and training programs;5
•
revising official language to be more inclusive of nontraditional families, such as by revising hospital visitation policies to allow patients to determine and
SPECIAL REP ORT: L G B T B io et h ic s: Visib ilit y, D i s p a ri ti e s , a n d D i a l og u e
S53
One of the most complex issues Veterans Affairs has encountered in its efforts to provide equitable health care to LGBT veterans centers on the collection of sexual orientation and gender identity data. restrict whom they wish to visit them and redefining “family” to include “anyone the patient considers to be family”; •
partnering with advocacy organizations to identify outreach mechanisms and materials to improve cultural competency of the workforce and health outcomes for LGBT patients;
•
undertaking specific initiatives to create a welcoming environment for LGBT veterans, such as by providing facility booths at Gay Pride events, organizing local events to recognize National Coming Out Day, and initiating hospital-wide conferences on LGBT veteran health care;
•
developing and providing clinical education training for health care providers, such as clinical guidance criteria for cross-sex hormone therapy, and establishing regional interdisciplinary clinical consultation programs on transgender health; and
•
taking steps to enable veterans to self-identify their sexual orientation, gender identity, and relationship status so that these demographic data can be used to assess health and health equity.
The VHA’s efforts to transform its organizational culture and create a welcoming environment for LGBT veterans have been recognized beyond the agency. In 2013, 121 Veterans Affairs facilities voluntarily participated in the Human Rights Campaign’s 2013 Health Equality Index (HEI), and 76 percent were awarded HEI Equality Leader status for meeting “core leader” criteria for LGBT care— for their patient nondiscrimination policies, equal visitation policies, employment nondiscrimination policies, and training in LGBT patient-centered care.6 One of the most complex and ethically interesting issues that Veterans Affairs has encountered in its efforts to provide equitable health care to LGBT veterans centers on data collection. LGBT persons, especially those who have served in the U.S. military, are understandably reluctant to share information that could be used to adversely affect their careers. In addition, health care providers do not S54
routinely initiate discussions about a patient’s sexual orientation, and intake forms in health care systems are not typically designed to collect information about sexual orientation or gender identity. These factors often make the specific needs of LGBT patients invisible, preventing the collection, discussion, and dissemination of information that can be used to establish best practices and to assess health and health equity. Indeed, it was with the specific purposes of advancing health equity and overcoming barriers to access and quality that the Institute of Medicine recently recommended collecting sexual orientation and gender identity data in electronic health records. As the Institute of Medicine observed, it is also important to create an environment in which individuals who have historically been stigmatized and discriminated against feel safe providing this information.7 Under the current electronic health information exchange system and the planned interoperable electronic record, VHA health records are available to health care professionals in the DoD, where they may be used for both health care and nonhealth care purposes (for example, for assessing fitness for duty). By law, reservists and National Guard members are eligible to receive care as civilians through the VHA but may be recalled to active duty in the military. Although the repeal of DADT now prevents the DoD from initiating an adverse action based on information about homosexuality among reactivated reservists or National Guard members, the Veterans Affairs’s electronic health record does not provide an environment in which information about transgender status is assured confidentiality relative to DoD. Under the health equity initiatives outlined above, the VHA is actively reaching out to transgender veterans to affirm a policy of inclusion and nondiscrimination. To make good on this promise, the VHA is seeking to ensure that the goal of data collection—even for the important purpose of health equity—is mindful of a transgender patient’s legitimate desire that certain information not be shared outside of the clinician-patient relationship. With this in mind, the ethical challenge is to ensure that functionalities for collecting gender information— specifically information about transgender status—in the Veterans Affairs electronic health record September-October 2014/ H A S T I N G S CE NTE R RE P O RT
•
enable veterans to select their self-identified gender from a variety of choices, including “other” and “individual chooses not to answer”;
•
provide a dynamic self-identified field that can be updated by the veteran; and
•
provide a mechanism for the self-identified gender field to be excluded from data-sharing outside the VA.
Improving ethical practices within a large, bureaucratic, integrated health care system depends on multilevel organizational change and learning strategies. By establishing an Office of Health Equity at the highest level of the organization and including equity as a specific objective in its strategic plan, the VHA’s goal is to diminish and, where possible, eliminate health disparities in veteran populations that have historically been subject to marginalization and discrimination. Acknowledgment
We gratefully acknowledge the work of the VHA LGBT Health Equity Workgroup for its recommendations report and also the individuals, medical facilities, program offices, and leadership that have supported and promoted the initiatives described in this paper.
1. Veterans Health Administration, “VHA Strategic Plan FY 2013-2018,” http://www.va.gov/health/docs/VHA_STRATEGIC_ PLAN_FY2013-2018.pdf. 2. U. Uchendu, “VHA Office of Health Equity: What Is It All About?,” accessed July 1, 2014, http://www.hsrd.research. va.gov/for_researchers/cyber_seminars/archives/video_archive. cfm?SessionID=769. 3. U.S. Department of Veterans Affairs, Veterans Health Administration, VHA Directive 2013-003, “Providing Health Care for Transgender and Intersex Veterans,” February 8, 2013, www. va.gov/vhapublications/ViewPublication.asp?pub_ID=2863. 4. Under Secretary for Health’s Information Letter (IL 10-201414), “Guidance Regarding the Provision of Health Care for Lesbian, Gay, and Bisexual Veterans, 10P4—Office of Patient Care Services,” July 1, 2014, http://www.va.gov/vhapublications/publications. cfm?pub=3. 5. U.S. Department of Veterans Affairs, Veterans Health Administration, VHA Directive 1018, “Nondiscrimination in Federally-Conducted Education and Training Programs,” May 20, 2013, www.va.gov/vhapublications/ViewPublication.asp?pub_ ID=1733. 6. Human Rights Campaign, “Healthcare Equality Index: HEI 2O13 Leaders in LGBT Healthcare Equality,” http://www.hrc.org/ hei/about-the-hei. 7. Institute of Medicine, Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding (Washington, D.C.: National Academies Press, 2011); Institute of Medicine, Collecting Sexual Orientation and Gender Identity Data in Electronic Health Records: Workshop Summary (Washington, DC: National Academies Press, 2013).
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