LGBT Health Volume 2, Number 2, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/lgbt.2014.0131
Perceived Stigma, Discrimination, and Disclosure of Sexual Orientation Among a Sample of Lesbian Veterans Receiving Care in the Department of Veterans Affairs Kristin M. Mattocks, PhD, MPH,1,2 J. Cherry Sullivan, MPH,1 Christina Bertrand, BA,1 Rebecca L. Kinney, MPH,1 Michelle D. Sherman, PhD,3 and Carolyn Gustason, RN1,4
Abstract
Purpose: Many lesbian women experience stigma and discrimination from their healthcare providers as a result of their sexual orientation. Additionally, others avoid disclosure of their sexual orientation to their providers for fear of mistreatment. With the increasing number of lesbian, gay, bisexual, and transgender (LGBT) veterans seeking care from the Veterans Health Administration (VHA), it is important to understand lesbian veterans’ experiences with stigma, discrimination, and disclosure of sexual orientation. This article examines lesbian veterans’ experiences with perceived stigma and discrimination in VHA healthcare, their perspectives on disclosure of sexual orientation to VHA providers, and their recommendations for improvements in VHA healthcare to create a welcoming environment for lesbian veterans. Methods: This is a mixed methods study of twenty lesbian veterans at four VHA facilities. The women veterans participated in a one-hour interview and then completed an anonymous survey. Results: Ten percent of lesbian veterans had experienced mistreatment from VHA staff or providers, but nearly 50% feared that their Veterans Affairs (VA) providers would mistreat them if they knew about their sexual orientation. A majority of lesbian veterans (70%) believed that VHA providers should never ask about sexual orientation or should only ask if the veteran wanted to discuss it. A majority (80%) believed the VHA had taken steps to create a welcoming environment for LBGT veterans. Conclusion: Though many lesbian veterans have fears of stigma and discrimination in the context of VHA care, few have experienced this. Most lesbian veterans believed the VHA was trying to create a welcoming environment for its LGBT veterans. Future research should focus on expanding this study to include a larger and more diverse sample of lesbian, gay, bisexual, and transgender veterans receiving care at VA facilities across the country. Key words: access
to care, lesbian, quality care, sexual orientation.
Introduction
R
ecent population estimates suggest that gay and lesbian service members represent 2.5% of active duty personnel and 2.8% of all military personnel when Guard and Reserves are included.1,2 Though women comprise only 14% of active duty personnel, lesbian and bisexual (LB) women comprise more than 43% of lesbian, gay, and bisexual (LGB) service members in the U.S. military.3 Once these women leave the military, many are eligible for healthcare provided by the Veterans Health Administration (VHA).4 Researchers have begun to investigate lesbian vet1
Department of Department of Department of 4 Department of 2 3
erans’ experiences of VHA care,5–8 but still much is poorly understood, including the degree to which lesbian veterans are comfortable disclosing their sexual orientation with their provider and whether VHA provides a welcoming, safe environment for these women. Previous civilian studies suggest lesbian women may experience discrimination, rejection, and/or poor care following disclosure of their sexual orientation to healthcare providers,9 and may engage in strategies to avoid conversations regarding sexual identity for fears of, or actual incidences of, discrimination, maltreatment, and/or stigma.4,10–12 This nondisclosure has been associated with fewer health care visits, lack of
Research and Education, VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts. Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts. Psychology, University of Minnesota, St. Paul, Minnesota. Nursing, University of Massachusetts, Amherst, Massachusetts.
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preventative care, and poorer health.4,11–14 Conversely, lesbian women who choose to disclose their sexual orientation to their provider report more comfort when accessing care and better communication with providers; they are also more apt to access healthcare services, experience greater overall satisfaction with care,15,16 and perceive their health care as more relevant to their needs.17 As a healthcare organization, VHA has instituted nondiscriminatory policies that expressly state that sexual orientation shall not serve as a barrier to receiving healthcare.18 However, many LGB service members experienced overt discrimination under ‘‘Don’t Ask, Don’t Tell,’’ which prohibited people who ‘‘demonstrate a propensity or intent to engage in homosexual acts’’ from serving in the U.S. Armed Forces.19 Recent evidence suggests that individuals who experienced investigation or punishment related to sexual orientation while in the military were less likely to have used the VHA in the past year,4 demonstrating how an unwelcoming environment for lesbian, gay, bisexual, and transgender (LGBT) service members may linger after discharge. Furthermore, recent evidence suggests that despite non-discriminatory policies, LGB veterans may still not feel comfortable disclosing their sexual orientation to their healthcare providers. In a recent study, only one-third of LGB veterans reported disclosing their sexual orientation to their VHA provider, while 25% indicated that they avoid VHA care for fear of stigma.4 While patients may feel discomfort disclosing their sexual orientation to their providers, VHA providers are also reluctant to breach the topic of sexual orientation with their patients,7 echoing similar findings in civilian populations.22 LGB patients report that, despite VHA providers’ awareness of their sexual orientation, health issues related to their sexuality are rarely, if ever, discussed.4 In light of VHA’s commitment to providing patient-centered comprehensive healthcare, these findings are concerning. Evidence indicates that a patient’s lack of sexual orientation disclosure contributes to poorer health outcomes4,11–15,23,24 it is vital to have a deeper understanding of lesbian veterans’ experiences with VHA care and what VHA can do to increase comfort for lesbian patients. The present work is a step toward understanding lesbian veterans’ perceptions and experiences with VHA care. Specifically, our study objectives were to: examine lesbian veterans’ experiences with perceived stigma and discrimination in VHA healthcare; examine veterans’ perspectives on disclosure of sexual orientation to VHA providers; and understand lesbian veterans’ perspectives on improvements in VHA healthcare to create a welcoming environment for LGBT veterans. Materials and Methods Participants and recruitment
We conducted interviews and surveys with 20 selfidentified lesbian veterans who receive care at VHA facilities in Northampton, Massachusetts; Minneapolis, Minnesota; Miami, Florida; and San Juan, Puerto Rico. These sites were chosen because of their diversity in geographic location and racial/ethnic composition. We used multiple strategies to recruit women to participate. We posted flyers in general primary care, women’s health primary care, mental health, and gynecology clinics, and asked clinicians in these clinics to refer potential participants. Women were considered eligible
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for the study if they were between the ages of 18 and 60, were enrolled within the Veterans Affairs (VA) Healthcare System, and self-identified as lesbian veterans. Women responding to study advertisements were screened for eligibility over the phone. We invited eligible women to participate, and sent follow-up letters confirming the date, time, and location of the interview and survey. Participants received a $25 cash voucher for participation. The research protocol was approved by the Institutional Review Board at VA Connecticut and by the individual Research and Development Committee at each facility. Procedure and analysis
Three research team members conducted the interviews. All interviewers were experienced with qualitative data collection methodologies. The semi-interviews used a grounded theory approach to understand lesbian veterans’ experiences in the military and how these experiences shaped their use of VHA healthcare, their perceptions and experiences with VHA care, and how the VHA can be more welcoming to LGBT veterans. Each interview took approximately 45 minutes to an hour to complete. Upon completing the interview, veterans
Table 1. Demographic Characteristics of Lesbian Veterans (n = 20) Characteristic Median Age Range 41–50 Relationship Status Married/Partnered 53% Never married 32% Separated 11% Divorced 5% Currently in a Same-Sex Relationship? Yes 60% No 40% Ever in a Same-Sex Relationship During VA Care? Yes 86% No 14% Number of Children 0 75% 1 11% 2 11% 3 5% Sexual Orientation Lesbian 100% Bisexual 0% Straight 0% Race African American 15% Hispanic/Latino 30% Asian, including Southeast Asia 5% White/Caucasian 35% Other 15% Religion Protestant 23% Catholic 12% Agnostic 6% Buddhist 6% Other 53% Totals may be > 100% due to rounding. VA, Veterans Affairs.
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completed a brief, anonymous survey soliciting their attitudes, beliefs, and experiences in VHA, particularly around their experiences receiving care as a lesbian veteran.25 Interviews were audio-recorded, transcribed, and entered into Atlas.ti (Scientific Software Development, 2014). Each transcript was read in its entirety by two members of the study team to gain a sense of each veteran’s experience. We used open coding, where each coder independently reviewed the transcripts line-by-line, creating code definitions as concepts emerged inductively from the data. Coders met to compare codes, resolve discrepancies, and review the code structure. The constant comparative method of qualitative analysis was used to compare coded segments of text to expand existing themes and identify new themes. Codes were refined until we reached a final coding structure. The three major thematic areas that arose were: perceived and actual barriers to VA care as a lesbian veteran; perspectives on provider behaviors regarding sexual orientation disclosure; and recommendations to improve VA care. Analysis
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partnered (53%, n = 11), had no children (75%, n = 15), and in a same sex relationship (60%, n = 12) at the time of the study. Other descriptives can be found in Table 1. Perceived and actual barriers to VA healthcare as a lesbian veteran
Overall, few lesbian veterans reported that they had experienced mistreatment, stigma, or discrimination as a result of their sexual orientation while in VHA care (Table 2). Ten percent of lesbian veterans indicated that they had experienced harassment from VHA providers due to their sexual orientation, and 10% reported that they had been refused treatment from VHA providers as a result of their sexual orientation. More women feared the possibility of mistreatment or antilesbian bias, with 44% of veterans fearing that their providers had conservative religious beliefs that would interfere with caregiving, while 39% fearing that they would receive poor treatment from their providers due to their sexual orientation. One woman veteran described her experience with perceived stigma and discrimination with her VA psychologist when she revealed her sexual orientation:
Descriptive statistics were used to describe the demographic characteristics, beliefs, and perceptions of the lesbian veterans. Statistical analyses of survey data were performed using Excel. Results
All of the women in the study identified as lesbian (n = 20) and were between 40 and 50 years old. Most were married or
‘‘Not initially, until I met my first, my first head doctor, and when I told him that I was gay, his demeanor changed. You know, he was distant from me as opposed to just asking me the questions that he normally would. He just.you know, our relationship changed and I could see it, once he found out that I was gay, you know, and because he was an older Indian man, you know. Maybe because it’s frowned upon in
Table 2. Perceived or Actual Barriers to VA Healthcare Utilization Among Lesbian and Bisexual Veterans (n = 20) Not a barrier Somewhat A major I have at all of a barrier barrier experienced this Fear of harassment by VA providers due to sexual orientation or gender identity Concern about judgment from other veterans Anti-LB comments made by VA staff in previous VA experiences Anti-LB comments made by other veterans Fear of discriminatory treatment from VA providers due to sexual orientation and/or gender identity Lack of inclusive language on VA forms/publications and in medical settings (e.g., posters) Same-sex relationships and support systems not validated by staff Hurtful/rejecting experiences in the military as a LB service member VA’s reputation for not being sensitive to LB Veterans and their needs Fear of receiving poorer treatment due to his/her sexual orientation and/or gender identity Fear of being refused treatment due to his/her sexual orientation and/or gender identity Hearing about other LB Veterans having bad experiences getting care at the VA Fear that being ‘‘out’’ in the VA system may result in loss of benefits/VA disability Fear that being ‘‘out’’ in the VA system may have negative consequences for their military career LB Veterans assuming that some VA providers have conservative religious beliefs LB, lesbian and bisexual.
40%
45%
15%
10%
25% 44% 36% 36%
56% 28% 43% 32%
19% 28% 21% 32%
30% 15% 40% 15%
19%
50%
31%
20%
17% 47%
44% 24%
39% 29%
15% 25%
33%
33%
33%
15%
33%
28%
39%
15%
45%
22%
33%
10%
28%
33%
39%
15%
37%
37%
26%
15%
30%
35%
35%
15%
28%
28%
44%
5%
150 his culture, you know? And he is not a veteran. He’s just a doctor who works at the VA, you know?’’
A substantial percentage (40%) of women veterans experienced anti-LGBT comments made by other veterans while at the VHA. One woman described her fears regarding antiLGBT comments made by other veterans at the VHA: ‘‘I know we’re going to have backlash from our fellow vets. That is going to be a given, ok? With the older Vets? Until they get to know you.’’
Another problem identified by lesbian veterans was the lack of staff support for their same sex relationships during the process of receiving medical care. Thirty-nine percent of lesbian veterans reported that their same-sex relationships and support systems were not validated by VHA staff. One woman spoke specifically about her difficulty in getting VHA staff to allow her wife to come with her into medical appointments: ‘‘It’s more like (they think) we’re sisters, or we’re friends. There will be times when I’ll say I want her to come with me, and they will say, ‘Well..’ And I would say, ‘She is my wife. She has the right to come with me.’ ’’
Similarly, another lesbian veteran reflected on her experience trying to get VHA staff to allow her partner to come with her to medical appointments: ‘‘And a lot of times when I’ve brought up, you know, that (my partner) needs to be included in this for whatever reason, and they’re like,’What do you need her for?’ And I’m like, ‘She.that’s my partner and she should know what’s going on.’ And they’re like, ‘Well, is she your spouse?’ So I said, ‘Yeah, you can consider it that.’ And they’re like, ‘Well if it’s not your husband and not your family so she can’t come in.’ ’’
Lesbian veterans’ perspectives on provider behaviors regarding sexual orientation disclosure
A substantial majority of lesbian veterans (70%) reported that VHA providers should either never ask about sexual orientation or only ask if the patient mentions it (Table 3). One woman described her feelings regarding whether VA providers should ask about sexual orientation: ‘‘No, I don’t think any of my doctors know, and I don’t think it’s necessary from them to know. They just need to know my medical history. To me, personally, I’m not sure what the intent of the question would be; why would they ask me? But if somehow I know, or I was informed, or they told me, or whatever, that they are also part of the community, I’d be more comfortable.there’s really no need for you to ask that question, you know?’’
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Table 3. Lesbian Veterans’ Experiences with VA Care (n = 20) % of respondents How appropriate is it for VA providers to ask about a patient’s sexual orientation during a VA appointment? Should never be asked 15% Should rarely be asked 10% Should only be asked if the patient 45% mentions it Should be asked for some patients 20% Should be asked for every patient 10% How many of your VA providers have specifically asked about your sexual orientation? Not applicable 5% None 50% A few 30% Some 20% Most/Many 0% All 0% With how many of your VA providers have you chosen to disclose your sexual orientation? None 20% A few 25% Some 25% Most/Many 10% All 20% How comfortable do you feel talking with your VA providers about your sexual orientation? Very uncomfortable 0% Uncomfortable 15% Somewhat comfortable 25% Comfortable 15% Very comfortable 45% How important is it for our VA hospital to be welcoming/friendly to lesbian/bisexual veterans? Not important at all 0% Unimportant 0% Somewhat important 5% Important 10% Very important 85% How welcoming/friendly do you think our VA hospital as a whole is to lesbian/bisexual veterans? Not welcoming at all 0% Unwelcoming 20% Somewhat welcoming 45% Welcoming 15% Very welcoming 20%
Other lesbian veterans feared that disclosing their sexual orientation to their VHA medical providers would jeopardize their military benefits or impact future military service. One woman described her reticence to disclose her sexual orientation in the context of ‘‘Don’t Ask, Don’t Tell’’:
Though 20% of lesbian women indicated they had never told any of their doctors about their sexual orientation, another 20% indicated that they have chosen to disclose their sexual orientation to all of their VA providers. One woman describes her willingness to share her sexual orientation with her providers:
‘‘ ‘Are you gay?’ I would say ‘no,’ but I’d be nodding ‘yes.’ So, like, they would know. But it was until ‘Don’t Ask, Don’t Tell’ got repealed, I was not out to my doctors. If they asked, I’m like, ‘Don’t put this anywhere in my medical record.’ ’’
‘‘When I get Pap smears they need to know your sexual orientation, how active you are to understand what they’re looking at. So yeah, I have been very open and telling them that I’m in a gay sexual relationship. I’m very open about that with my doctor.’’
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Table 4. Lesbian Veterans’ Recommendations for VA Care (n = 20) Not useful at all Somewhat useful Very useful How useful would it be for this VA to: Host events specifically for LB veterans at the hospital? Have LB newsletters/magazines available in the hospital? Have information about LB community resources available in the hospital? Have VA staff be involved in LB oriented events in the community (such as LGBT Pride month events)? Post a Patient Bill of Rights that explicitly ensures healthcare for and nondiscrimination of LB veterans? Place advertisements or articles in city LB newspaper about VA services and the VA’s desire to be welcoming to LB veterans? Display images in VA clinics that reflect LB lives (e.g., rainbow flags, posters with same-sex couples)? Use inclusive language (e.g., forms and providers referring to ‘‘partner’’ instead of ‘‘husband or wife’’)?
15% 20% 0%
50% 35% 30%
35% 45% 70%
20%
25%
55%
10%
5%
85%
5%
45%
50%
10%
30%
60%
10.5%
10.5%
79%
LGBT, lesbian, gay, bisexual, and transgender.
Several lesbian veterans spoke of the importance of the VA providing high quality healthcare to women veterans, first and foremost. These women noted that if providers were providing comprehensive care for women veterans that high quality, comprehensive care for lesbian and bisexual veterans would naturally follow. One lesbian veteran summarized her feelings on this matter: ‘‘You know men, women, lesbian, gay, whatever. Let’s just take good care of veterans. I’m way into that.’’
Recommendations for improvements in VHA care for lesbian veterans
When considering recommendations for VHA care, lesbian veterans indicated numerous avenues for improvements in VHA care that could lead to a more welcoming environment for LGBT veterans (Table 4). Lesbian veterans endorsed posting a Patient Bill of Rights in the waiting areas, using inclusive language in standard VHA forms (using the word ‘‘partner’’ in addition to ‘‘husband’’ and ‘‘wife’’), and having information about lesbian community resources available in the hospital. Several lesbian veterans endorsed improved cultural competence in LGBT issues aimed at VHA staff and providers. One lesbian veteran stated that staff and providers should be taught that LGBT veterans and are no different than heterosexual veterans, and that an educational program aimed at cultural competence would be appropriate: ‘‘ I think it comes down to a lack of knowledge.just more education. It always comes down to more education. Not about ‘don’t beat up the gays,’ but just that they’re really no different than other veterans.’’
Another lesbian veteran wanted the VA to place more emphasis on inclusion of LGBT family members into medical care: ‘‘I think it would be interesting and useful for the VA to do some outreach to our partners.outreach for lesbian veterans families.’’
However, some lesbian veterans were extremely pleased with the VHA efforts already in place to ensure cultural competence for LGBT veterans. Eighty percent of lesbian veterans in the current study noted that the VA had created a welcoming environment for LGBT patients. One woman described this environment as follows: ‘‘You know, one of the things that made me inordinately pleased was there was a screensaver on.it just said the VA is open and affirmative environment and it was a LGBT screensaver. And it wasn’t for patients.I think it was for staff! And that just made me feel like all, ‘Cool! All right!’ If the organization is on board and is accepting and willing and has it as a screen saver which they know that the patients are going to see. That says something. That really says something about being welcoming.’’
Discussion
To the best of our knowledge, this is the first paper that specifically explores lesbian veterans’ experiences and perceptions with stigma and discrimination in VHA care, and their comfort with revealing their sexual orientation to VHA providers. In our study, though many lesbian veterans feared negative attitudes and mistreatment from VHA staff and providers, few veterans had actually experienced mistreatment from their VHA providers based on their sexual orientation. Lesbian veterans’ experiences of mistreatment and perceptions of LGBT-related stigma echo findings from the recent Institute of Medicine report highlighting refusal of treatment, verbal abuse, and disrespectful treatment for many LGBT individuals seeking healthcare.23 Despite some lesbian veterans’ experiences with mistreatment related to sexual orientation, a majority of lesbian veterans in our study believed that the VHA was trying to create a welcoming environment for LGBT veterans. Findings regarding the degree to which the VHA creates a welcoming environment for LGBT veterans from this study differ substantially from other recent VHA studies that have examined patients’ perspectives on affirming VHA environments. In their recent study of LGBT veterans and their providers
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at two VHA facilities in Oklahoma and Texas, Sherman and colleagues found that only 30% of LGBT veterans endorsed the VHA as a welcoming environment.7,25 In contrast, 80% of the lesbian veterans in the current study rated the VHA as a welcoming environment for LGBT veterans. These differences may be attributable to the relatively conservative nature of Texas and Oklahoma in comparison to states such as Massachusetts, which was the first state in the country to legalize same-sex marriage in 2004, a full decade before the current study was launched. Additionally, our study only included lesbian women veterans, in contrast to the Sherman study that was comprised of gay men (30%) who may experience more stigma and less-welcoming environments. 25 In our study, several lesbian veterans acknowledged that their willingness to disclose their sexual orientation to their VA provider had increased substantially after the repeal of ‘‘Don’t Ask, Don’t Tell’’ (DADT). Though DADT was a Department of Defense (DOD) policy that did not impact access to VHA healthcare for LGBT veterans, many veterans were afraid to disclose their sexual orientation for fear of this information being ‘‘leaked’’ back to DOD, which they believed would ultimately affect their military pensions or ability to return to military service in the future. Though the consequences of DADT have been explored by others,27 this is one of the first studies that has examined the lingering effects of these policies among LGBT veterans and their willingness to disclose their sexual orientation to their VA healthcare providers. One interesting finding from our study was the notion that some lesbian veterans felt that it was more important that VA providers to be proficient in women’s health care, rather than specific to lesbian and bisexual healthcare. Though the VHA is mandated to offer a female provider to all female veterans,28 several women in our study switched their care from a female VA provider to a male VA provider because they felt the female provider wasn’t able to offer the high-quality, comprehensive medical care that was needed as an lesbian veteran. One of the biggest frustrations cited by lesbian veterans was the belief that VA staff were reticent to allow same sex partners to join the lesbian veteran in healthcare visits and decision-making. The VHA has addressed this issue in its patient non-discrimination policy16 with regard to visitation that defines ‘‘family member’’ as anyone the veteran chooses. This policy also allows the veteran to have whomever they wish join them in a treatment room. Finally, the policy allows all veterans to designate a signed medical power of attorney document that could allow anyone the veteran wishes for healthcare decision-making. This study has several limitations, including the small sample size of 20 lesbian veterans that limited the overall generalizability of the study findings. Although 20 participants has been noted to be of sufficient sample size for the purposes qualitative research,33 this study may have not reach concept saturation due to the factors mentioned in the subsequent sentences, still we are confident that the our findings add to the current literature. Furthermore, though our original recruitment was targeted to lesbian and bisexual veterans at four VHA facilities, we were not able to recruit any bisexual veterans. This lack of recruitment may be due to the smaller number of individuals in the military self-identifying as bisexual in comparison to gay or lesbian, thus making the eligible recruitment pool limited. Future studies should aim to proportionately target larger populations of lesbian, gay, bisexual, and
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transgender veterans in order to better comprehend their specific healthcare needs. Simultaneously, these studies should look for more effective recruitment modes, such as Respondent-Driven Sampling (RDS),29–32 to target those lesbian, gay, bisexual, or transgender veterans who feel the most vulnerable to discrimination. The women in this study were on average, older veterans who may have different healthcare needs than their younger lesbian counterparts. As the number of lesbian women between the ages of 18–39 years in the military continues to increase, so will the need to further understand their barriers to care and healthcare needs (e.g., post-traumatic stress disorder [PTSD], prenatal care). Our study sample did not include lesbian veterans living in predominately rural areas of the country, where attitudes towards LGBT individuals may be more conservative. Though our recruitment strategies included posting flyers in VA women’s health and primary care clinics, we likely missed lesbian veterans who did not receive care during the recruitment phase and study period. Very little research on the specific health and health care needs of lesbian veterans has been published to date. Research in non-veteran populations has demonstrated that lesbian persons often fear negative consequences of disclosing their sexual orientation to health care providers. These disclosure-related fears might have been amplified among veterans due to DADT: In our anecdotal experience, many veterans mistakenly believed DADT was a policy that VA shared with DOD. With the repeal of DADT, lesbian veterans may begin to feel more comfortable disclosing their sexuality to their VA healthcare providers without fear of reprisal. In turn, it is essential that VA healthcare providers create a healthcare environment free of assumed heterosexuality (e.g., not assuming that all female veterans require birth control for sexual activity) and ensure that they are knowledgeable about lesbian health issues. A safe environment that encourages acceptance of all sexual orientations is essential to improving the quality of care and the health outcomes of women veterans. The implementation of effective interventions that aim to educate both VA providers (and patients) on healthcare needs specific to the sexual orientation, is the first step in ensuring the future health of women veterans. Conclusion
Future research should focus on expanding this study to include a larger and more diverse sample of lesbian, gay, bisexual, and transgender veterans receiving care at VA facilities across the country. Questions regarding sexual orientation and behavior should also be included in all VA surveys to ensure that the needs of this population are being met across all areas of VA care. Acknowledgments
This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development. All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. 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 Stated Government. The authors would like to thank Laurie Zephyrin, Sally Haskell, Anne Sadler, Erin Krebs, Silvina Levis-Dusseau, Ann Cheney, and Mabel Quinones-Vazquez for their support and assistance of this study. This work was supported by VA
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HSR&D-funded Women’s Health Research Network (Project # SDR 10–012) and by VA Women’s Health Services (WHS). Author Disclosure Statement
No competing financial interests exist. References
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18. VHA Office of Health Equity: Lesbian, Gay, Bisexual, & Transgender (LGBT) Veterans Internal Health Care Fact Sheet. Washington, D.C.: Veteran Health Administration, 2013. 19. Public Law 103–160, Section 654, Title 10 div A., title V, 571(a)(1), November 30, 1993, 107 Stat. 1670. United States Government. 20. Boehmer U, Case P: Physicians don’t ask, sometimes patients tell: Disclosure of sexual orientation among women with breast carcinoma. Cancer 2004;101:1882–1889. 21. Sobecki JN, Curlin FA, Rasinski KA, Lindau ST: What we don’t talk about when we don’t talk about sex: Results of a national survey of U.S. obstetrician/gynecologists. J Sex Med 2012;9:1285–1294. 22. Mayer KH, Bradford JB, Makadon HJ, et al.: Sexual and gender minority health: What we know and what needs to be done. Am J Public Health 2008;98:989–995. 23. Durso LE, Meyer IH: Patterns and predictors of disclosure of sexual orientation to healthcare providers among lesbians, gay men, and bisexuals. Sex Res Social Policy 2013;10:35–42. 24. Bjorkman M, Malterud K: Lesbian women’s experiences with health care: A qualitative study. Scand J Prim Health Care 2009;27:238–243. 25. Sherman M, Kauth M, Shipherd J: Provider beliefs and practices about assessing sexual orientation in two Veterans Affairs hospitals. LGBT Health 2014;1:185–191. [Epub ahead of print]: DOI: 10.1089/lgbt.2014.0008. 26. Institute of Medicine: The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, D.C.: The National Academies Press, 2011. 27. Burks DJ: Lesbian, gay, and bisexual victimization in the military: An unintended consequence of ‘‘Don’t Ask, Don’t Tell’’? Amer Psychol 2011;66:604–613. 28. Veterans Health Administration: VHA Handbook 1300.01. Washington, DC: Department of Veteran Affairs, 2010. 29. Decker MR, Marshall BD, Emerson M, et al.: Respondentdriven sampling for an adolescent health study in vulnerable urban settings: A multi-country study. J Adolesc Health 2014;55(6 Suppl):S6–S12. 30. Prybylski D, Manopaiboon C, Visavakum P, et al.: Diverse HIV epidemics among people who inject drugs in Thailand: Evidence from respondent-driven sampling surveys in Bangkok and Chiang Mai. Drug Alcohol Depend 2015:148;126–135. 31. Matiko E, Khatib A, Khalid F, et al.: HIV prevalence and risk behaviors among people who inject drugs in two serial cross-sectional respondent-driven sampling surveys, Zanzibar 2007 and 2012. AIDS Behav 2014:19;36–45. 32. Tun W, Sheehy M, Broz D, et al.: HIV and STI prevalence and injection behaviors among people who inject drugs in Nairobi: Results from a 2011 bio-behavioral study using respondent-driven sampling. AIDS Behav 2014:19;24–35. 33. Bertaux D: Biography and Society: The Life History Approach in the Social Sciences. SAGE Studies in International Sociology: Thousand Oaks, CA, 1981.
Address correspondence to: Kristin M. Mattocks, PhD, MPH Department of Research and Education VA Central Western Massachusetts Healthcare System 421 North Main Street Leeds, MA 01053 E-mail: [email protected]
Perceived Stigma, Discrimination, and Disclosure of Sexual Orientation Among a Sample of Lesbian Veterans Receiving Care in the Department of Veterans Affairs Kristin M. Mattocks, PhD, MPH,1,2 J. Cherry Sullivan, MPH,1 Christina Bertrand, BA,1 Rebecca L. Kinney, MPH,1 Michelle D. Sherman, PhD,3 and Carolyn Gustason, RN1,4
Abstract
Purpose: Many lesbian women experience stigma and discrimination from their healthcare providers as a result of their sexual orientation. Additionally, others avoid disclosure of their sexual orientation to their providers for fear of mistreatment. With the increasing number of lesbian, gay, bisexual, and transgender (LGBT) veterans seeking care from the Veterans Health Administration (VHA), it is important to understand lesbian veterans’ experiences with stigma, discrimination, and disclosure of sexual orientation. This article examines lesbian veterans’ experiences with perceived stigma and discrimination in VHA healthcare, their perspectives on disclosure of sexual orientation to VHA providers, and their recommendations for improvements in VHA healthcare to create a welcoming environment for lesbian veterans. Methods: This is a mixed methods study of twenty lesbian veterans at four VHA facilities. The women veterans participated in a one-hour interview and then completed an anonymous survey. Results: Ten percent of lesbian veterans had experienced mistreatment from VHA staff or providers, but nearly 50% feared that their Veterans Affairs (VA) providers would mistreat them if they knew about their sexual orientation. A majority of lesbian veterans (70%) believed that VHA providers should never ask about sexual orientation or should only ask if the veteran wanted to discuss it. A majority (80%) believed the VHA had taken steps to create a welcoming environment for LBGT veterans. Conclusion: Though many lesbian veterans have fears of stigma and discrimination in the context of VHA care, few have experienced this. Most lesbian veterans believed the VHA was trying to create a welcoming environment for its LGBT veterans. Future research should focus on expanding this study to include a larger and more diverse sample of lesbian, gay, bisexual, and transgender veterans receiving care at VA facilities across the country. Key words: access
to care, lesbian, quality care, sexual orientation.
Introduction
R
ecent population estimates suggest that gay and lesbian service members represent 2.5% of active duty personnel and 2.8% of all military personnel when Guard and Reserves are included.1,2 Though women comprise only 14% of active duty personnel, lesbian and bisexual (LB) women comprise more than 43% of lesbian, gay, and bisexual (LGB) service members in the U.S. military.3 Once these women leave the military, many are eligible for healthcare provided by the Veterans Health Administration (VHA).4 Researchers have begun to investigate lesbian vet1
Department of Department of Department of 4 Department of 2 3
erans’ experiences of VHA care,5–8 but still much is poorly understood, including the degree to which lesbian veterans are comfortable disclosing their sexual orientation with their provider and whether VHA provides a welcoming, safe environment for these women. Previous civilian studies suggest lesbian women may experience discrimination, rejection, and/or poor care following disclosure of their sexual orientation to healthcare providers,9 and may engage in strategies to avoid conversations regarding sexual identity for fears of, or actual incidences of, discrimination, maltreatment, and/or stigma.4,10–12 This nondisclosure has been associated with fewer health care visits, lack of
Research and Education, VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts. Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts. Psychology, University of Minnesota, St. Paul, Minnesota. Nursing, University of Massachusetts, Amherst, Massachusetts.
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preventative care, and poorer health.4,11–14 Conversely, lesbian women who choose to disclose their sexual orientation to their provider report more comfort when accessing care and better communication with providers; they are also more apt to access healthcare services, experience greater overall satisfaction with care,15,16 and perceive their health care as more relevant to their needs.17 As a healthcare organization, VHA has instituted nondiscriminatory policies that expressly state that sexual orientation shall not serve as a barrier to receiving healthcare.18 However, many LGB service members experienced overt discrimination under ‘‘Don’t Ask, Don’t Tell,’’ which prohibited people who ‘‘demonstrate a propensity or intent to engage in homosexual acts’’ from serving in the U.S. Armed Forces.19 Recent evidence suggests that individuals who experienced investigation or punishment related to sexual orientation while in the military were less likely to have used the VHA in the past year,4 demonstrating how an unwelcoming environment for lesbian, gay, bisexual, and transgender (LGBT) service members may linger after discharge. Furthermore, recent evidence suggests that despite non-discriminatory policies, LGB veterans may still not feel comfortable disclosing their sexual orientation to their healthcare providers. In a recent study, only one-third of LGB veterans reported disclosing their sexual orientation to their VHA provider, while 25% indicated that they avoid VHA care for fear of stigma.4 While patients may feel discomfort disclosing their sexual orientation to their providers, VHA providers are also reluctant to breach the topic of sexual orientation with their patients,7 echoing similar findings in civilian populations.22 LGB patients report that, despite VHA providers’ awareness of their sexual orientation, health issues related to their sexuality are rarely, if ever, discussed.4 In light of VHA’s commitment to providing patient-centered comprehensive healthcare, these findings are concerning. Evidence indicates that a patient’s lack of sexual orientation disclosure contributes to poorer health outcomes4,11–15,23,24 it is vital to have a deeper understanding of lesbian veterans’ experiences with VHA care and what VHA can do to increase comfort for lesbian patients. The present work is a step toward understanding lesbian veterans’ perceptions and experiences with VHA care. Specifically, our study objectives were to: examine lesbian veterans’ experiences with perceived stigma and discrimination in VHA healthcare; examine veterans’ perspectives on disclosure of sexual orientation to VHA providers; and understand lesbian veterans’ perspectives on improvements in VHA healthcare to create a welcoming environment for LGBT veterans. Materials and Methods Participants and recruitment
We conducted interviews and surveys with 20 selfidentified lesbian veterans who receive care at VHA facilities in Northampton, Massachusetts; Minneapolis, Minnesota; Miami, Florida; and San Juan, Puerto Rico. These sites were chosen because of their diversity in geographic location and racial/ethnic composition. We used multiple strategies to recruit women to participate. We posted flyers in general primary care, women’s health primary care, mental health, and gynecology clinics, and asked clinicians in these clinics to refer potential participants. Women were considered eligible
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for the study if they were between the ages of 18 and 60, were enrolled within the Veterans Affairs (VA) Healthcare System, and self-identified as lesbian veterans. Women responding to study advertisements were screened for eligibility over the phone. We invited eligible women to participate, and sent follow-up letters confirming the date, time, and location of the interview and survey. Participants received a $25 cash voucher for participation. The research protocol was approved by the Institutional Review Board at VA Connecticut and by the individual Research and Development Committee at each facility. Procedure and analysis
Three research team members conducted the interviews. All interviewers were experienced with qualitative data collection methodologies. The semi-interviews used a grounded theory approach to understand lesbian veterans’ experiences in the military and how these experiences shaped their use of VHA healthcare, their perceptions and experiences with VHA care, and how the VHA can be more welcoming to LGBT veterans. Each interview took approximately 45 minutes to an hour to complete. Upon completing the interview, veterans
Table 1. Demographic Characteristics of Lesbian Veterans (n = 20) Characteristic Median Age Range 41–50 Relationship Status Married/Partnered 53% Never married 32% Separated 11% Divorced 5% Currently in a Same-Sex Relationship? Yes 60% No 40% Ever in a Same-Sex Relationship During VA Care? Yes 86% No 14% Number of Children 0 75% 1 11% 2 11% 3 5% Sexual Orientation Lesbian 100% Bisexual 0% Straight 0% Race African American 15% Hispanic/Latino 30% Asian, including Southeast Asia 5% White/Caucasian 35% Other 15% Religion Protestant 23% Catholic 12% Agnostic 6% Buddhist 6% Other 53% Totals may be > 100% due to rounding. VA, Veterans Affairs.
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completed a brief, anonymous survey soliciting their attitudes, beliefs, and experiences in VHA, particularly around their experiences receiving care as a lesbian veteran.25 Interviews were audio-recorded, transcribed, and entered into Atlas.ti (Scientific Software Development, 2014). Each transcript was read in its entirety by two members of the study team to gain a sense of each veteran’s experience. We used open coding, where each coder independently reviewed the transcripts line-by-line, creating code definitions as concepts emerged inductively from the data. Coders met to compare codes, resolve discrepancies, and review the code structure. The constant comparative method of qualitative analysis was used to compare coded segments of text to expand existing themes and identify new themes. Codes were refined until we reached a final coding structure. The three major thematic areas that arose were: perceived and actual barriers to VA care as a lesbian veteran; perspectives on provider behaviors regarding sexual orientation disclosure; and recommendations to improve VA care. Analysis
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partnered (53%, n = 11), had no children (75%, n = 15), and in a same sex relationship (60%, n = 12) at the time of the study. Other descriptives can be found in Table 1. Perceived and actual barriers to VA healthcare as a lesbian veteran
Overall, few lesbian veterans reported that they had experienced mistreatment, stigma, or discrimination as a result of their sexual orientation while in VHA care (Table 2). Ten percent of lesbian veterans indicated that they had experienced harassment from VHA providers due to their sexual orientation, and 10% reported that they had been refused treatment from VHA providers as a result of their sexual orientation. More women feared the possibility of mistreatment or antilesbian bias, with 44% of veterans fearing that their providers had conservative religious beliefs that would interfere with caregiving, while 39% fearing that they would receive poor treatment from their providers due to their sexual orientation. One woman veteran described her experience with perceived stigma and discrimination with her VA psychologist when she revealed her sexual orientation:
Descriptive statistics were used to describe the demographic characteristics, beliefs, and perceptions of the lesbian veterans. Statistical analyses of survey data were performed using Excel. Results
All of the women in the study identified as lesbian (n = 20) and were between 40 and 50 years old. Most were married or
‘‘Not initially, until I met my first, my first head doctor, and when I told him that I was gay, his demeanor changed. You know, he was distant from me as opposed to just asking me the questions that he normally would. He just.you know, our relationship changed and I could see it, once he found out that I was gay, you know, and because he was an older Indian man, you know. Maybe because it’s frowned upon in
Table 2. Perceived or Actual Barriers to VA Healthcare Utilization Among Lesbian and Bisexual Veterans (n = 20) Not a barrier Somewhat A major I have at all of a barrier barrier experienced this Fear of harassment by VA providers due to sexual orientation or gender identity Concern about judgment from other veterans Anti-LB comments made by VA staff in previous VA experiences Anti-LB comments made by other veterans Fear of discriminatory treatment from VA providers due to sexual orientation and/or gender identity Lack of inclusive language on VA forms/publications and in medical settings (e.g., posters) Same-sex relationships and support systems not validated by staff Hurtful/rejecting experiences in the military as a LB service member VA’s reputation for not being sensitive to LB Veterans and their needs Fear of receiving poorer treatment due to his/her sexual orientation and/or gender identity Fear of being refused treatment due to his/her sexual orientation and/or gender identity Hearing about other LB Veterans having bad experiences getting care at the VA Fear that being ‘‘out’’ in the VA system may result in loss of benefits/VA disability Fear that being ‘‘out’’ in the VA system may have negative consequences for their military career LB Veterans assuming that some VA providers have conservative religious beliefs LB, lesbian and bisexual.
40%
45%
15%
10%
25% 44% 36% 36%
56% 28% 43% 32%
19% 28% 21% 32%
30% 15% 40% 15%
19%
50%
31%
20%
17% 47%
44% 24%
39% 29%
15% 25%
33%
33%
33%
15%
33%
28%
39%
15%
45%
22%
33%
10%
28%
33%
39%
15%
37%
37%
26%
15%
30%
35%
35%
15%
28%
28%
44%
5%
150 his culture, you know? And he is not a veteran. He’s just a doctor who works at the VA, you know?’’
A substantial percentage (40%) of women veterans experienced anti-LGBT comments made by other veterans while at the VHA. One woman described her fears regarding antiLGBT comments made by other veterans at the VHA: ‘‘I know we’re going to have backlash from our fellow vets. That is going to be a given, ok? With the older Vets? Until they get to know you.’’
Another problem identified by lesbian veterans was the lack of staff support for their same sex relationships during the process of receiving medical care. Thirty-nine percent of lesbian veterans reported that their same-sex relationships and support systems were not validated by VHA staff. One woman spoke specifically about her difficulty in getting VHA staff to allow her wife to come with her into medical appointments: ‘‘It’s more like (they think) we’re sisters, or we’re friends. There will be times when I’ll say I want her to come with me, and they will say, ‘Well..’ And I would say, ‘She is my wife. She has the right to come with me.’ ’’
Similarly, another lesbian veteran reflected on her experience trying to get VHA staff to allow her partner to come with her to medical appointments: ‘‘And a lot of times when I’ve brought up, you know, that (my partner) needs to be included in this for whatever reason, and they’re like,’What do you need her for?’ And I’m like, ‘She.that’s my partner and she should know what’s going on.’ And they’re like, ‘Well, is she your spouse?’ So I said, ‘Yeah, you can consider it that.’ And they’re like, ‘Well if it’s not your husband and not your family so she can’t come in.’ ’’
Lesbian veterans’ perspectives on provider behaviors regarding sexual orientation disclosure
A substantial majority of lesbian veterans (70%) reported that VHA providers should either never ask about sexual orientation or only ask if the patient mentions it (Table 3). One woman described her feelings regarding whether VA providers should ask about sexual orientation: ‘‘No, I don’t think any of my doctors know, and I don’t think it’s necessary from them to know. They just need to know my medical history. To me, personally, I’m not sure what the intent of the question would be; why would they ask me? But if somehow I know, or I was informed, or they told me, or whatever, that they are also part of the community, I’d be more comfortable.there’s really no need for you to ask that question, you know?’’
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Table 3. Lesbian Veterans’ Experiences with VA Care (n = 20) % of respondents How appropriate is it for VA providers to ask about a patient’s sexual orientation during a VA appointment? Should never be asked 15% Should rarely be asked 10% Should only be asked if the patient 45% mentions it Should be asked for some patients 20% Should be asked for every patient 10% How many of your VA providers have specifically asked about your sexual orientation? Not applicable 5% None 50% A few 30% Some 20% Most/Many 0% All 0% With how many of your VA providers have you chosen to disclose your sexual orientation? None 20% A few 25% Some 25% Most/Many 10% All 20% How comfortable do you feel talking with your VA providers about your sexual orientation? Very uncomfortable 0% Uncomfortable 15% Somewhat comfortable 25% Comfortable 15% Very comfortable 45% How important is it for our VA hospital to be welcoming/friendly to lesbian/bisexual veterans? Not important at all 0% Unimportant 0% Somewhat important 5% Important 10% Very important 85% How welcoming/friendly do you think our VA hospital as a whole is to lesbian/bisexual veterans? Not welcoming at all 0% Unwelcoming 20% Somewhat welcoming 45% Welcoming 15% Very welcoming 20%
Other lesbian veterans feared that disclosing their sexual orientation to their VHA medical providers would jeopardize their military benefits or impact future military service. One woman described her reticence to disclose her sexual orientation in the context of ‘‘Don’t Ask, Don’t Tell’’:
Though 20% of lesbian women indicated they had never told any of their doctors about their sexual orientation, another 20% indicated that they have chosen to disclose their sexual orientation to all of their VA providers. One woman describes her willingness to share her sexual orientation with her providers:
‘‘ ‘Are you gay?’ I would say ‘no,’ but I’d be nodding ‘yes.’ So, like, they would know. But it was until ‘Don’t Ask, Don’t Tell’ got repealed, I was not out to my doctors. If they asked, I’m like, ‘Don’t put this anywhere in my medical record.’ ’’
‘‘When I get Pap smears they need to know your sexual orientation, how active you are to understand what they’re looking at. So yeah, I have been very open and telling them that I’m in a gay sexual relationship. I’m very open about that with my doctor.’’
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Table 4. Lesbian Veterans’ Recommendations for VA Care (n = 20) Not useful at all Somewhat useful Very useful How useful would it be for this VA to: Host events specifically for LB veterans at the hospital? Have LB newsletters/magazines available in the hospital? Have information about LB community resources available in the hospital? Have VA staff be involved in LB oriented events in the community (such as LGBT Pride month events)? Post a Patient Bill of Rights that explicitly ensures healthcare for and nondiscrimination of LB veterans? Place advertisements or articles in city LB newspaper about VA services and the VA’s desire to be welcoming to LB veterans? Display images in VA clinics that reflect LB lives (e.g., rainbow flags, posters with same-sex couples)? Use inclusive language (e.g., forms and providers referring to ‘‘partner’’ instead of ‘‘husband or wife’’)?
15% 20% 0%
50% 35% 30%
35% 45% 70%
20%
25%
55%
10%
5%
85%
5%
45%
50%
10%
30%
60%
10.5%
10.5%
79%
LGBT, lesbian, gay, bisexual, and transgender.
Several lesbian veterans spoke of the importance of the VA providing high quality healthcare to women veterans, first and foremost. These women noted that if providers were providing comprehensive care for women veterans that high quality, comprehensive care for lesbian and bisexual veterans would naturally follow. One lesbian veteran summarized her feelings on this matter: ‘‘You know men, women, lesbian, gay, whatever. Let’s just take good care of veterans. I’m way into that.’’
Recommendations for improvements in VHA care for lesbian veterans
When considering recommendations for VHA care, lesbian veterans indicated numerous avenues for improvements in VHA care that could lead to a more welcoming environment for LGBT veterans (Table 4). Lesbian veterans endorsed posting a Patient Bill of Rights in the waiting areas, using inclusive language in standard VHA forms (using the word ‘‘partner’’ in addition to ‘‘husband’’ and ‘‘wife’’), and having information about lesbian community resources available in the hospital. Several lesbian veterans endorsed improved cultural competence in LGBT issues aimed at VHA staff and providers. One lesbian veteran stated that staff and providers should be taught that LGBT veterans and are no different than heterosexual veterans, and that an educational program aimed at cultural competence would be appropriate: ‘‘ I think it comes down to a lack of knowledge.just more education. It always comes down to more education. Not about ‘don’t beat up the gays,’ but just that they’re really no different than other veterans.’’
Another lesbian veteran wanted the VA to place more emphasis on inclusion of LGBT family members into medical care: ‘‘I think it would be interesting and useful for the VA to do some outreach to our partners.outreach for lesbian veterans families.’’
However, some lesbian veterans were extremely pleased with the VHA efforts already in place to ensure cultural competence for LGBT veterans. Eighty percent of lesbian veterans in the current study noted that the VA had created a welcoming environment for LGBT patients. One woman described this environment as follows: ‘‘You know, one of the things that made me inordinately pleased was there was a screensaver on.it just said the VA is open and affirmative environment and it was a LGBT screensaver. And it wasn’t for patients.I think it was for staff! And that just made me feel like all, ‘Cool! All right!’ If the organization is on board and is accepting and willing and has it as a screen saver which they know that the patients are going to see. That says something. That really says something about being welcoming.’’
Discussion
To the best of our knowledge, this is the first paper that specifically explores lesbian veterans’ experiences and perceptions with stigma and discrimination in VHA care, and their comfort with revealing their sexual orientation to VHA providers. In our study, though many lesbian veterans feared negative attitudes and mistreatment from VHA staff and providers, few veterans had actually experienced mistreatment from their VHA providers based on their sexual orientation. Lesbian veterans’ experiences of mistreatment and perceptions of LGBT-related stigma echo findings from the recent Institute of Medicine report highlighting refusal of treatment, verbal abuse, and disrespectful treatment for many LGBT individuals seeking healthcare.23 Despite some lesbian veterans’ experiences with mistreatment related to sexual orientation, a majority of lesbian veterans in our study believed that the VHA was trying to create a welcoming environment for LGBT veterans. Findings regarding the degree to which the VHA creates a welcoming environment for LGBT veterans from this study differ substantially from other recent VHA studies that have examined patients’ perspectives on affirming VHA environments. In their recent study of LGBT veterans and their providers
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at two VHA facilities in Oklahoma and Texas, Sherman and colleagues found that only 30% of LGBT veterans endorsed the VHA as a welcoming environment.7,25 In contrast, 80% of the lesbian veterans in the current study rated the VHA as a welcoming environment for LGBT veterans. These differences may be attributable to the relatively conservative nature of Texas and Oklahoma in comparison to states such as Massachusetts, which was the first state in the country to legalize same-sex marriage in 2004, a full decade before the current study was launched. Additionally, our study only included lesbian women veterans, in contrast to the Sherman study that was comprised of gay men (30%) who may experience more stigma and less-welcoming environments. 25 In our study, several lesbian veterans acknowledged that their willingness to disclose their sexual orientation to their VA provider had increased substantially after the repeal of ‘‘Don’t Ask, Don’t Tell’’ (DADT). Though DADT was a Department of Defense (DOD) policy that did not impact access to VHA healthcare for LGBT veterans, many veterans were afraid to disclose their sexual orientation for fear of this information being ‘‘leaked’’ back to DOD, which they believed would ultimately affect their military pensions or ability to return to military service in the future. Though the consequences of DADT have been explored by others,27 this is one of the first studies that has examined the lingering effects of these policies among LGBT veterans and their willingness to disclose their sexual orientation to their VA healthcare providers. One interesting finding from our study was the notion that some lesbian veterans felt that it was more important that VA providers to be proficient in women’s health care, rather than specific to lesbian and bisexual healthcare. Though the VHA is mandated to offer a female provider to all female veterans,28 several women in our study switched their care from a female VA provider to a male VA provider because they felt the female provider wasn’t able to offer the high-quality, comprehensive medical care that was needed as an lesbian veteran. One of the biggest frustrations cited by lesbian veterans was the belief that VA staff were reticent to allow same sex partners to join the lesbian veteran in healthcare visits and decision-making. The VHA has addressed this issue in its patient non-discrimination policy16 with regard to visitation that defines ‘‘family member’’ as anyone the veteran chooses. This policy also allows the veteran to have whomever they wish join them in a treatment room. Finally, the policy allows all veterans to designate a signed medical power of attorney document that could allow anyone the veteran wishes for healthcare decision-making. This study has several limitations, including the small sample size of 20 lesbian veterans that limited the overall generalizability of the study findings. Although 20 participants has been noted to be of sufficient sample size for the purposes qualitative research,33 this study may have not reach concept saturation due to the factors mentioned in the subsequent sentences, still we are confident that the our findings add to the current literature. Furthermore, though our original recruitment was targeted to lesbian and bisexual veterans at four VHA facilities, we were not able to recruit any bisexual veterans. This lack of recruitment may be due to the smaller number of individuals in the military self-identifying as bisexual in comparison to gay or lesbian, thus making the eligible recruitment pool limited. Future studies should aim to proportionately target larger populations of lesbian, gay, bisexual, and
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transgender veterans in order to better comprehend their specific healthcare needs. Simultaneously, these studies should look for more effective recruitment modes, such as Respondent-Driven Sampling (RDS),29–32 to target those lesbian, gay, bisexual, or transgender veterans who feel the most vulnerable to discrimination. The women in this study were on average, older veterans who may have different healthcare needs than their younger lesbian counterparts. As the number of lesbian women between the ages of 18–39 years in the military continues to increase, so will the need to further understand their barriers to care and healthcare needs (e.g., post-traumatic stress disorder [PTSD], prenatal care). Our study sample did not include lesbian veterans living in predominately rural areas of the country, where attitudes towards LGBT individuals may be more conservative. Though our recruitment strategies included posting flyers in VA women’s health and primary care clinics, we likely missed lesbian veterans who did not receive care during the recruitment phase and study period. Very little research on the specific health and health care needs of lesbian veterans has been published to date. Research in non-veteran populations has demonstrated that lesbian persons often fear negative consequences of disclosing their sexual orientation to health care providers. These disclosure-related fears might have been amplified among veterans due to DADT: In our anecdotal experience, many veterans mistakenly believed DADT was a policy that VA shared with DOD. With the repeal of DADT, lesbian veterans may begin to feel more comfortable disclosing their sexuality to their VA healthcare providers without fear of reprisal. In turn, it is essential that VA healthcare providers create a healthcare environment free of assumed heterosexuality (e.g., not assuming that all female veterans require birth control for sexual activity) and ensure that they are knowledgeable about lesbian health issues. A safe environment that encourages acceptance of all sexual orientations is essential to improving the quality of care and the health outcomes of women veterans. The implementation of effective interventions that aim to educate both VA providers (and patients) on healthcare needs specific to the sexual orientation, is the first step in ensuring the future health of women veterans. Conclusion
Future research should focus on expanding this study to include a larger and more diverse sample of lesbian, gay, bisexual, and transgender veterans receiving care at VA facilities across the country. Questions regarding sexual orientation and behavior should also be included in all VA surveys to ensure that the needs of this population are being met across all areas of VA care. Acknowledgments
This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development. All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. 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 Stated Government. The authors would like to thank Laurie Zephyrin, Sally Haskell, Anne Sadler, Erin Krebs, Silvina Levis-Dusseau, Ann Cheney, and Mabel Quinones-Vazquez for their support and assistance of this study. This work was supported by VA
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HSR&D-funded Women’s Health Research Network (Project # SDR 10–012) and by VA Women’s Health Services (WHS). Author Disclosure Statement
No competing financial interests exist. References
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Address correspondence to: Kristin M. Mattocks, PhD, MPH Department of Research and Education VA Central Western Massachusetts Healthcare System 421 North Main Street Leeds, MA 01053 E-mail: [email protected]
