LGBT Health Volume 1, Number 3, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/lgbt.2014.0008

Provider Beliefs and Practices About Assessing Sexual Orientation in Two Veterans Health Affairs Hospitals Michelle D. Sherman, PhD,1–3 Michael R. Kauth, PhD,2,4–6,10 Jillian C. Shipherd, PhD,5,7,8,11 and Richard L. Street Jr., PhD 6,9,10

Abstract

Purpose: Despite known health disparities for lesbian, gay, and bisexual (LGB) individuals, research in the civilian sector has documented low rates of patient disclosure and provider assessment of this domain. Very little is known about Veterans Health Affairs (VHA) providers’ care of LGB veterans, a population that has been relatively invisible until recently because of the vestiges of the Department of Defense policy of ‘‘Don’t Ask, Don’t Tell.’’ This study examined the attitudes, beliefs, and clinical practices of VHA healthcare providers regarding sexual minority veterans. Methods: Physical and mental health VHA healthcare providers (n = 202) from two southern VHA hospitals completed an anonymous self-report questionnaire. Measures included comfort in providing care to LGB veterans, factors affecting decisions about assessing sexual orientation with veterans, and attitudes toward sexual minority individuals. Results: Although approximately half of VHA providers thought that sexual orientation should be routinely discussed, the providers rarely assessed this issue with their patients. Over half of providers believed that veterans would disclose their sexual orientation if it was important to them, and almost half of providers believed sexual orientation is not relevant to healthcare. Conclusion: Many VHA providers may be unaware of the unique health disparities experienced by LGB individuals. Culturally appropriate care cannot be provided to LGB veterans unless providers explicitly assess sexual orientation in healthcare visits. Central to this assessment is providing patients with a clear rationale for the purpose of the assessment and related documentation. Staff training is needed to address providers’ beliefs and reservations about discussing sexual orientation that emerged in this investigation. Key words: lesbian/gay, patient–provider communication, sexual orientation, veterans, Veterans Affairs hospital.

Introduction

he Institute of Medicine1 and U.S. Health and Human Services’ Healthy People 20202 encourage healthcare providers to regularly assess sexual orientation to reduce health disparities and address health concerns among lesbian, gay, and bisexual (LGB) individuals. Routinely talking to all patients about sexuality and sexual behavior can reduce transmission of sexually transmitted diseases and improve mental and physical well-being. Gay

T

and lesbian individuals who are open with their providers about their sexual orientation are more likely to get appropriate health screenings,3,4 experience their healthcare as more relevant,5 and report higher satisfaction with care6 than LGB individuals who do not disclose. However, recent studies have found that many healthcare providers are not aware of specific LGB health concerns and infrequently ask patients about sexual orientation.7–9 Therefore, it is important to understand and address providers’ beliefs and attitudes about discussing sexual orientation with patients.

1

Oklahoma City VA Medical Center, Oklahoma City, Oklahoma. South Central Mental Illness Research, Education and Clinical Center. University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma. 4 Michael E. DeBakey VA Medical Center, Houston, Texas. 5 VA Central Office, Patient Care Services Lesbian, Gay, Bisexual, and Transgender (LGBT) Program, VA Health Services Research & Development Houston Center of Excellence, Houston, Texas. 6 Baylor College of Medicine, Houston, Texas. 7 VA Boston Healthcare System, Boston, Massachusetts. 8 School of Medicine, Boston University, Boston, Massachusetts. 9 Texas A&M University, College Station, Texas. 10 VA Health Services Research & Development Houston Center of Excellence, Houston, Texas. 11 National Center for PTSD, Women’s Health Sciences Division. 2 3

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The rate of sexual orientation disclosure by LGB individuals to healthcare providers is unknown. LGB individuals cite a broad range of fears about disclosing to a healthcare provider10 and may avoid or delay seeking care because of these concerns and/or negative past experiences.11 Patients’ fears can be addressed when providers initiate an open dialog and create a safe, comfortable environment for disclosure of sensitive information. A recent literature review12 found that asking women about sexual orientation facilitated disclosure in half of all studies reviewed. One study13 found that when physicians specifically asked about sexual orientation, 100% of lesbian women disclosed. Further, research in other clinical contexts indicates that patients are willing to disclose psychosocial and personally sensitive information when physicians inquire.14,15 Thus, explicit provider inquiry about sexual orientation can likely increase the probability that patients will disclose, which can lead to improved care. Healthcare provider beliefs regarding sexual orientation

Historically, some healthcare providers have reported negative attitudes and discomfort in providing care to LGB individuals. Surveys conducted 25–30 years ago indicated 30–60% of physicians felt uncomfortable providing care to gay patients.16–18 Research during the same era with nurses revealed negative beliefs, such as thinking lesbianism is immoral, disgusting, illegal, and a disease.19,20 Although research with different healthcare provider groups has demonstrated some improvement in attitudes toward sexual minorities over the past 30 years,21,22 a range of attitudes and comfort levels continue to exist. Existing research on healthcare providers’ treatment of LGB individuals is sparse, but a survey of LGB physicians by the Gay and Lesbian Medical Association revealed important findings.23 Two-thirds of physicians said that they know gay patients who received substandard care or were denied care because of sexual orientation, 52% observed colleagues providing poor care or denying care to patients based on sexual orientation, and 88% had heard colleagues make disparaging remarks about gay patients. Healthcare provider practices with assessing sexual orientation

Little is known about assessment of sexual orientation, but the literature available suggests rates of provider inquiry are low, ranging from 0%24 to 24%.13 Rates of assessment may be increasing and may vary by physician gender, age, and specialty. In a large, recent survey, 28% of OBGYNs reported that they ask about sexual orientation.25 When asked why they do not assess sexual orientation, providers report numerous beliefs (e.g., none of their patients are LGB; sexual orientation is irrelevant to healthcare; sexual orientation is private and should not be discussed), worry (e.g., fear of upsetting the patient or being intrusive; personal discomfort with the topic), a lack of awareness of health risks associated with sexual minority status, a lack of knowledge about LGB sexual practices and terminology, and brief appointment times.7,8,26–28 Provider beliefs and practices in Veterans Health Affairs with LGB individuals

The Veterans Health Affairs (VHA) has begun several initiatives to create a welcoming environment for LGB veterans.

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Some promising research is underway, examining health disparities among LGB veterans,29,30 utilization rates of VHA care, and barriers to seeking VHA services.31,32 However, little research exists about patient–provider communication about sexual orientation in the VHA system. Assessing sexual orientation and behavior with patients at intake in both primary care and mental health not only demonstrates respect for sexual minorities but also yields critical information about key intimate relationships, environmental support, and potential health risks. Only one study has specifically examined VHA providers’ beliefs about lesbian, gay, bisexual, and transgender (LGBT) issues among veterans.33 This online survey of 166 VHA mental health professionals revealed concerns about poor treatment of LGBT veterans by other veterans and staff; a need for more clinical resources for LGBT veterans; a need for staff training on care of LGBT veterans; and concerns about safeguarding veterans’ privacy in the electronic medical record. The current exploratory study examines the attitudes, beliefs, and clinical practices regarding sexual minority veterans of physical and mental health providers at two VHA hospitals. To the best of our knowledge, this is the first project to study these constructs among VHA providers with a mixed methods design, and it offers important findings that may shape future training efforts. A similar exploration of provider beliefs and practices about gender identity is underway, and results will be reported when available. Methods

VHA mental health and primary care providers were recruited from two southern VHA medical centers (Oklahoma City, OK, and Houston, TX) through service-wide e-mails and staff-meeting presentations at both sites from July to December 2012. The study was approved by the Institutional Review Boards and Research Committees at the respective institutions. The first page of the survey emphasized the voluntary nature of participating in the anonymous survey, and that subjects are providing informed consent by completing the survey. A waiver of written informed consent was obtained by both Institutional Review Board committees. Participant surveys

Providers were asked to complete a 47-item anonymous questionnaire either via a paper-and-pencil survey or an online SurveyMonkey version that assessed providers’ practices, beliefs, comfort, and attitudes about LGBT issues; the entire survey is available as Supplementary Material (Supplementary Data are available online at www.liebertpub.com/ lgbt) (the data on transgender attitudes and practices are not presented here). Most items were created by the research team to measure constructs of interest and were primarily Likert-scale items; respondents also wrote in additional comments. The Attitudes Toward Lesbians and Gay Men (ATLG) scale, short version,34 was also included; this 6-item measure asks respondents to indicate how much they agree with statements about homosexuality on a 5-point Likert scale. Higher scores reflect more positive attitudes toward gay and lesbian individuals. Half of the items pertain to gay men (e.g., ‘‘I think gay men are disgusting’’) and the other half are about lesbians (e.g., ‘‘Sex between two women is just plain wrong’’). The scale has demonstrated internal validity, test– retest reliability, and convergent and discriminant validity.

SEXUAL ORIENTATION ASSESSMENT IN VHA HOSPITALS

The provider survey was piloted and reviewed by national experts in LGBT research and LGBT veterans.

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Table 1. Demographic Characteristics of Veterans Health Affairs Providers (n = 202) n

Analysis

Descriptive statistics, T tests, and correlations were performed with Microsoft Excel and SAS. Themes in the provider qualitative data were explored via content analysis,35 and samples of responses were reviewed to identify distinctive themes, continuing this process until thematic saturation was reached. Final categorization was conducted conjointly by first and second author. Disagreements were resolved with the rest of the research team. Results

As described in Table 1, the providers (n = 202) were predominantly Caucasian, non-Hispanic. About 60% of respondents were female and 24% male; 16% did not indicate their gender. Almost three-quarters identified as heterosexual and approximately half were married. While almost half of providers worked in mental health, there was a range of professional disciplines (19% physicians, 16% psychologists, 15% social workers). Over three-quarters of providers reported having a friend, family member, or close acquaintance who was LGBT. Provider attitudes toward gay and lesbian individuals

While the ATLG scale (short version) was on average quite favorable (M = 24.45, SD = 5.9, scale 6–30), considerable variability emerged. Some groups of providers had more positive attitudes (Table 2), specifically those who were nonheterosexual, Caucasian, and nonveteran. Providers who worked in mental health areas had received training in LGBT issues in professional education, and had a family member or friend who was LGBT also reported more positive attitudes. There were no significant differences by provider gender or provider age. Several significant associations emerged between ATLG scores and provider beliefs and behaviors (see Table 3); more positive attitudes toward gay and lesbian individuals were associated with greater comfort talking about sexual orientation and higher reported rates of explicitly assessing this domain with veteran patients than those with less positive attitudes. Factors affecting provider inquiry about sexual orientation

Routine assessment of sexual orientation was rare in our sample, with only 10% (n = 21) of providers reporting that they ask all of their patients. Half (50%, n = 101) of providers reported that they have asked none of their patients about sexual orientation in the past year. Approximately one-quarter (26%, n = 53) of providers indicated that they have asked between 25% and 50% of their patients in the past year. Thus, the majority of VHA providers in our sample report that they assess sexual orientation with none or very few of their patients. Several factors likely contribute to these low rates of assessment, including varying provider attitudes toward LGB individuals as discussed above. Three other key themes were examined in the study, including provider discomfort in talking about sexual orientation, provider beliefs about the appropriateness of such assessment, and provider perceptions of deterrents to clinical discussions. Comfort in assessing sexual orientation. Providers reported a range of comfort levels in talking about sexual orientation

%

Gender Male 49 24 Female 121 60 Missing 32 16 Age 20–30 28 14 31–40 51 25 41–50 42 21 51–60 28 14 61 + 16 8 Missing 37 18 Race (may identify as more than one) White/Caucasian 127 63 Asian, including Southeast Asia 18 9 Black or African American 16 8 American Indian/Alaska Native 4 2 Other 6 3 Missing 31 15 Hispanic or Latino background Yes 8 4 No 162 80 Missing 32 16 Relationship status (may identify as more than one) Married 97 48 Partnered 16 8 Single 33 16 Divorced 24 12 Separated 2 1 Never married 8 4 Missing 22 11 Sexual orientation Heterosexual/straight 146 72 Homosexual/gay or lesbian 12 6 Bisexual 4 2 Questioning 2 1 Prefer not to answer 4 2 Missing 34 17 Discipline Physician 38 19 Psychologist 32 16 Social worker 30 15 Nurse 22 11 Therapist/case manager 10 5 Mental health trainee 23 11 Missing 47 23 Primary worksite Mental health 97 48 Specialty clinic 44 22 Primary care 24 12 Inpatient 8 4 Missing 29 15 Received formal training in LGBT issues in professional education Yes 95 47 No 79 39 Missing 28 14 Received formal training in LGBT issues after professional education Yes—in VA system 26 13 Yes—in private sector 44 22 Yes—in VA and private sector 16 8 No 83 41 Missing 33 16 LGBT, lesbian, gay, bisexual, and transgender.

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Table 2. Attitudes Toward the Lesbians and Gay Men (ATLG) Scale, Short Version, by Provider Groups Provider

n

Mean SD

t

df

p

Age 20–39 79 25.18 5.43 1.67 164 0.10 40 and up 86 23.66 6.23 Gender Male 49 23.71 5.42 0.52 167 0.60 Female 121 24.28 6.82 Worksite Mental health 97 25.79 5.07 3.46 167 < 0.001 Not mental health 76 22.73 6.42 Sexual orientation Heterosexual 146 23.92 6.00 2.66 161 0.009 Nonheterosexual 18 27.68 3.97 Race Caucasian 127 25.26 5.48 4.47 162 < 0.001 Non-Caucasian 44 20.18 7.95 Military history Veteran 14 21.14 7.35 2.22 168 0.03 Nonveteran 158 24.76 5.70 Has LGB family member/friend Yes 158 24.95 5.60 4.39 167 < 0.001 No 14 18.27 5.89 Training in professional education about LGBT issues Yes 95 26.08 5.21 4.18 169 < 0.001 No 79 22.45 6.13 with patients. The question assessing their comfort in this domain was asked twice, assessing comfort in talking with male and female patients. Almost half (48%, n = 97) reported feeling ‘‘very comfortable’’ with such discussions when talking with females, and 45% (n = 91) felt comfortable when talking with males. About one-fifth reported feeling ‘‘somewhat comfortable’’ (21%, n = 42) with females and 22% (n = 44) were ‘‘somewhat comfortable’’ with males. Notably, 11% (n = 22) of providers reported feeling ‘‘very’’ or ‘‘somewhat’’ uncomfortable in these discussions with both men and women. Slightly under half of providers had received training in their professional education about LGB issues. On items assessing

Table 3. Correlations Between Attitudes Toward the Lesbians and Gay Men (ATLG) Scale, Short Version, and Provider Beliefs and Behaviors r Belief it is important for VA to be welcoming to LGBT veterans Comfort talking with male veterans about sexual orientation Comfort talking with female veterans about sexual orientation Proportion of male veterans provider has asked directly about sexual orientation Proportion of female veterans provider has asked directly about sexual orientation Belief it is appropriate for VA providers to ask about a patient’s sexual orientation during a clinical visit

p

0.56 < 0.001 0.41 < 0.001 0.40 < 0.001 0.19

0.01

0.20

0.01

0.25 < 0.001

comfort in discussing sexual orientation (5-point Likert scale response options with higher scores reflecting greater comfort), providers with training on LGB issues reported more comfort in talking with male veterans about sexual orientation (M = 4.3, SD = 0.94) than those without training (M = 3.9, SD = 1.2), t(170) = 2.57, p = 0.011. Similar results emerged for talking with female patients, as those with training on LGB issues (M = 4.3, SD = 0.97) reported more comfort than providers without training (M = 3.97, SD = 1.16) t(171) = 2.10, p = 0.037. Providers who had LGB training thought VHA providers should assess sexual orientation during appointments more often (M = 3.65, SD = 1.01, where a higher score on this 5-point Likert scale reflected belief that sexual orientation should be assessed more often) in comparison to providers without training (M = 3.18, SD = 1.3), t(170) = 2.68, p = 0.008. Beliefs about appropriateness of assessing sexual orientation. Providers also reported a range of opinions

about the appropriateness of assessing sexual orientation in clinical encounters. Only 21% (n = 42) believe that sexual orientation should be assessed ‘‘with every patient,’’ and 26% (n = 53) believe that it should be asked ‘‘usually.’’ More commonly, 28% (n = 57) of the providers said that sexual orientation should be assessed ‘‘only if the patient mentions it.’’ Twenty percent (n = 40) of providers think that it should be ‘‘rarely’’ or ‘‘never’’ asked. Perceived barriers to assessing sexual orientation. In response to the question, ‘‘To what extent do each of the following issues affect whether or not you ask about sexual orientation?’’ providers rated whether each of the 12 issues had ‘‘no, some, or strong’’ effect on their practice. Table 4 summarizes the percentages of providers who believe that each item has ‘‘some’’ or a ‘‘strong’’ effect. The issue rated as having a large impact by the greatest number of providers was ‘‘Veterans will disclose the information if it’s important to them,’’ with 56% (n = 113) rating it as having ‘‘some’’ or a ‘‘strong’’ effect. The second most frequent item was ‘‘Fear of offending the patient.’’ Providers wrote several comments that are consistent with this view: The biggest factor that makes me hesitate to ask directly is because of my fear of offending someone who is heterosexual (did not report gender or profession). Sometimes veterans act offended when I ask this question. When I have a veteran who has been married for over 25 years, I generally have an inward flinch when I ask and he generally reacts as though he’s horrified that I would ask (female psychologist). Some providers (41%, n = 83) reported that ‘‘Sexual orientation is not relevant to the veteran’s healthcare.’’ Qualitative comments reflected a similar sentiment: I don’t think it’s any of my business unless they experience issues related to it (female nurse). It is rarely relevant to the care I need to provide (female physician). In addition to perceived barriers of time limitations (38%, n = 77) and lack of specialized services for LGBT veterans at VHA (36%, n = 73), almost one-third of providers noted that ‘‘concern about other veteran’s reactions to LGBT veterans’’ has considerable influence on their decision regarding assessing sexual orientation. Providers shared similar themes in their comments:

SEXUAL ORIENTATION ASSESSMENT IN VHA HOSPITALS

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Table 4. Number and Percent of Providers (n = 202) Who Reported That Each Issue Has ‘‘Some’’ or a ‘‘Strong’’ Effect on Decision Making About Assessing Sexual Orientation

Veterans will disclose the information if it’s important to them Fear of offending the patient Sexual orientation is not relevant to the Veteran’s healthcare Too many other things I have to assess—don’t have enough time Lack of specialized services at our VA for lesbian/gay/bisexual (LGB) Veterans Concern about other Veterans’ reactions to lesbian/gay/bisexual/transgender (LGBT) Veterans (e.g., in waiting rooms, shared hospital rooms, groups or classes) Haven’t considered asking about sexual orientation Uncertainty about if/how to document this information in CPRS Don’t know how to ask about sexual orientation Fear of consequences for Veteran’s access to health care and service connection/disability Institutional climate/environment not conducive to such discussions (e.g., fear of negative reactions from my colleagues or supervisors) Personal discomfort with the issue of sexual orientation I do fear for some of the veterans as they are not always respected by staff and their peers after they share such information (female therapist/case manager). I have personally experienced some veterans talking negatively about LGBT individuals and how they feel disrespected as ‘‘straight’’ veterans. This is one reason I don’t feel that I should talk so much about it; as the majority of the vets are straight (female nurse). Almost one-third of providers indicated that they ‘‘haven’t considered asking about sexual orientation’’ (29%, n = 59); a female psychology trainee said: I don’t regularly think about it. If it doesn’t come up, then (I am) less likely to inquire. One fifth (n = 40) of providers reported that their lack of knowledge about how to assess sexual orientation had a considerable effect on their practice. A female nurse noted: I would very much like more information on how to approach this situation so the patient can be more at ease and understand that their medical care will not be affected. Thank you for broaching this subject. It is long overdue. Notably, 15% (n = 30) of providers indicated that the ‘‘Institutional climate/environment is not conducive to such discussions’’ had ‘‘some’’ or a ‘‘strong’’ effect on their practices; this theme arose quite often in the qualitative comments, including: The military and VA have a very gender-typed tradition— very ‘‘macho’’ and not tolerant of diversity. This anti-gay culture is so deeply entrenched, I think veterans who are GLBTQ have learned to keep this information private. Similarly, providers have learned not to ask (don’t ask, don’t tell) to protect their clients (female social worker). Am ashamed of my fear to ask in this system but feel like the environment is a powerful deterrent (female, did not provide profession). Discussion

Current best practice is for healthcare providers to assess sexual orientation and discuss sexual health and behavior with patients. LGB individuals are at increased risk for a number of health concerns36,37 that may go undetected without regular assessment. In the primary care setting, specific sexual health screens (e.g., anal pap smears) might be missed altogether without data on sexual practices. Fortunately, this

n

%

113 93 83 77 73 61

56 46 41 38 36 30

59 49 40 39 30

29 24 20 19 15

24

12

has been a focus of VHA educational initiatives, including a VHA webinar on taking a history of sexual health that is available to all VA employees on the intranet. In this study, providers at two VHA hospitals rarely assessed sexual orientation, with half having asked none of their patients in the past year. These rates are similar to those reported in non-VHA settings.7,9,13,25 Our finding that approximately one-quarter of providers had assessed sexual orientation with 25–50% of their patients in the past year is noteworthy. Post hoc examination revealed that mental health providers were slightly more likely to ask about sexual orientation than were primary care providers; however, because of the very small sample, this finding should be interpreted with caution and future study is needed. It is not known what criteria these providers use in their decision to assess sexual orientation, and further empirical examination of this issue is needed. It is possible that such decisions are shaped by stereotyped views of LGB veterans that may not always be accurate. Regarding beliefs about assessing sexual orientation, about half of VHA providers thought that sexual orientation should be typically discussed with patients; one-fifth thought that sexual orientation was not appropriate to discuss in a clinic setting. Eleven percent of providers feel very or somewhat uncomfortable discussing sexual orientation with patients. These findings are consistent with analogous nonVHA investigations, such as research with family physicians in which slightly over half reported that it was very important to know about patients’ sexual orientation, and over threequarters of physicians reported that asking patients about sexual orientation is difficult.7 To the best of our knowledge, this is the first study to explore factors that affect VHA providers’ decision making about assessing sexual orientation. Over half of providers reported that their decision regarding discussing this issue is affected by their belief that veterans will disclose their orientation if it is important to them. Similarly, over 40% of providers report that sexual orientation is not relevant to the veteran’s healthcare, and almost one-third of providers indicated that they had not considered asking about sexual orientation. Although several of the barriers identified in this study have been described in civilian research (especially fears of offending the patient, viewing sexual orientation as irrelevant to healthcare, brief appointment

190

times),7,8,26,28 some of the concerns that emerged in this exploratory project warrant further investigation, such as the lack of specialized services in VHA for LGB individuals, concerns about other veterans’ reactions to LGB veterans, and fear of the consequences for veteran’s access to healthcare and service connection/disability. Many VHA providers may be unaware of the unique health disparities experienced by LGB individuals and how the failure to talk openly about sexuality contributes to continued disparities. These disparities cannot be reduced and culturally appropriate care cannot be provided to LGB veterans unless these discussions occur in routine healthcare visits. Previous research suggests that many LGB patients are reluctant to disclose their sexual orientation out of fear of discrimination.24,38 Worry about discrimination may be especially potent among LGB veterans who have experienced discrimination against same-sex behavior and LGB identities in the military.39 In light of the veterans’ fears and negative experiences, the providers’ assumption that patients will share their sexual orientation ‘‘if it is important to them’’ (endorsed by 56% of providers) may be faulty, resulting in neither providers nor patients initiating the discussion, and the providers’ continued presumption of the patient’s heterosexuality. The consequence of perpetuating a ‘‘don’t ask, don’t tell’’ approach is clinical care provided in a heterosexist framework, resulting in poorer care for the patient. As seen in Table 1, demographic information was missing on salient dimensions of our sample at rates higher than what is seen in civilian surveys involving sexual orientation,40 which likely impacted our findings. While the reason for nonresponse on these items is not known, respondents may have feared that their responses were identifiable and felt uncomfortable expressing opinions about this sensitive topic, even though they were assured that the survey was anonymous. Several limitations of the study are noteworthy. First, because data were collected at two southern VHA hospitals, the generalizability of the findings to other parts of the country is unknown. Second, most of the items were created by the research team (because of the lack of existing measures to assess the constructs of interest); therefore, the measures do not have established psychometric properties. Finally, the findings should be considered in the context that only 24% of the respondents who reported their gender were male. The VHA encourages providers to create a culturally sensitive, safe, and supportive environment. VHA providers need to provide a clear rationale for asking about sexual orientation and convey that argument convincingly to all patients as part of routine assessments.41 VHA providers need to understand LGB veterans’ concerns about disclosure and discuss documentation concerns and limits on confidentiality. VHA providers can reassure veterans that discrimination of patients based on sexual or gender minority status is prohibited, and violations will not be tolerated within the VHA. However, open disclosure of sensitive information by patients is unlikely unless patients are reassured of protections and treated with respect and dignity. Staff training is needed to address the providers’ beliefs and reservations about discussing sexual orientation that emerged in this study. Training should focus on communication techniques for discussing sexual orientation in a supportive, nonjudgmental manner with all patients. Providers in this study who had received training on LGBT issues reported greater comfort in discussing sexual

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orientation with both male and female patients. Interestingly, this finding was not driven by the presence of trainees in the sample. Post hoc examination explored the possibility that providers trained more recently may have been more likely to have been trained in LGBT issues. Contrary to expectations, when trainees were removed from the analyses, a larger percentage of providers had received training in LGBT issues, which was a disturbing finding. Fortunately, VA has undertaken a variety of initiatives that provide education to staff at all levels of training.42 These initiatives include nationwide trainings in LGBT health (including the assessing sexual health webinar noted above), the creation of nine LGBT health postdoctoral psychology fellowship positions, and an inclusive poster campaign to assure that LGBT Veterans feel welcome at VHA facilities. Although the VHA may have unique challenges in treating LGB veterans because of its unique history and structure, addressing LGB patient needs is salient for all healthcare systems. The VHA has recently affirmed its commitment to providing excellent care for all veterans, including LGB veterans. Specifically, the VHA has undertaken several policy, educational, and clinical initiatives toward the goal of increasing assessment of sexual orientation, reducing health disparities, and creating a more welcoming environment for LGB veterans. This work is occurring across a variety of offices within VHA, including, but not limited to, Patient Care Services, the Office of Diversity and Inclusion, and the Office of Health Equity. Together, they are coordinating systematic change within the largest healthcare system in the world. VHA’s efforts, if successful, can serve as a model for other healthcare systems as they work to provide clinically and culturally appropriate care to LGB patients. Acknowledgments

This article is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, South Central Mental Illness Research, Education and Clinical Center (MIRECC), and the VA Health Services Research & Development Houston Center of Excellence. Thank you to Drs. Lauren Ridener, Gregory Beaulieu, and Kristi Bratkovich for their contribution to the project. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Author Disclosure Statement

No competing financial interests exist for any author. References

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Address correspondence to: Michelle D. Sherman, PhD 921 NE 13th Street (116A) Oklahoma City, OK 73104 E-mail: [email protected]