VA Community Provider Toolkit

Transgender Veterans

"Transgender people have served, are serving, and will continue to serve"
Allyson Robinson
~ West Point Graduate and former officer in the U.S. Army ~

Quick Facts

Quick Facts About Our Nation's Transgender Veterans

Transgender people can have a variety of identities including people who don’t identify as male or female, sometimes called non-binary gender identification or gender non-conforming.
Over 134,000 U.S. Veterans are estimated to be transgender, with over 15,000 transgender people currently serving in the U.S. military (active duty and reserves). Note that these estimates were obtained before transgender people were allowed to serve openly in the U.S. military.¹
Transgender people are at least 2-3x more likely to have served in the U.S. military than non-transgender people. Transgender people are motivated to join the military for similar reasons as non-transgender people – patriotism, life direction, and a family history of service. Additionally some transgender people join the military to escape family rejection or violence, or to enter an environment with clear rules about gender expression.¹
Recent research suggests that Veteran status may contribute to resilience and positive mental health outcomes among some transgender individuals. A recent study of 183 transgender and gender non-conforming older adults (43 Veterans, and 140 non-Veterans) found that prior military service was associated with lower depression symptomatology, as well as greater psychological health related quality of life. ²
Transgender people were not allowed to openly serve in the U.S. military until June 30, 2016, nearly 5 years after the repeal of Don’t Ask, Don’t Tell (DADT). This status of transgender Servicemembers is currently in transition. For more information, see the Department of Defense transgender policy webpage.³
Transgender Veterans have always been eligible for being treated at the VHA, for more information about what care is currently covered see policy report documents reports by the Department of Veterans Affairs (2013) and Kauth and Shipherd (2016).^4,5
As of 2017, more than 5,000 transgender Veterans were receiving transition-related care in the VA healthcare system. This figure is considered to be low relative to the number of transgender Veterans in the system given that not all transgender Veterans meet criteria for a diagnosis and also many choose not to disclose their gender identity to providers.⁶
For more information about transgender Veterans, please explore the VA LGBT Health Program Website. You can also find information on transgender Veterans and VA transgender care through the Transgender American Veterans Association website. Of particular interest, is the section with stories of transgender lives and service.

¹ Gates & Herman, 2014; [LINK].
² Hoy-Ellis et al., 2017; [LINK].
³ Sisk & Jordan, 2016; [LINK].
⁴ Department of Veterans Affairs, 2013; [LINK].
⁵ Kauth & Shipherd, 2016; [LINK].
⁶ Cramer, 2017; [LINK].
⁷ Brown & Jones, 2016; [LINK].
⁸ Sherman, Kauth, Shipherd, & Street, 2014; [LINK].
⁹ Simpson et al., 2013; [LINK].

Educational Materials

The VA LGBT Health Program produces a host of online trainings, available on-demand both within and outside the VA, including trainings on transgender-specific care.
- Additionally, the VA provides a number of outreach materials and fact sheets about transgender health.
- If you are interested in requesting an in-person training, try contacting your local VA’s LGBT Veteran Care Coordinator.
While not specific to Veterans, additional educational materials on transgender care can be found at the World Professional Association for Transgender Health website, at the University of California San Francisco’s Center for Excellence in Transgender Health website, and at the Fenway Institute.

Creating a Welcoming Environment

Gender identity is complex, and people describe their gender in a lot of different ways. As with all identities, it is important to validate the gender identities of transgender clients. One way of doing this is to ask your clients how they identify their gender, and what pronouns they use. In some cases, transgender Veterans will use different pronouns and names than what is written on their legal documents, which means that medical records, especially electronic medical records, can be difficult to amend to reflect a client’s identity appropriately.

It is important to work with your clients, and with the system in which you are practicing, to navigate any barriers that might arise in charting and other documentation. Consider using paperwork that asks clients to identify their sex assigned at birth and gender identity, as well as paperwork which either allows people to write in their gender identity or lists multiple gender identities that a person can choose from when completing necessary forms.

Names and pronouns are just one part of creating a welcoming environment. A lot of what we do in our day to day lives and practice is gendered. Wherever something in your clinical practice is gendered, consider how you can be inclusive of all gender identities. For some helpful tips, visit the links below.

Useful Tips

Creating a Trans Welcoming Environment: A Tip Sheet for SA Service Providers »
This brief, easy to read (and use) tip sheet is written specifically for sexual assault service providers who are working with a transgender or gender non-conforming client. It is intended as an overview, a set of reminders, to ensure heightened sensitivity to the needs of trans* survivors.
Create a Safe and Welcoming Clinic Environment »
Transgender people may avoid seeking care due to prior discrimination or disrespect in a clinic setting. Providing a safe, welcoming and culturally appropriate clinic environment is essential to ensure that transgender people not only seek care, but return for follow-up. There are several key components to creating an appropriate setting for transgender care.

Resilience and Stress-Related Growth

Resilience

“Commonly refers to the ability to withstand or overcome significant stress or adversity,” though there is no one, widely agreed upon definition that identifies exactly what fosters resilience in transgender and other minority populations.¹ Some potential resilience factors that have been more widely studied include family support, peer support, and identity pride.¹ Research suggests that high social support may foster resilience, while low social support increases minority stress. Both concepts can be interrelated with ‘coming out’ for the first time as transgender.^{1, 2} Pride in one’s identity/identities may also be a mediating factor, with important implications for multiple intersecting identities that may place someone at higher risk for stigma and discrimination, such as transgender women of color.³

Stress-Related Growth

The idea that personal growth can occur through adversity, or trauma, depending upon how adversities and the ability to overcome adversities are perceived. When applied to LGBTQ communities, stress-related growth often takes into account resilience factors such as community support and connectedness of individuals to communities.⁴ Similar to resilience, there are important implications for intersectional identities, with several research studies focusing on the interaction between gender identity, religion, and stress-related growth.^{5, 6}

Community Pride

With the aforementioned importance of community connectedness and community pride, it may be important for clinicians working with transgender Veterans to consider ways of fostering pride during the coming out process, as well as during times of increased identity distress. One way of doing this is to help transgender Veterans connect with one another through VA and community groups. It may also be helpful to identify influential figures that Veterans can relate to who have publicly displayed resilience and/or stress-related growth. See a list of notable transgender Veterans.

¹ Colpitts & Gahagan, 2016; [LINK].
² Singh, Hays, & Watson, 2011; [LINK].
³ Singh & McKleroy, 2011; [LINK].
⁴ Vaughan & Waehler, 2010; [LINK].
⁵ Rodriguez & Follins, 2012; [LINK].
⁶ Golub, Walker, & Longmire-Avital, 2010; [LINK].

Treatment Considerations/Health Disparities

Transgender Veterans face a number of physical and mental health disparities. They are also more likely than non-transgender Veterans to have experienced military sexual trauma (MST), as well as non-sexual harassment and assaults. Some may even have been dishonorably discharged. Despite these barriers, transgender Veterans have serviced honorably for decades, with higher rates of service connected disability than among non-transgender Veterans.¹

While it is sometimes possible to have dishonorable discharges related to sexuality and gender amended through Vet Centers and other legal services, the complicated history of transgender military service and VA care may leave transgender people feeling uncertain about the safety of seeking important medical services both in and out of the VA. Studies have found that transgender Veterans may fear disclosing their identity to providers ^8,9. Increased understanding of the unique needs of transgender Veterans can positively impact treatment planning and delivery. VA is working hard to create a welcoming environment for transgender Veterans including having visible signs that help dispel understandable fears that they are not welcome at VA.

Transgender Veterans’ racial and ethnic identities, socioeconomic status, religious or spiritual affiliation, age cohort, disability status, and era of service, among other characteristics, are all important aspects of identity that impact each Veteran’s experience, worldview, and treatment. Providers should integrate all of these factors into treatment.²⁶ Below is other important information to consider when working with transgender Veterans.

Important Considerations/Health Disparities

Transgender Veterans are more likely to have suicidal ideation/attempts. In fact, they are more than 20x more likely to engage in suicidal behavior compared with non-transgender Veterans.¹ One online survey of transgender Veterans found that 66% had a lifetime suicide attempt and 57% had attempted in the past year.² Factors that were predictive of suicide attempts were a male identity, older age, stigma experienced during military service, depression and PTSD symptoms.

Among Veterans who died of suicide, transgender Veterans died younger (49 years old) compared with non-transgender Veterans (55-60 years old).³

These findings are consistent with other, civilian research that found 41% of transgender survey respondents had attempted suicide in their lifetime.⁴

A common resource given to Veterans for suicide risk reduction is the Veteran’s Crisis Line (1-800-273-8255, Press #1). While some transgender Veterans feel comfortable utilizing this resource, others may feel more comfortable speaking with someone whom they know has special experience in transgender care. In these cases, you may consider also giving the Veteran the number for Trans Lifeline (1-877-565-8860), a transgender crisis line run by transgender people for transgender people. The line is available for all crisis calls, not just for those with imminent suicide risk.
Transgender Veterans, particularly transgender women of color, are more likely to be HIV positive than non-transgender Veterans. The rate of HIV among Veterans is already higher than in the civilian population, and one study found that transgender Veterans in VA care were nearly 5x more likely to be HIV positive compared to non-transgender Veterans. ⁵

Pre-exposure Prophylaxis (PrEP) is a new treatment option to help prevent HIV infections. It is over 90% effective (some estimates are even higher). Providers should discuss PrEP (and sexual behaviors) in a non-shaming way. For information, visit the Center for Disease Control’s website.

Several studies have found that minority stress, higher rates of homelessness, experience of discrimination, and limited access to healthcare may impact adherence to and effectiveness of antiretroviral treatments (ART’s) in this population if infected with HIV.⁶

While hormones can be taken alongside ART’s, problems with adherence to ART can lead to dangerously high levels of hormones in transgender Veterans who take both medications (see clinical guidelines). A medical provider with experience prescribing ART and hormone therapy can help transgender clients find the safest way to manage their medications to avoid side-effects and these risks.
It is important to note that being transgender is not a mental illness. Not all transgender people are diagnosed with Gender Dysphoria. Transgender people who want medical treatments such as hormone therapy or surgical interventions will often need a diagnosis of Gender Dysphoria to access care (see wpath.org for more information). For additional information about culturally-appropriate mental health treatment see “The psychologist's role in transgender-specific care with U.S. veterans” (Johnson, Shipherd, & Walton, 2015).⁷

Transgender people regularly face discrimination and stigma, which alongside the lack of legal protections have a negative impact on the mental health of transgender Veterans.⁸ One study found that transgender Veterans were 10% or more likely than non-transgender peers to have been diagnosed with depression, serious mental illness, post-traumatic stress disorder, and alcohol abuse.⁹
Transgender Veterans experience a high incidence of MST. One study found that nearly one in seven transgender Veterans receiving VA care had endorsed MST in their medical record.¹⁰ It is likely that this is an underrepresentation of how many transgender Veterans actually experience MST, given the potential consequences of reporting MST for this population.

In addition to potential concerns that all Veterans may have about reporting MST while serving (e.g., more harassment, demotion, etc.), transgender Veterans may also have faced concerns about the exposure of their gender or sexual orientation if they disclosed.

Worries about exposure of one’s gender or sexual identity may still be a motivating factor to not report MST and other interpersonal violence, as transgender people face a number of other forms of discrimination both in and out of the military.¹¹ Indeed, LGBT Veterans report that discrimination in the military makes them less likely to talk with providers openly.^{12, 13}
Minority Stress

Minority stress refers to the buildup of chronic stress caused by being part of a stigmatized minority group.^{14, 15, 16} High levels of minority stress have been linked to poor health outcomes and higher rates of suicide among sexual and gender minorities. Transgender people may have a low prevalence of reporting sexual and physical violence due to fear and mistrust of police.^{15, 17}

Intimate Partner and Domestic Violence

According to the National Transgender Discrimination Survey (NTDS), over 54% of transgender people experience some intimate partner violence over their lifetime, with rates much higher among those who have engaged in sex work (77%), those who have been homeless (72%), undocumented residents (68%), those with disabilities (61%), and people of color (73%).

Transgender people are also more likely to experience violence and rejection from others in the home besides intimate partners, such as parents and other family members. According to the NTDS, 10% of those who were out to their immediate family experienced violence, and 8% were kicked out of their home. For those whose families are accepting of their gender identity, risk for suicide and negative health outcomes is greatly reduced.¹⁸

Harassment and Violence (Non-Military)

According to the National Transgender Discrimination Survey (NTDS), in just the past year, 46% of transgender people were verbally harassed, and 9% were physically attacked. Harassment may lead transgender people to fear using public accommodations, such as restrooms and public transportation. According to the NTDS, 31% of transgender people experienced some form of mistreatment in a place of public accommodations, and 20% did not use at least one type of public accommodation due to fear of violence or discrimination. At VA facilities, violence and discrimination on the basis of sexual or gender identity are strictly prohibited, and transgender people may use public accommodations consistent with their self-identified gender, regardless of gender expression or appearance.^{19, 20}

.
Transgender people may face discrimination around housing. The National Transgender Discrimination Survey (NTDS) report found that:
- 30% of transgender people had experienced homelessness at some point in their lives, 12% due specifically to being transgender
- 23% of transgender people experience some form of housing discrimination
- 70% of transgender people who stayed in homeless shelters in the last year report some form of discrimination or harm due to gender identity
Among transgender Veterans, rates of homelessness are (21%), nearly 3x higher than the rate of homelessness in the general population over a lifetime (21% versus 7.4%, respectively).²¹

According to the same study, while still lower than the national average, transgender Veterans were more likely to own their homes than transgender respondents who had not served in the military.

Many states continue to allow discrimination against transgender people in housing and employment. This remains true, despite the documented health benefits of anti-discrimination policies among transgender Veterans.²²
Changes in sexual functioning are common after initiating hormone therapy and undergoing gender-affirming surgeries. Some of these changes may be desired by the individual and lead to a greater degree of sexual satisfaction and confidence. Other changes may require a period of adjustment.

Military experience is known to contribute to higher than average rates of sexual dysfunction, particularly for those who also experience symptoms of PTSD.^{23, 24} Little research has examined the sexual practices of transgender people. Much of the existing research on sexual functioning has focused on post-operative ability to orgasm in transgender people who have undergone gender affirming genital surgery.

An important consideration when discussing sexual functioning with transgender Veterans is the role that hormone therapy may play in the sexual response cycle. For example, some transgender Veterans who take estrogen experience erectile dysfunction and/or lowered sex drive, especially at higher doses. For some, one or both of these side-effects is desired, and for some it is not. Conversely, those who take testosterone may experience enlargement of their clitoris and/or increased sex drive. In some cases, increased sex drive can also be associated with changes in to whom a client is or is not attracted, which may cause distress in some clients.

It is important not to assume which side effects of hormone therapy are and are not desired by transgender Veterans and to discuss any concerns that do come up thoroughly with the same respect and dignity given to all Veterans. Due to the limited medical and research oriented writings on this topic, it may be helpful to direct transgender Veterans towards community blogs and websites where they can problem solve with other transgender people what have experienced similar bodily changes. These sites often discuss alternative ways of engaging in sexual behaviors that may be specific to transgender communities.

It is also important to note that transgender Veterans may have experienced being over sexualized by medical professionals and sexual partners, making it difficult or painful to discuss sexual concerns. As a provider, it is important to take a sexual history, but not to over focus on sexual concerns if they are not what is most important to the Veteran. It may also be important to acknowledge the role that over-sexualization by providers and partners has played in the experience of trauma for those who have been experienced sexual trauma in their lives.
Little research has been done on the use of evidence based psychotherapies (EBP’s) for the treatment of gender-related distress. However, Dialectical Behavior Therapy’s conceptual framework focused on both validation of the self and change-based skills building has been posited as a useful strategy for treatment of gender-related distress.²⁵ For other presenting complaints, EBPs such as Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), Mindfulness Based Stress Reduction (MBSR), Compassion Focused Therapy (CFT), Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and others, are likely to work in similar ways with both transgender and non-transgender individuals. VHAs offer individual, group, and couple’s and family therapy services for transgender Veterans. For information about available services in your area, please contact your local VA and ask for the LGBT Veteran Care Coordinator.
It is important to note that not all transgender Veterans want gender affirming medical treatments. For those who do, they may choose to undergo some treatments and not others. For those who are interested in gender affirming medical interventions, it may be important to help explore multiple available options, including the financing of those options. If Veterans use additional medical insurance, including Medicare, these plans might be able to cover medical interventions that the VA does not.

The VA does currently provide hormone therapy, pre-surgical and pre-hormone evaluations and letters of support, speech therapy, gender affirming mental health care, and all other general health care.

The VA does not currently provide or fund gender affirming surgical procedures. It does, however, cover pre-and post-operative medical care. In some cases, surgical procedures that are considered gender affirming to some may be performed for other medical reasons (e.g., mastectomy due to breast cancer or back pain, orchiectomy due to prostate cancer or other urological concerns).

Letters of Support

Transgender Veterans may request a letter of support from a social worker, psychologist or psychiatrist as part of receiving hormone treatment and when undergoing gender affirming surgeries (even though performed outside of the VA, as is the case currently). There are many guidelines and trainings available to help you write a letter. In some cases, surgeons may ask for a letter from a “gender expert” in addition to a letter from a treating provider. Surgeons require slightly different elements to letters/evaluation, so it is important to consult with the surgeon/surgery center to determine what is needed.

Perhaps the most used guidelines for evaluating hormone and surgery readiness are those described by the World Professional Association for Transgender Health (WPATH).

For transgender Veterans seeking hormones or surgery, VA evaluations are meant to determine that the Veteran has a Gender Dysphoria diagnosis and has capacity to make an informed medical decision. It is important to document that they have a good understanding of the mostly irreversible nature of hormone and surgical interventions as well as post-surgical care requirements. In addition, when there are co-occurring medical or mental health conditions, or other social factors like housing difficulties, that may increase the likelihood of medical complications, a reasonable plan to reduce risks should be established.

Importantly, these letters and evaluations should be framed as a way to increase the likelihood of successful outcomes from treatments, not as gatekeeping for preventing treatments all together.

Types of Medical Procedures

In order to write a letter of support, you will need to make sure that the Veteran you are working with understands the risks and benefits of the wanted treatment. For a list of gender affirming medical treatments, please see the following handout:
- Gender Affirming Medical Treatments for Transgender Patients
Varying Techniques

Not all surgeons who perform gender affirming surgeries use the same techniques. Variations in techniques mean variation in pricing, recovery time, complication rate, scarring, sensation, functionality, and appearance. It may be important to help transgender Veterans that you work with locate a surgeon, understanding also that financial and geographic limitation may play a role in surgery selection.
- Triggers for suicidal ideation/attempts may be intertwined with the experience of discrimination and minority stress. Let transgender Veterans know they have multiple options for seeking support in times when they may become high risk for suicide.
  - Veteran’s Crisis Hotline: 1-800-273-8255, Press #1 for Veterans
  - Trans Lifeline: 1-877-565-8860
- Gender Dysphoria is not a diagnosis appropriate or needed by all transgender Veterans. Transgender individuals do face mental health disparities and may benefit from culturally competent mental health care.
- Military Sexual Trauma (MST) is an experience relevant to many transgender Veterans. Disclosing MST to law enforcement or military providers may be complicated by realistic fears of reprisal and/or outing of their gender or sexual identity.
- Minority stress, housing difficulties, and higher rates of other traumas, including violence, can lead to symptoms of depression and posttraumatic stress. Safety concerns are important to many transgender Veterans.
- Sexuality is an important part of many transgender Veteran’s lives. The effects of hormones and gender-affirming surgeries vary by individual.
- Evidence-based psychotherapies likely benefit transgender Veterans in similar ways as they can benefit all Veterans. Ensuring general cultural competence when treating transgender Veterans is essential in providing care that is not only accepting but also effective.
- The VA can provide transgender Veterans pre-treatment evaluations and letters of support for hormones and gender-affirming surgeries. At this time, VA offers hormone therapy but not gender-affirming surgeries. Evaluations are most effective (and accurate) when viewed as a method to increase positive outcomes from treatment instead of a barrier to receiving needed care.

¹ Blosnich, Brown, Shipherd, & Kauth, 2013; [LINK].
² Lehavot, Simpson, & Shipherd, 2016. [LINK].
³ Blosnich, Brown, Wojcio, Jones, & Bossarte, 2014; [LINK].
⁴ James et al., 2016; [LINK].
⁵ Brown & Jones, 2016; [LINK].
⁶ Sevelius, Carrico, & Johnson, 2010; [LINK].
⁷ Johnson, Shipherd, & Walton, 2015; [LINK] .
⁸ Blosnich et al., 2016; [LINK].
⁹ Brown & Jones, 2016; [LINK].
¹⁰ Lindsay et al., 2016; [LINK].
¹¹ James et al., 2016; [LINK].
¹² Sherman, Kauth, Shipherd, & Street, 2014; [LINK].
¹³ Sherman et al., 2014; [LINK].
¹⁴ Meyer et al., 2003; [LINK]
¹⁵ Hendricks & Testa, 2012; [LINK]
¹⁶ Kelleher, 2009; [LINK]
¹⁷ Xavier et al., 2004; [LINK]
¹⁸ Ryan, 2009; [LINK]
¹⁹ VA Office of Diversity and Inclusion, 2017; [ LINK]
²⁰ Department of Veterans Affairs, 2017; [LINK]
²¹ Harrison-Quintana & Herman, 2012; [LINK]
²² Breyer et al., 2014; [LINK]
²³ Cosgrove et al., 2002; [LINK]
²⁴ Stephenson, Riley, Rogers, Suarez, Metheny, Senda, Saylor, & Bauermeister, 2017; [LINK]
²⁵ Sloan, C.A., Berke, D.S., & Shipherd, J.C. (in press). Utilizing a dialectical framework to inform conceptualization and treatment of gender dysphoria. Professional Psychology: Research and Practice).
²⁶ Adult Transgender Care: An Interdisciplinary Approach for Training Mental Health Professionals. Kauth, M.R. & Shipherd J.C. (Eds.). New York: Routledge.

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