U d t di th H lth N d f LGBT V t 

U

n

ders

tanding the 

Health

Nee

ds o

f LGBT

V

e

t

the Department of Veterans Affairs

Kristin Kristin M Mattocks PhD MPH Kristin

M. Mattocks Mattocks, PhD, MPH

Associate Chief of Staff/Research, VA Central Western Mas

Assistant Professor of Psychiatry and Quantitative Health Assistant Professor of Psychiatry and Quantitative Health 

University of Massachusetts Medical School

HSR&D Cyberseminar

July 10th, 2013
Poll Question #1 Poll Question #1

What is your primary role in VA? What is your primary primary role in VA?

– student, trainee, or fellow student, trainee, or fellow – clinician– researcher researcher– manager or polic manager manager or polic

y-maker

– I am not affiliated with the VA. I am not affiliated with the VA.
Poll Question Poll Question #2

How knowledgeable are you about iHow knowledgeable knowledgeable are you about i

related to LGBT Veterans in the VA?

– Very knowledgeable Very knowledgeable– Somewhat knowledgeable Somewhat knowledgeable– Somewhat unknowledgeable Somewhat unknowledgeable– Completely unknowledgeable Completely unknowledgeable
LGB in the Military LGB in the Military Military

In 1993, Public Law 103 In 1993, Public Law 103-160 enacted: “Don’t Ask, Don’t T

160 enacted: “Don’t Ask, Don’t T

– Over 14,000 LGB discharged under DADT: dispropor

numbers of women and minorities.

– Nearl

y 114,000 servicemembers servicemembers dischar dischar

ged since WW

of actual/perceived homosexuality

– Many discharged may have received dishonorable dis

Many discharged may have received dishonorable disbarrin

g them from VA medical care and other benefits

– Current House legislation ( Current House legislation (Pocan: Wisconsin & Range

: Wisconsin & Range

York) would allow those given dishonorable dischargetheir records for benefit eli

g y ibilit

y.

Most recent estimates suggest that those who identify as gay, and bisexual (LGB) represent 2.2% of military person

*Gates G. Lesbian, gay, and bisexual men and women in the US military: Updated estimates. The WM 2010 ay 2010.
Discharges Under Don’t A

Don’t Tell (1994 Don’t Tell (1994-2009)

1400

997

1145

1034

1212 1227

921 1000

1200

617

772

870 885

770

653

726

612 627 619

773

828

718

921

854

636

800

1000

612 

428

516

437

507

422

388 410

259

317 316 291

373

249 254

400600 

259

224 249 254 216 219 190 239 209 169

0

200

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Gates, G. Discharges Under DADT: Women and Ethnic Minorities. September 2010.The Williams Institute.
Percent of women amon

DADT discharges

45%

31% 30%

33% 33%

30% 31%

38%

34%

39%

35%40%

s

22%

28%

24%

30%

28%

30%

25%30%

DADT Discharges % 

10%15%20%

% of Total D

0%5%

10%

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Gates, G. Discharges Under DADT: Women and Ethnic Minorities. September 2010.The Williams Institute.
How many LGBT Veteran

the VA?

We have no idea! We have no idea!

No data available for number of LGBVeterans in VA system Veterans Veterans in VA system.

– No systematic data collection upon en

No systematic data collection upon en

that includes sexual orientation that includes includes sexual orientation orientation

– Given military estimates (perhaps 66,0

Given military estimates (perhaps 66,0

servicemembers at any given time?) V

at any given time?), V

could be largest integrated provider of LGBT 

p po

pulations.

Mattocks K, Kauth M, Sandfort T, Matza A, Sullivan C, Shipherd J. Understanding healthcare needs of sexual and How targeted research and policy can improve health. LGBT Health, in press.
LGBT in the VA LGBT in the VA

While DADT was a While DADT was a DoD policy, there were likely r

policy, there were likely r

eff t t th D t t f V t Aff i (VA) ffec

ts 

to the 

Depar

tmen

t o

f

V

e

terans Aff

airs (VA)

– Fear that disclosure of sexual orientation would 

Fear that disclosure of sexual orientation would 

documented in charts/shared would possibly imdocumented documented in charts/shared charts/shared would possibly possibly im

pension benefits

– Fear that disclosure might impact future militar

Fear that disclosure might impact future militar

und DADT er DADT.

– General fear of disclosure of sexual orientation 

General fear of disclosure of sexual orientation healthcare providers healthcare providers

VA promotes environment of patient VA promotes environment of patient-centered car

centered car

important to consider patient’s disclosure/non important to consider patient’s disclosure/non-disc

disc

preferences in context of optimal care.

* Seaver et al (2008). Healthcare preferences among lesbians: A focus group analysis. JWH; 17(2): 215 et al (2008). Healthcare preferences among lesbians: A focus group analysis. JWH; 17(2): 215-225. E

E

(2001). Does “Don’t Ask, Don’t Tell” apply to healthcare? LBG people’s disclosure to healthcare providers. 5(4): (2001). Does “Don’t Ask, Don’t Tell” apply to healthcare? LBG people’s disclosure to healthcare providers. 5(4): 
What do we know about LG

What do we know about LG

Veterans’ Health?
Might LGBT Veterans Experie

Dual Health Disparities

?

Existing research on Veterans Existing Existing research research on Veterans Veterans’ health dis

health dis

dis

– Poor perceived self Poor perceived self-health, high rates o

health, high rates o

utilization, p multi

ple medical comorbiditi

– High rates of PTSD, depression, subst

High rates of PTSD, depression, substabuse

Existing research on LGBT health dispari

– Hi

g e ates o s o g, obes ty, e po

h

er rates

of 

s

m

oking, obesity,

e

xpo

traumatic events, traumatic events, suicidality suicidality, substance 

, substance 

How do these health dis

parities interact f

LGBT Veterans?
Lesbian and bisexual (LB

Veterans

Com

p 

ared to heterosexual Veterans and civilian 

LB Veterans experience higher rates of:

– Childhood and adult sexual and physical viole

Childhood and adult sexual and physical viole

–

Substance abuse ubstance abuse

– Mental health problems Mental health problems– Increased suicidal ideation Increased suicidal ideation

LB Veterans report higher rates of military sexua( ) MST

) than heterosexual women Veterans. Unc

MST was related to perceived sexual orientation military service.

Lehavot K & Simpson T. (2013). Incorporating Lesbian and Bisexual Women into Women Veterans’ Health Priorities. Journ

Medicine (in press). Mattocks K, Sadler A, Yano E, Krebs E, Zephyrin L, Brandt C, Kimerling R, Sandfort T, Dichter M, Weis

Sexual victimization, health status, and VA healthcare utilization among lesbian and bisexual OEF/OIF veterans. Journal of 

Medicine (in press). Blosnich J, Foynes M, Shipherd J: Health disparities among sexual minority women veterans. J Women8. [Epub ahead of print]. Booth B, Davis T, Cheney A, Mengeling M, Torner J, Sadler A. Physical health status of female vetesex partnership and in-military rape. Psychosomatic Medicine; 2012; 74: 916-924. 
Gay Veterans Gay Veterans

Few targeted targeted studies of this group to und

studies studies of this group to und

und

general health disparities/healthcare utiliz

Many g gy existin existing studies of studies of gay Veterans foc

Veterans foc

various aspects of HIV.Some existing gg studies suggest elevated rsubstance abuse, PTSD, and depression

– Data suggest that military Data suggest that military service before repe

ervice before repe

DADT C l f l id i DADT Concealment of sexual identity

to high rates of depression & PTSD

C k RL oo , R.L., Mii cg nn s, K A. ., Fi lli e n, D A. ., G lt ou e , JL G d AJ .L., Gordon, A.J., S t ame J., M tt k K attocks,K., C t lS rystal,S., K K L B ith 

raemer, K.L., Braith

Rodriquez-Barradas, M., Justice, A.C. (2010). Erectile dysfunction drug receipt, risky sexual behavior and sexually transmit

HIV-Infected and HIV-uninfected men. Journal of General Internal Medicine, 25(2), 115-21.

Blosnich, J. & Silenzio, V. (in press). Physical health indicators among lesbian, gay, and bisexual U.S. Veterans. Annals of 
Transgender Veterans Transgender Veterans

Transgender persons still prohibited from military service. Identification in VA medical record: some meet standards Gender Identity Disorder (GID), so identifiable via ICD codGID 

prevalence in VA: 22.9/100,000 

persons

– GID prevalence in US: GID prevalence in US: 4.3/100,000 persons

246 new Veterans diagnosed with GID each year in VA.Use of VA Use of VA 5 times higher 5 times higher among GID Veterans than other 

among GID Veterans Veterans than other 

Veterans with GID had risk for suicide Veterans with GID had risk for suicide-related events related events 20X than for general VHA Veteran population.E id t th t th i f t E

vidence sugges ence sugges

ts th

a

t the growing presence o ng presence o

f

transgen ransgen

support groups within VA have been beneficial to patients

Shipherd, J. C., Mizock, L., Maguen, S., & Green, K. E. (2012). Male-to-female transgender veterans and VA health care utilization. Inte

Health, 24(1), 78-87. Shipherd, J.C., Maguen, S., Skidmore, W.C., & Abramovitz, S.M. (2011). Potentially traumatic events in a transgen

associated symptoms. Traumatology, 17(20, 56-67. Shipherd, J. C., Green, K. E., & Abramovitz, S. (2010). Transgender clients: Identify

mental health treatment. Journal of Gay & Lesbian Mental Health, 14(2), 94-108.Maguen, S., Shipherd, J. C., & Harris, H. N. (2005). Pro

for transgender patients. Cognitive and Behavioral Practice, 12(4), 479-490.
VA Providers VA Providers

Previous non Previous non-VA studies suggest LGBT patients 

VA studies suggest LGBT patients 

about poor care discrimination and rejection froabout poor care, discrimination discrimination, and rejection rejection fro

providers.

– Patients may engage in protective behaviors t

Patients may engage in protective behaviors t

sexual orientation.

– Healthy People 2020: Providers should facilit

Healthy People 2020: Providers should facilit

open discussion re: sexuality open discussion discussion re: sexuality sexuality

A recent VA study suggests more than 50% of pdidn’t ask about sexual orientation, but assumed patient would bring it up if it was important*.

.

*Sherman, M., Kauth, M., Ridener, L., Shipherd, J.C. Bratkovich, K. & Beaulieu, G.: Welcoming SexuMinority Veterans to VA Care: Challenges and Recommendations. Under review.
VA Policies and Program

Designed to Improve Care Designed Designed to Improve Improve Care 

LGBT Veterans
VA Policies/Practices Targeting Imp

LGBT Care

Office of Health E Office of Health E

qy g p uit

y LGBT Work LGBT Work

grou

p:

– “Sexual orientation” and “gender identity exp

“Sexual orientation” and “gender identity expnow included in VA non now included in VA non-discrimination policie

discrimination policie

– Deputy Under Secretary for Health encourag

facilities to participate in Human Rights CampHealth Equality Index: 121 VA facilities particHealth Equality Equality Index: 121 VA facilities facilities partic

partic

the self study.

– Learn more about HEI: more about HEI: http:// http://www.hrc.org/he

www.hrc.org/he

– Results of VA HEI: 76% of participating VA hospitals 

awarded 2013 HEI Equality Leader status, a designatiawarded hospitals and clinics that meet foundational c

equit bl LGBT it

able LGBT care.
VA Policies/Practices Targeting Imp

LGBT Care

VA Trans VA Trans

g y( ) ender Health Polic ender Health Polic

y

(June 2011 June 2011

)

– General health care, mental health care, horm

General health care, mental health care, hormtherapy, pre therapy, pre-operative evaluation for sex operative evaluation for sex reassi t d di ll 

ignmen

t surgery, an surgery, an

d medically necess

y necess

operative care.

– Transgender Veterans should be referred to 

Transgender Transgender Veterans Veterans should be referred referred to 

name and gender they prefer, regardless of lstatus.

T d Ed ti W k (Offi f P Transgen ransgen

der Education 

Wor

kgroup (Office o

f

P

a

Care Services)

– Webinars, toolkits, online Webinars, Webinars, toolkits, toolkits, online rspository rspository of transg

of transg

healthcare resources
Dedicated LGBT Progra

Coordinators

Office of Patient Care Services Office of Patient Patient Care Services Services: Hired 2 

: Hired

2 

Program Coordinators.

– Advise senior VA leadership on LGBT Advise senior VA leadership on LGBT policy/

policy/

related to LGBT Veterans.

– Spearheading development of educatio

Spearheading development of educatio

i iti ti d li i l lt ti initi

atives an

d cli

nical consult

ation prog

on prog

– Adapt current educational materials (e

Adapt current educational materials (e

C i t l) d t Caregiver suppor ver suppor

t manual) an

d crea

te 

ones (e.g. VA LGBT Fact Sheet).
VA Policies/Practices Targeting Imp

LGBT Care

New postdoctoral psychology fellow

postdoctoral psychology fellow

program for LGBT Health (launching September 2013) September 2013).

– Seven fellowships funded in first year.

LGBT Research Working Group LGBT Research Research Working Working Group

– Monthly calls to feature ongoing VA re

Monthly calls to feature ongoing VA re

dedicated to understanding LGBT Vetededicated dedicated to understanding understanding LGBT Vete

Vete

– 50 VA investigators nationwide 50 VA investigators nationwide

– Id tif i h/ h th d 

Identify gaps in researc n research/

s

hare meth

o

d
Future Directions Future Directions

Need systematic data collection straNeed systematic systematic data collection collection stra

stra

in VA

Research examining after Research examining after

-effects of 

effects of 

– Physical and mental health conditions Physical and mental health conditions– H lth tili ti Healthcare utilization

– Experiences with military sexual traum

Experiences with military sexual traum

i ti t t i l intima

te par

tner violence

Improving cultural competence of providers
Questions or interested in L

Research Workgroup?

Kristin Mattocks ( Kristin Mattocks

(kristin mattocks@v

kristin.mattocks@v

Office: 413 Office: 413-584-4040 x2060 4040 x2060
LGBT Health Journal LGBT Health Journal

LGBT Health is the quarterly peer-reviewed journal dedicpromoting optimal healthcare for millions of sexual and geminority persons worldwide by focusing specifically on hemaintaining sufficient breadth to encompass the full range rel t evan

t bi h i l biopsyc

hosocial and h lth li i Thi J 

d

health policy issues. This 

Jo

to promote greater awareness of the health concerns parteach sexual minority population, and to improve availabilit

delivery of culturally competent healthcare services delivery of culturally competent healthcare services.http://www.liebertpub.com/manuscript/lgbt ://www.liebertpub.com/manuscript/lgbt-health/618 health/618/Journal editor: Dr. William Journal editor: Dr. William Byne (william.byne@va.gov

)
Full citations of research include

cyb i ersem na

r

Gates, G. (2003). Lesbians More Likely to Have Served in the Military. Washington, DC. The Urban Institute.Gates,( ) G.2004). Ga

y y Men and Lesbians in the U.S. Military: Estimates from Census 2000. Washin

g , ton DC. The U

Gates, G. (2010). Lesbian, gay, and bisexual men and women in the US military: Updated estimates. UC Los Ange

Institute. Retrieved from: http://escholarship.org/uc/item/0gn4t6t3

Burks, D. (2011). Lesbian, gay, and bisexual victimization in the military: An unintended consequence of ‘Don’t AskAmerican Psychologist, 66, 11, 604-613.Simpson, T.L., Balsam, K., Cochran, B.N., Lehavot, K., Gold, S.D. Veterans Administration health care utilization amveterans. Psychological Services Psychological Services. In press.Shipherd, J.C., Maguen, S., Skidmore, W.C., & Abramovitz, S.M. (2011). Potentially traumatic events in a transgend

and associated symptoms. Traumatology, 17(2), 56-67.

Seaver M, Freund K, Wright L, Tjia J, Frayne S. (2008). Healthcare preferences among lesbians: A focus group an

Women’s Health, 17(2), 215-225.

Eliason M & Schope R. (2001). Does “Don’t Ask, Don’t Tell” apply to health care? Lesbian, gay, and bisexual peophealth care providers health care providers. Journal of the Gay and Lesbian Medical Association Journal of the Gay and Lesbian Medical Association, 5(4) 125 5(4), 125-134.Cook, R.L., Mcginnis, K.A., Fiellin, D.A., Goulet, J.L., Gordon, A.J., Samet J., Mattocks,K., Crystal,S., Kraemer, K.L

Rodriquez-Barradas, M., Justice, A.C. (2010). Erectile dysfunction drug receipt, risky sexual behavior and sexually t

in HIV-Infected and HIV-uninfected men. Journal of General Internal Medicine, 25(2), 115-21.

Burks, D.J., Robbins, R., Durtschi, J.P. (2011 ). American Indian gay, bisexual and two-spirit men: a rapid assessm

factors, barriers to prevention and culturally-sensitive intervention. Culture, Health, & Sexuality, 13(3), 283-98. 

Bl i h osn c , J &.Sil i enz o, V (i ) Ph i l h lth i di t l bi d bi l U S V t V. (in press). Physical health indicators among lesbian, gay, an

d bisexual U.S. V

eterans. A 

An

Cochran, Balsam, Flentje, Malte, & Simpson (2013). Mental health characteristics of sexual minority veterans. Jourin pressBlosnich, J., Bossarte, R., Silenzio, V. (2012). Suicidal Ideation Among Sexual Minority Veterans: Results from the 2005-2010 Massachusetts Behavioral Risk Factor 

Journal of Public Health, 102 (S1), S44-45.
Full citations of researc

included in included in cybersemina cybersemina

Lehavot K & Simpson T. (2013). Incorporating Lesbian and Bisexual Women into Women Veterans’ Health Prioritie

Internal Medicine (in press).

Mattocks K, Sadler A, Yano E, Krebs E, Zephyrin L, Brandt C, Kimerling R, Sandfort T, Dichter M, Weiss, J, Allison 

victimization, health status, and VA healthcare utilization among lesbian and bisexual OEF/OIF veterans. Journal o

Medicine (in press).

McDuffie, E., & Brown, G. R. (2010). 70 US Veterans with Gender Identity Disturbances: A Descriptive Study. Intern

Transgenderism, 12(1), 21-30.

Shi

pherd, , J. C. Mizock, , L. Ma

guen,, , ( ) S., & Green, K. E. (2012). Male-to-female trans

gender veterans and VA health 

International Journal of Sexual Health, 24(1), 78-87.Blosnich, J., Bossarte, R., Silver, E., & Silenzio, V. (2013). Health Care Utilization and Health Indicators Among a NVeterans in Same-Sex Partnerships. Military Medicine, 178(2), 207-212.Shipherd, J.C., Maguen, S., Skidmore, W.C., & Abramovitz, S.M. (2011). Potentially traumatic events in a transgen

Frequency and associated symptoms. Traumatology, 17(20, 56-67.

Shipherd, J C Green K E & J. C., Green, K. E., 

& Abramovitz Abramovitz, S (2010) Transgender clients: Identifying and minimizing barriers to m

S. (2010). Transgender clients: Identifying and minimizing barriers to m

treatment. Journal of Gay & Lesbian Mental Health, 14(2), 94-108.

Maguen, S., Shipherd, J. C., & Harris, H. N. (2005). Providing culturally sensitive care for transgender patients. Cog

Practice, 12(4), 479-490.

Simpson TL, Balsam K, Cochran BN, Lehavot K, Gold SD: Veterans administration health care utilization among se

Psychol Serv. 2013 May;10(2):223-32.

Blosnich Blosnich J, Silenzio Silenzio V: Physical health indicators among lesbian gay and bisexual U S Veterans Ann V: Physical health indicators among lesbian, gay, and bisexual

U.S. Veterans. Ann Epidemiol Epidemiol. 2

2

S1047-2797

Cochran BN, Balsam K, Flentje A, Malte CA, Simpson T: Mental health characteristics of sexual minority veterans. J 2013;60(2-3):419-35.Blosnich J, Foynes M, Shipherd J: Health disparities among sexual minority women veterans. J Womens Health 20ahead of print]Sh M erman, 

M., K th au , M., Ridener, 

L., Shi h d Shi

pher

d, J C. . B tk i h Bratkovich, K & B li G W l i S l d G d M

K. &

Beaulieu, 

G.: 

W

elcoming 

Sexual an

d

Gen

der M

VA Care: Challenges and Recommendations. Professional . Under review.
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U.S. Veterans Affairs, Veterans Health Administration. (2013). VHA Directive 2013-003: Providing Health Care for T

Intersex Veterans. Retrieved from http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2863

Price, E., & Limberg, D. (2013). Addressing the Mental Health Needs of Gay Military Veterans: A Group Counseling 

Military and Government Counseling, 1(1), 26.

Ard, K. L., & Makadon, H. J. (2011). Addressing intimate partner violence in lesbian, gay, bisexual, and transgender 

general internal medicine, 26(8), 930-933.

Boehmer, U. (2002). Twenty years of public health research: Inclusion of lesbian, gay, bisexual, and transgender po

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Doll, L. S., & Beeker, C. (1996). Male bisexual behavior and HIV risk in the United States: Synthesis of research wit

behavioral interventions. AIDS Education and Prevention, 8(3), 205-225.

Sandfort, T. G. M., & Dodge, B. (2009). Homosexual and bisexual labels: The need for clear conceptualizations, accoperationalizations, and appropriate methodological designs. In V. Reddy, T. G. M. Sandfort, & R. Rispel (Eds.), Fro

social science: Perspectives on same-sex sexuality, gender and HIV/AIDS in South Africa (pp. 51-57). Pretoria: Hum

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261-275). Bloomington, Indiana: Indiana University Press.

Booth B Davis T Cheney A Booth

B, Davis

T, Cheney

A, Mengeling Mengeling

M, Torner J Sadler A Physical health status of female veterans: Contribut

J, Sadler

A. Physical health status of female veterans: Contribut

partnership and in-military rape. Psychosomatic Medicine; 2012; 74: 916-924. 

Mattocks K, Kauth M, Sandfort Sandfort T, Matza A, Sullivan C, A, Sullivan C, Shipherd Shipherd J. Understanding healthcare needs of sexual and 

J. Understanding healthcare needs of sexual and 

veterans: How targeted research and policy can improve health. LGBT Health, in press.