**Transcript of Cyberseminar**

**Spotlight on Women’s Health**

**Understanding the Health Needs of LGBT Veterans in the Department of Veterans Affairs**

**Presenter: Kristin M. Mattocks, PhD, MPH**

**July 10, 2013**

**Understanding the Health Needs of LGBT Veterans in the Department of Veterans Affairs**

**July 10, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact:**kristen.mattocks@va.gov**.*

Molly:     We are at the top of the hour now, so I would like to introduce our speaker. We have Dr. Kristin Mattocks presenting for us today. She is the associate chief of staff and research at the VA Central Western Massachusetts, and assistant professor for quantitative health sciences at the University of Massachusetts Medical School in western Massachusetts. At this time, I would like to thank Dr. Mattocks for presenting for us. Are you ready to share your screen Kristin? 

Dr. Mattocks:     Yes, I am. 

Molly:     Excellent, thank you. 

[Background Noise]

Molly:     Just go ahead and click that button that says show my screen. We should be set. Perfect. 

[Background Noise]

Dr. Mattocks:     Okay. Are we ready? 

Molly:     Yes, go ahead. 

Dr. Mattocks:     Okay, great. Thanks. I want to start by thanking Molly and the others for inviting me to present today. I would also like to start out by saying that this is a relatively new area that we are getting into in the VA. I am extremely proud of the work that many researchers across the country have started to do in this area. You will see that in today’s presentation I am going to be presenting a lot of the work that some of my colleagues have done in the area. You will see that at the end of the presentation, there is a very comprehensive list of many of the publications I will be talking about today. If you have specific questions about some of the research I will be presenting, you can look toward the end of the presentation for that. 

Moving forward, I know that one of the things that we like to do with these cyberseminars is to present poll questions to warm the group up and to engage all of you in the presentation, since you are sitting at your computers. Today’s first poll question is what your primary role is at the VA. You have a couple of choices here. You can be a student trainee, fellow, clinician, researcher, manager or policy maker. I know there are some folks that are not in the VA on the telephone. That is an option too. Go ahead and take a second to fill out the poll question here. That would be great. We will look at the results in a few seconds. 

Molly:     Thank you very much. It looks like everybody is streaming in his or her answers. Just click that circle next to the best option and press submit. Do not use the hand-raising icon, as I am not going to mute you. Please just click directly on your screen. We have an 80% vote and answers are still streaming in. we are going to give people a few more seconds. We do understand that you might have multiple roles, but please choose the one that is your primary role. Okay, it looks like everyone has answered. I am going to close that and share the results. Dr. Mattocks, you should be able to see those now. Would you like to talk through them really quickly? 

Dr. Mattocks:     Great, thank you. It looks like in terms of primary role in the VA, the majority of folks on the call are clinicians, about 35% are clinicians. Twenty-seven percent are managers or policy makers. Twenty-one percent are researchers. Five percent of us are student trainees or fellows. Eleven percent at not currently affiliated with the VA. That is great. Thanks for that. 

Molly:     Thank you very much. I will turn it back over to you now. 

Dr. Mattocks:     Okay. We have one more question we would like you to answer. This is a little bit more directly related to the presentation today. We want to get a sense of how knowledgeable each of you are about issues related to LGBT Veterans in the VA, or for those of you in the VA, LGBT populations in general. You can be very knowledgeable, somewhat knowledgeable, somewhat unknowledgeable or completely unknowledgeable. I am hoping that by the end of today’s presentation I will bump you up a notch or two in the scale here. Go ahead and fill out that question. 

Molly:     Thank you. It looks like people are a little more gun shy to answer this one. They are coming in. We will give people a little bit more time to get their responses in. It looks like we have had just about 80% vote. At this time, I am going to go ahead and close the poll. I will share the results. 

Dr. Mattocks:     Okay, great. Here we have a pretty mixed split. Fifty percent of people on the call feel they are somewhat knowledgeable about these issues. There is a pretty even split between people who are very knowledgeable, somewhat unknowledgeable and completely unknowledgeable. This is great. I hope today’s presentation will move us a little bit forward in our knowledge in this area. Great. 

Okay. Now we are moving forward with the presentation itself. I thought I would start today’s talk by bringing people a little bit up-to-date on a policy that many of us know about. I think it is important to understand some of the LGBT Veterans we have in the VA today. It is good to get a sense of peoples’ experiences before they came to us in the VA. 

As many of you know, there was a policy in place for a number of years called “Don’t Ask, Don’t Tell.” This was public law 103-160. During the tenure of that policy from 1993 to 2011, over 14,000 lesbian, gay and bisexual individuals were discharged under “Don’t Ask, Don’t Tell.” Research that has come out recently from Gary Gates and some of his colleagues at The Williams Institute has shown that over time, a disproportionate number of women and minorities were discharged under that policy. In a couple of slides I am going to show you what that looks like. 

I also want everybody on the call to know that it was not just under “Don’t Ask, Don’t Tell” that people who were suspected of being homosexual or having homosexual behavior were discharged. In all, recent estimates suggest that nearly 114,000 people have been discharged from the military since World War II because of actual or perceived homosexuality. One of the interesting things that we are really just starting to learn about and really do not know the answer to at this point, is that it is thought that some or many, depending on who you talk to and what source you look at, people discharged under “Don’t Ask, Don’t Tell” for actual or perceived homosexual behavior received dishonorable discharges. 

The important thing to know about that is that if you receive a dishonorable discharge from the military, you are not entitled to any of the many benefits. For us here on the call, the important thing to think about in context of that is that you would not be eligible for VA benefits. It is very interesting. If you really try to dig into the statistics or data available online to find out exactly what proportion of people were discharged with a dishonorable discharge, it is really hard to investigate that. As I mentioned, some studies report that most people were given an honorable discharge. I think this is something that really needs to be looked at in the future in terms of our Veterans being able to access VA benefits. 

I was delighted to find out the other day that there is actual current House legislation sponsored by Representatives Pocan and Rangel of Wisconsin and New York, which would allow those given dishonorable discharges to update their records for benefit eligibility. I saw that legislation come through at the end of June. To the best of my knowledge, that legislation has not been acted upon. I feel like that would be something that would be very much of benefit to our Veterans who received dishonorable discharges. 

The most recent estimates in terms of the proportion of people in the military who identify as gay, lesbian and bisexual is about 2.2% of military personnel. That varies a little bit according to active duty, National Guard or Reserves. That is our current estimate on those numbers. You can get a sense of the size of the population. 

The next stuff I am showing you here looks at the actual discharges under “Don’t Ask, Don’t Tell.” What has been done here is to have it broken out by gender. Gary Gates has done this work at The Williams Institute. The green line at the top represents the total number of discharges over years. The red line represents the number of men discharged. The yellow line represents the number of women discharged. You can see there are some very interesting things. I have a little pen here I can write with. There are some very interesting trends here. There is something very interesting going on here, around the years of 2001 and 2002. 

You can see there is steady increase across all these years. Then there is a pretty precipitous decline around 2001 and 2002 in terms of the number of discharges under “Don’t Ask, Don’t Tell.” Another year here is not represented in the policy. You can see that over the last couple of years the discharges were about 500 a year. I want to draw your attention right now to the number of women discharged in proportion to the number of men. As many of us know on the phone, the military has disproportionately larger numbers of men than women. It is a little bit surprising to see such high numbers of women being discharged. Let’s get away from that. 

The next slide highlights this issue a little bit more. As you can see across the years from 1997 to 2009, the proportion of women among under complete “Don’t Ask, Don’t Tell” discharge is pretty significant. The very interesting thing to note here is that across all of these years, the proportion of women in the military varies to between 14% and 15%. Again, if women are only about 15% of the military, at one point later on in the “Don’t Ask, Don’t Tell” policy they were representing about 40% of all discharges. That is pretty substantial. 

To move from the military to the VA, the question that many of us have on our minds is how many LGBT Veterans there are in the VA. I have to tell you the simple, although unpleasant, answer is that we have no idea. At present, there is not systematic data collection mechanism to get a sense of the number of LGBT Veterans in the VA system. When Veterans come into the VA and they fill out their enrollment forms, there is no question at that point that talks about sexual identification or orientation. We do not really have a way to look at it. 

However, if you take some of those military estimates that have come out before, you get a sense that there is perhaps 66,000 lesbian, gay or bisexual service members at any time. The very interesting and really important thing to us at the VA is that the VA very much has the potential to be one of the largest integrated providers or care to the LGBT population. We do not know exactly what those numbers are for sure. If we are to take some of the estimates in terms of people who have served in the military and who eventually migrated into the VA and stayed in the system, we do have the potential to be one of the largest service providers. That is important for all of us on the phone. What that means is that it really is up to us to get it right in terms of targeting our policies and programs to make sure that care of LGBT Veterans is what we want it to be. 

“Don’t Ask, Don’t Tell” was repealed in 2011. The point that I really want to make here is that although “Don’t Ask, Don’t Tell” was a DOD policy and not a VA policy, it is quite likely that there were carry-over ripple effects, as I call them, into the Department of Veteran’s Affairs. For many LGBT Veterans we have spoken with, we have learned that there really was a very active fear of disclosure of sexual orientation would somehow impact Veteran’s pension benefits. Others worried that disclosing their sexual orientation to a healthcare provider could somehow be linked back to the DOD and impact future military service, if people decided to reenlist at some point. There is always a general fear of disclosure of sexual orientation to healthcare providers, in that it might result in discrimination or poor treatment, something like that. 

This is very important because as you know, the VA very much promotes an environment of patient centered care. It is important for all of us to consider patients’ preferences for disclosure and non-disclosure. There is a very active debate or conversation going on about whether we really should move in the direction of insisting that people disclose their sexual orientation to providers. In many ways, it is good. I think other people feel like patients should really have the ability to make that decision themselves. That is something to consider. 

The next section in terms of what I am going to be presenting is really going to be a compendium of many studies that are being done in the VA now, and over the past couple of years. I have citations for these studies at the end of the presentation. One of our concerns as we think about LGBT Veterans is thinking about the kinds of health conditions they might have in context of this idea of dual health disparities. 

What am I talking about when I talk about dual health disparities? All of us know that existing research suggests that Veterans have substantial health disparities as compared to the civilian population. We know that Veterans have poor perceived self-health. They have high rates of healthcare utilization in general. They have more medical comorbidities. We have high rates of PTSD, depression, substance abuse and so on. There are many disparities just by nature of being a Veteran. 

If you add to that some of the existing literature from civilian LGBT populations in terms of LGBT health disparities, we are looking at LGBT populations that experience higher rates of smoking, obesity, exposure to traumatic events, suicidality and substance abuse. One of our questions going forward, at least from a research perspective, is how these health disparities interact with each other. What, as providers, policy makers and researchers, can we do to learn more about LGBT Veterans? What I am going to do is go through a couple of different populations. I am going to focus on what we know about lesbian and bisexual Veterans, what we know about gay Veterans and what we know about transgendered Veterans. Each of these next three slides is really going to be a set of compendium of lots of research that people have done. 

There have been several very good papers that have come out recently that look at lesbian and bisexual Veterans. Karen Lehavot and Tracy Simpson have written a good paper that has just come out in The Journal of General Internal Medicine this month, in a special issue dedicated to women Veterans. Anne Sadler has done some great work, along with Brenda Booth and some other folks. We are moving in the direction of having some very good research. 

What we know is that compared to heterosexual Veterans and civilian women, lesbian and bisexual Veterans experience higher rates of childhood and adult physical and sexual violence, substance abuse, mental health problems and increased suicidal ideations. Some recent research we have done also suggests that lesbian and bisexual Veterans report higher rates of military sexual trauma as compared to heterosexual women Veterans. What we do not know, but is a topic to move forward with in terms of research, is whether people who identify as lesbian, bisexual or gay experience targeted sexual violence in the military because of their presumed or actual sexual orientation. When people were serving in the military, were they targeted victims of military sexual trauma or other forms of violence because of their sexual orientation? This one study certainly suggests there are higher rates, but we do not know if it was targeted or not. That is something I think we are very interested in pursuing as we go forward. 

In terms of gay Veterans, unfortunately there have been few targeted studies. What I mean by targeted is just specifically looking at gay men as a population, gay Veterans as a population in the VA, to understand their general health disparities and healthcare utilization. There have certainly been several studies focusing on gay Veterans with a specific focus on HIV. I think many of us in the research world are hoping that we can do some studies that move beyond HIV and into understanding other aspects of gay Veterans’ health. Some existing studies that have been done suggest elevated rates of substance abuse, PTSD and depression. 

Not surprisingly, there are some studies that suggest the concealment that has had to happen during the time of “Don’t Ask, Don’t Tell” has caused a substantial amount of stress, minority stress, in this particular population leading to high rate of depression and PTSD. That is certainly true across lesbians and bisexual women as well. That is also something we hope to explore more. I have listed down here at the bottom some folks who have really begun to move in this direction of understanding the experiences of gay Veterans a little bit more. 

I have to say that I am very proud of the work we have done across the VA in terms of transgendered Veterans. I have to give a huge amount of credit to Jillian Shipherd and some of her colleagues at VA Boston for the work they have done in this area. I think that Jillian has really spearheaded so much of the important policies that have come out regarding transgendered Veterans. There are some citations here at the bottom that you can look at. 

As most of you know, transgendered person are still prohibited explicitly from military service. Unlike the other lesbian, bisexual and gay Veterans, it has been a little bit easier to identify transgendered Veterans in the VA medical record. As many of you know, some Veterans meet standards for gender identity disorder. That is something identifiable in the VA medical record via ICT 9 coding. 

Our current understanding of the prevalence of GID in the VA is 22.9 per 100,000 persons. I would like to point out that in comparison to the general GID prevalence in the U.S. population, which is about 4.3 out 100,000 persons. We are seeing a pretty substantial rate of GID in the VA. Every year we know there are about 246 new Veterans that are diagnosed with GID. Some interesting statistics and studies have come out focusing on the healthcare use and some of the conditions of these Veterans. We know the use of the VA is approximately five times higher among GID Veterans than other Veterans. Unfortunately, Veterans with GID have risks for suicide related events that were about 20 times higher than for the general VHA Veteran population. We know there are some substantial mental health issues that need to be addressed there.

I have to say that growing evidence from across the country, from many VA facilities, suggests there is a growing presence of transgendered support groups at many facilities across the VA. These support groups have been very beneficial for patients. I feel there is some promise in that area. 

I guess the other question that comes to mind is that we have learned a little bit about each of the populations and some of the existing research that has been done in the VA on those populations. What about providers? Providers are a very important component of this equation. Any type of patient/provider relationship requires an examination of how the providers relate to the patients. There have not been many VA studies on this issue. Other non-VA studies have certainly suggested that LGBT patients worry about poor care, discrimination and rejection from providers, as I mentioned before. Patients may engage in protective behaviors to mask sexual orientation. I would like to point out that in the most recent Healthy People 2020, it suggests providers should facilitate open discussions regarding sexuality and talk with the patients about important reasons why it is important to disclose sexuality and have sexuality be something that is a topic of conversation in healthcare recommendations from providers to patients. 

To date there has only been one VA study that focuses on providers’ attitudes or perspectives regarding sexual orientation. In that study, which is a study that is focused on two sites in the Midwestern United States, it suggests that more than 50% of providers did not ask about sexual orientation. They assumed that the patient would bring up sexual orientation if it were important. This is a study that was headed up by Michelle Sherman, Jillian Shipherd, Lauren Ridener, Michael Kauth and some others. That paper is currently under review. Unfortunately, that is really the only look we have been able to take at providers’ perceptions regarding the LGBT population. My guess is that as we continue this research in the VA on these issues, that we will have a better sense of some of these issues regarding providers’ perspectives. 

That is the majority of the research that has been done to date, focusing on LGBT populations in the VA. I wanted to give you the sense that we are in our infancy. I think that we certainly have enough strength and enough researchers moving forward that I anticipate we will continue to grow substantially in the future. I am going to focus a little bit now on some of the great things that the VA has done in terms of policies and programs designed to improve care for LGBT Veterans. I am certain that many folks on the phone have heard of these things. I think they are being pretty widely distributed. 

There are a couple of things I would like to point out. The VA has an office of health equity. In that office there is an LGBT working group. Here are some of the things that working group has done recently. They have ensured that sexual orientation and gender identity expression is included in all VA non-discrimination policies. In addition, the Deputy Under Secretary for Health encouraged all VA facilities to participate in the Human Rights Campaign’s Health Equality Index. I am pleased and delighted to say that 121 VA facilities participated in that study. If you would like to learn more about the components of what is in that Health Equality Index, I have included the link here. That is the Human Rights Campaign’s website. You can learn more about that Health Equity Index. I am delighted to announce the results of the VA Health Equity Index, which I believe are going to be presented tomorrow at a press conference, show that 76% of participating VA hospitals were awarded 2013 HEI Equality Leader status. That is a designation awarded to hospitals and clinics that meet foundational criteria for equitable LGBT care. This is wonderful; both in the respect that so many VA facilities participated in the Health Equality Index in the first, but that out of those 121, 76% earned this designation. I think this is another great example of the VA moving in the right direction in terms of LGBT care. 

Some of the other things that have happened in the VA related to policies and practices targeted at improving LGBT care are that we have a VA transgender health policy. This was implemented in June of 2011. That policy focuses on general healthcare, mental healthcare, hormone therapy, preoperative evaluation for sex reassignment surgery and medically necessary postoperative care. It sets the standards for those things. It also very clearly states that transgendered Veterans should be referred to by the name and gender they prefer, regardless of legal status. That was something very important to do in the VA as well. 

We have also formed a transgender education workgroup. That is within The Office of Patient Care Services. That workgroup has created webinars, toolkits and online repositories for transgender healthcare resources. The other thing that has worked to ensure the success of the VA’s focus on LGBT Veterans has been the designation of two LGBT program coordinators within The Office of Patient Care Services. Those coordinators are Dr. Jillian Shipherd, who is at the VA Boston Healthcare System and Dr. Michael Kauth, who is at the VA in Houston. Michael and Jillian work to advise senior leadership on LGBT policy and practice related to LGBT Veterans. They helped spearhead the development of educational initiatives in the clinical consultation programs. 

I know that they are working hard right now to develop and disseminate a scan echo program related to LGBT health. I think that will be coming out in the next month or two, if I understand correctly. They are adapting current educational materials we have in the VA, for example, The Caregiver’s Support Manual, to be sure to include LGBT families and create a new VA LGBT fact sheet. I think that having those two people appointed and designated in the VA is really helping to march the agenda forward. 

We have done some other interesting things in the VA. There are probably several of you on the phone who have been involved in the new postdoctoral psychology fellowship program for LGBT health. Those fellows will be joining us in September of 2013. There have been seven fellowships funded in the first year. That is tremendous. I lead an LGBT research working group. We have monthly calls that feature ongoing VA research dedicated to understanding LGBT Veterans. We have about 50 VA investigators, clinicians and policy makers nationwide on that call. The nice thing about the call is by meeting monthly, we feel like we really keep a good handle on what is going on in terms of research. We identify gaps in research. We work together on ways to move forward to close those gaps. 

In terms of future directions for the VA as a whole, we certainly need to move in the direction of health systematic data collection strategies, making sure that we ask about sexual orientation or figure out a way to make sure we know if people wish to disclose whom our LGBT Veterans. We can make sure we can provide the best healthcare services possible. I think there is an enormous amount of work to be done on examining the aftereffects of “Don’t Ask, Don’t Tell,” including physical and mental health conditions, healthcare utilization and specifically the idea that some folks may have been targets of military sexual trauma based on their sexual orientation and intimate partner violence. I think we certainly have a lot more to learn in that area. 

Lastly, I think one of the things we are all working toward is improving cultural competence of providers. There are many educational materials out there now. Earlier this morning I got an email from some folks in Cincinnati who were talking about all the great things they are doing at their facility to promote cultural competence of their providers and their staff. I think that is exciting. I am sure that many other facilities are doing similar things. I think there is a lot of great work going on there. 

I will close by saying that if anyone on this call is interested in participating in that LGBT research workgroup, I would be more than happy to have additional folks on that workgroup. There is my email and my office number. I also wanted to promote or talk about a new journal, called LGBT Health. It is launching its first edition this week. There have been many press releases about it. You will find that in that journal we have the paper I have presented to you just now, which is a paper focusing on the health of LGBT Veterans. I believe that paper will be released tomorrow. I am also focusing on this journal because the journal editor is Dr. William Byne, who is a VA physician. I think he is very interested in ensuring that VA research related to LGBT populations is published as much as possible. There is the information for that journal. 

The next three slides, for your benefit, really focus on the research that has been done in this area. I have tried to focus mostly on research that involves Veteran populations in these three slides here. I figured that some of you on the phone might just like to read some more about some of these studies that have been done. I thought it would be good for all of you to have them. This is a bibliography of some of the work that has been done. I would suggest that moving forward, if you have questions about some of these specific studies, that you might want to go to Medline and look up some of these papers. 

I think that is it for today. I am happy to entertain any questions. 

Molly:     Thank you very much Dr. Mattocks. Can I ask you to back up a little bit and put up your contact information slide? 

Dr. Mattocks:    Yes. 

Molly:     Excellent. We have many questions that have come in. We will get right to it. The first one that came in is if there is a location for the training at the Orlando campus. 

Dr. Mattocks:     I am not sure about that. I can check with people who might be more knowledgeable about that and get back to someone. 

Molly:     Thank you. I encourage that person to contact you offline. I also noticed some attendees are using hand-raising icon. I am not going to unmute you. Please type your question or comment into the question section of that. Go to Webinar Control Panel on the right hand side of your screen. The next question is if VA care will be available for spouses of our 100% Veterans. 

Dr. Mattocks:     Of our 100% service connected LGBT Veterans, or Veterans in general? 

Molly:     That is a great question. I encourage that person to clarify.

Dr. Mattocks:     If the question is specific to LGBT Veterans, I think the question is related to the recent DOMA legislation that came out last week that allows the same types of marriage benefits to LGBT populations. My guess, and the VA directives that have come out seem to very clearly say, that the VA will do everything in its power to ensure that the benefits are equivalent for married LGBT couples, as well as straight couples. I think that is probably what question was about. 

Molly:     Excellent, thank you. She did specify that she was talking about 100% service connected. 

Dr. Mattocks:     Okay. 

Molly:     Okay. Somebody did write in a comment very early on in the presentation. The numbers are probably larger for people identifying when you include transgendered individuals. Most or many of them transition after their service. 

Dr. Mattocks:     Absolutely. I agree completely. I think that recently there was a great article or story that came out about a Navy SEAL that transitioned. I agree completely. 

Molly:     Thank you. Many people are asking about where to get a copy of your PowerPoint. Please refer back to the reminder email you received about three hours ago. If you scroll down there is a link leading to the slides. The topic is made even more urgent since DOMA, the Defense of Marriage Act, was stricken down and VA LGBT employees and Veterans will be impacted. 

Dr. Mattocks:    Absolutely. I think many of us across the VA were delighted to see the relative speed in which... which is a funny thing to say in VA.... with which our leaders and VACO put out policy announcements stating that these benefits would be available to employees. I applaud the VA for doing that. 

Molly:     Thank you for that reply. There are many great questions coming in. We will move right along. If GID is identified, can the individual be assisted by the VA with sexual reassignment surgery or at least for male to female orchiectomy? I do not know if I pronounced that right. 

Dr. Mattocks:     My understanding, and I would double check with the transgender healthcare policy, but my most recent understanding is that the VA does not pay for the reassignment surgery itself. It pays for what I said in the slides, everything leading up to it, postoperative care and things like that. That is my most recent understanding. If it is helpful to the group, we can send around that transgender health policy so people can look at the specifics of what is in that policy. 

Molly:     Thank you. Several people did write that question in. it is a topic that people would like to know more about. This person asks how he can join the LGBT research working group. 

Dr. Mattocks:     My information is right there. Shoot me an email. For folks on the phone, the workgroup meets on the first Tuesday of the month at 1:00. If you send me an email, I will put you on our list and I will send you a meeting announcement. I will ask you to print that. 

Molly:     Thank you. Getting back to the questions, where are the postdoctoral fellowships offered? 

Dr. Mattocks:     That is a good question. I am not going to get all of them right. I know for a fact that West Haven has one. Boston has one. There are five others. I can find out more about that. Those are two locations for certain. 

Molly:     We do have somebody that just wrote in. West Haven, Boston, Milwaukee, Hawaii, Houston and Bedford. Thank you to that person. 

Dr. Mattocks:     Perfect. 

Molly:     And San Francisco. 

Dr. Mattocks:     I was going to say we were still missing one. 

Molly:     Okay. The next question is if the two LGBT coordinators that you mentioned are focused on a local or national level. Do they advise the national leadership? 

Dr. Mattocks:     They are very much on the national level. They work very closely with national leadership across the board, mental health, patient care services and the Office of Health Equity. They are very active on the national level. I cannot emphasize enough how much good work Jillian and Michael do in that area. I am amazed at their energy. They do a really great job. They are definitely on the national level. I think they are informed by local things going on and it translates to the national level. 

Molly:     Thank you for that reply. The next question is what the standard of care is on a gynecological care of the transsexual patient that has had gender reassignment surgery from male to female. 

Dr. Mattocks:     That is a great question. I am not a clinician. I cannot give you the specifics of that. If that person could email me, I can hook you up with the information to answer your question. That is a really great question. 

Molly:    Thank you. That was a good one. Okay. To Dr. Mattocks or others in the group, are you aware of any work that has been done to survey VA staff attitudes toward LGBT Veterans, and knowledge of LGBT healthcare needs? 

Dr. Mattocks:     We are moving in that direction. I am going to cite the study that I pointed out earlier by Michelle Sherman and Michael Kauth. That study was done and is currently being done in Oklahoma and Texas. It is a two-site study. I think they have a couple of papers coming out of that project. We are moving in that direction. I also know there was a recent grant submission that was really going to focus on understanding the patient experiences of being in the VA as an LGBT patient. I think that we still have a good amount of work to do in terms of formal surveying of VA providers on a larger basis, to understand some of the perceptions and experiences of VA providers. 

Molly:     Thank you for that reply. I have many more coming in. what do you think would be the best way, right now, to capture information like demographics and cultural competencies, of LGBT Veterans nationwide? Is anyone working on capturing this information in CPRS, so we can run administrative data studies? 

Dr. Mattocks:     Wouldn’t that be nice? Nobody is. I can tell you that. Nobody is doing anything on a national basis at this point, because we do not have any formal systematic way to capture it in the first place. As I mentioned earlier in my conversation, I think there is a very spirited conversation going on about whether we should be capturing that on a national basis. There are people who really believe that is something that is still such protected and private information that it should never go into the electronic medical record. There is a camp of people who really strongly believe that. There is a similar camp of people who believe we really need to move in the direction of capturing that information so that we can do large national studies. That conversation is very active and ongoing. I think that at this point, in terms of doing studies, it would really be posting flyers and advertising, getting people that way. I do not know of another systematic way to do it. 

I have to say that one of the best presentations I heard in the past year was by Carolyn Clancy, who was the director of The Agency for Healthcare Research and Quality. Everybody on the phone should know that this is not something that we are facing alone in the VA. She gave us all our marching orders about a year ago. She said it does not matter what institution you are with, whether it is VA, Medicare or Medicaid, or other sorts of large payers or small community hospitals or healthcare centers. We need to figure out a way to better capture LGBT patients’ experiences. The way to do that is going to begin with systematic data collection. I think that we have a call to action from some of the highest leaders across the country in terms of thinking about healthcare. I believe that it is probably going to be a couple of years until we figure out how to do that in a way that makes sense and is comfortable for people to do that. That is a great question. We are moving in that direction. 

Molly:     Thank you. We do have many comments coming in about gender reassignment surgery. There are many differing opinions. We will get to those in a moment. I do want to interrupt and say that one of the people is analyzing data at West Haven right now, on clinician attitudes. It sounds like that is taking place. 

Dr. Mattocks:     Great. I am glad to hear that. I would be curious to learn more about what you are doing. That is wonderful. 

Molly:     Okay. This looks like a big comment. As an LGBT-SEPM, Danville, VA Illana Healthcare hosted its first annual LGBT pride program this June, complete with keynote speaker Suki De La Croix, entertainment and Hillary Clinton’s 2011 address to the United Nations concerning human rights. I am interested in the number of other facilities that have hosted LGBT programs this year and how they were received, as well as subject matter. I invite Dr. Mattocks or any attendees to reply. 

Dr. Mattocks:     That is great. I did get an email earlier from some folks in Cincinnati that were telling me about some of the things they have done at their facility. I know of at least one facility that is doing it. My guess is that there are many more facilities doing that type of thing. It seems like there was something that came out recently. I can get hold of it. It was colleagues in Chicago, if I am not mistaken. One facility shared with us the things they had done at their facility along the lines of LGBT health and reaching out into the community, things like that. It was a great PowerPoint presentation. They said they were happy to share it with other facilities, in terms of some of the other work they had done. I was really impressed. If that person wants to email me, I can get hold of that presentation and pass it along. 

Molly:     Thank you. We also had an attendee reply that the Dallas, Texas VA had their first LGBT pride observance. It went really well. Thank you to that person. 

Dr. Mattocks:     Wonderful. 

Molly:     Further information from around the country is here. In Saint Louis, we are doing a survey on LGBT Veterans and their experience at the VA as well. 

Dr. Mattocks:     Good. I think the best way that we can move forward as an organization is to share this information with each other. If I can serve as a repository for some of these things, if people want to send me what they have, I can send it out as we move forward and people have questions. I am happy to play that role for pride events and for research coming out of these different facilities. One of the great things I think has come out of our LGBT workgroup is getting people to collaborate with each other at different facilities. We have done a lot work sharing how people handle surveys using SurveyMonkey. That was before we got the VA directive that we were not supposed to use SurveyMonkey, and things like that. That is another nice thing that has come out of the research working group. We also had Gary Gates on our call last month. He gave a really great overview about his work on identifying LGBT members of the military. I hope to bring in special speakers like that over time, to bring us up-to-date on larger issues of LGBT research. 

Molly:     Thank you. Somebody wrote in asking where he or she can find training resources for providers. 

Dr. Mattocks:     Great question. There is a SharePoint site where these materials that have been developed sit. If that person wants to email me, I believe that SharePoint site is shareable. I am pretty sure it is. I will give them that site. 

Molly:     Thank you. Just so everybody knows, this is being recorded and you will receive a follow-up email with a link to the recording, handouts and any additional information that Dr. Mattocks provides for us. There are more reports from around the country. Wilmington, Delaware had their LGBT awareness last month. 

Dr. Mattocks:     Great to hear that. 

Molly:     All right. We have a very engaged audience, probably over a dozen questions pending. Okay. This is a personal opinion about the gender reassignment, the other discussion about reassignment, etc. I do not see how it could be called service connected. I do not see why the VA should be paying for it. It is a personal pre-existing condition. Thank you for your opinion. These are some more comments. VA templates require change at the national level. We must know sexual orientation for data collection. Is anything being done to change these national templates to inquire about sexual orientation as they do with sex, race, etc.? 

Dr. Mattocks:     I think that gets to what I was talking about earlier. At this very moment, I do not think anything is being done. I could be misspeaking. I guarantee that I think it is something that is going to be on the table soon. Change is incremental. I think that we are moving in that direction, but it is going to take some time to do that. I agree, it would be great if when a person walked into the VA and they filled out their enrollment forms, there were a place they could state if they wanted to, what their sexual orientation was. Not yet. 

Molly:     Excellent, thank you. This is also a comment from that same person. I believe the current generation of Veterans will find that more welcoming than threatening. In addition, it may actually help those who are hesitant to disclose this in order to do so. 

Dr. Mattocks:     It is funny. This is an anecdotal story. We launched a survey for one of the other projects I am on about five or six years ago, back in 2008. We ended up including sexual orientation on the survey. There was some worry that if we put sexual orientation on the survey that it would turn people off or scare them, whatever. I think there was some worry that people would not complete the survey and get turned off for the whole study. There are all of those fears. In the end, everybody completed the sexual orientation question. Nobody ran away. Nobody dropped out of the study. As a matter of fact, I think there were very few missing. I think there are many things we fear and if we just do it, it is actually okay. 

Molly:     Great. I just want to mention all of the other places around the country that are doing things. Richmond VA is joining forces with the community, with their pride celebration in September. James V. Haley in Tampa hosted their second pride program last month. They presented on improving the quality of services and supports offered to LGBT older adults. It was well attended and well received. West Palm Beach Virginia Medical Center’s pride celebration was June 14th with 30 attendees. The speaker was the Florida State coordinator from PFLAG. Let’s see. I am sure we will have more come in. Miami VA did a cultural awareness day. This hosted documentaries, community speakers and a historical perspective of LGBT history within the U.S. military, along with community programs. The reception was overwhelmingly positive. It sounds like we are getting a lot of them around the country. 

Dr. Mattocks:     I would really encourage people to send me that information, even if it is just a little blurb. I think it would be really great to put that together as a compendium. Then once you share that with other VA facilities, I think it spurs action in other facilities. It lets people know it is possible. Just shoot me emails with a short blurbs about what you have going on. I will put it together and send it out to the group. 

Molly:     Thank you. Okay. There are lots more coming in. Are there funding opportunities or grants that would be available for folks interested in doing LGBT Veteran research specifically? 

Dr. Mattocks:     I think that HSR&D is the place to go in the VA. I think that there is one grant proposal in right now, specifically looking at LGBT health. There may have been others in the past that I am not aware of. I think HSR&D is very open to this type of thing. There is still an existing proposal out there, if you look up NIH by health of LGBT QI populations. I think there is still an existing call for proposals. The last I heard they were not getting many proposals. They were a little bit frustrated. I think there are probably a lot of smaller agencies or groups that would fund things. Try the usual funding routes. I think that people are becoming more open to this. I think the VA in particular is going to start to welcome these types of grants very much. 

I also want to point out that along those lines, many of the funding streams and certainly HSR&D have a one-year $100,000 pilot program. For folks that want to do some kind of smaller scale LGBT research in the VA, that pilot program may be the way to go. 

Molly:     Great. Okay. Are there required qualifications of workgroup members, for example, mental health provider licensure of any sort? 

Dr. Mattocks:     For the research workgroup? If it is for the research workgroup, absolutely not. 

Molly:     Thank you. All right. Let’s see. Is it cruel to provide hormone therapy in male to female and not offer an orchiectomy (castration)? Can they pay and have the surgery done at the VA? 

Dr. Mattocks:     Was the word cruel? Did you ask if it is cruel? 

Molly:     Yes. 

Dr. Mattocks:     Okay. Good question. I would refer back to the transgender health policy. I would also say that on matters of transgender health, I would absolutely defer to Jillian Shipherd. I am pretty certain that she is away the month of July on vacation. She is the person to ask many of the transgender health questions to. She has done so much work in this area over the years. She is probably the right person to send the transgender health questions to. She is at VA Boston. 

Molly:     Thank you. Great. What is the LGBT workgroup’s primary focus? What does the group membership entail? 

Dr. Mattocks:     That is a good question. When we started a year ago, I just reached out to some people I know who are interested in LGBT work. We thought we would first start by coming together and seeing where we were. Our goal over time is really going to be to identify the gaps in the research and to figure out ways that we can fill those gaps. We really want to be leaders in the field in terms of pushing research agenda along, in terms of LGBT health. In terms of qualifications, we welcome anybody who is interested in participating. What happens every month is that I ask someone to present on their research findings or their research ideas, maybe even a paper they have written recently. I do not want anyone to feel that if they were to participate in the group that they would be obligated to present or write a paper. I am just as happy for people to participate who are going to take some of this research back to their facilities and figure out how to implement it. I do not have any strict criteria. I am happy to have as many people join the group as would like. I think that is going to be really great way we can disseminate the information. 

Molly:     Thank you. This is a comment. I would support appropriate healthcare based on whatever gender they are at the time. I just do not see the reassignment being covered. 

Dr. Mattocks:     Okay. Thank you. 

Molly:     For those who want to know what SEPs are doing around the country and pride celebrations, one can join the national mailing list by contacting Matt Bessell, a licensed social worker at the Northport VA Medical Center. The mailing list is a weekly clearinghouse of LGBT and Veteran/federal employee related information. Currently more than 275 members are there. That is Matt Bessell at the Northport VAMC. Thank you for that information. 

Dr. Mattocks:     Thanks Matt. That is really helpful. 

Molly:     It was not Matt. 

Dr. Mattocks:     Thanks friend of Matt. 

Molly:     How can currently non-VA affiliated researchers who do LGBT research and have an interest in VA populations get involved in the great work you are doing? 

Dr. Mattocks:     That is a great question. I think that there are so many of us across the VA who work closely with non-VA researchers. I think one can inform the other on so many areas. A good way to get involved, depending on where the questioner lives, is to get involved with a local VA researcher that you know. That notwithstanding, we have several people on our LGBT workgroup who are not VA researchers. I very much encourage that. I think that what is done on the non-VA side can be very informative to the VA side, and vice-versa. Please contact me and we will get you into our group too. It is not limited to VA researchers. 

Molly:     Thank you for that response. Kristin, we are at the top of the hour. Are you able to stay on and answer the remaining questions? It looks like we have nine or ten. 

Dr. Mattocks:     Sure. 

Molly:     Great, thank you. We do still have a large portion of our audience with us. Many people want to get out information for their local sites. I have done research for Vet Center Services at Northampton Pride in Massachusetts for several years, Transpride at Northhampton. We will be at Blue Ridge Pride this year. Presence in the community is very well received, and heartfelt thank-yous. Thank you to that person. I think you covered this, but I will read it anyway. Does the VA ask this question of their gender identification on their intake questionnaire? This is not hard to code, whatever demographic, at initial intake. They update the demographics on a regular basis. It should just be a normal part of VA intake. 

Dr. Mattocks:     Sorry, but we do not yet. We are moving there, but we do not yet. 

Molly:     Thank you. I am interested in LGBT substance use. I was wondering if there is any publicly available data of LGBT patient health behaviors in VA systems. 

Dr. Mattocks:     That is a great question. Publicly available? I would have that person contact me. I do have some data that person might be interested in looking at. I know that for example, just in terms of what has been done before, Brenda Booth and Anne Sadler, some of those folks have done it. Brenda Booth’s recent paper did look at substance abuse as part of another analysis, in terms of LGBT. I think it was specifically in the LGBT population. We have done some of that work in our own study. I think there is an enormous amount of room left to go with this. If that person could contact me, we could talk more about what their interest was. I think we have some data that might be helpful. 

Molly:     Thank you Kristin. We have a very important announcement that just came in, clearly from one of your colleagues. Happy Birthday Dr. Mattocks. Thank you for taking the time to present to the field on your birthday. 

Dr. Mattocks:     Thank you. 

Molly:     I have a female to male transgender patient who is relocating from Arizona to California and is having trouble obtaining credit in his new gender or name, renting an apartment or getting cable connected, etc.? Is there some way to help them? 

Dr. Mattocks:     Where is the person moving to? 

Molly:     Somewhere in California. I can ask the person to write in with more information. 

Dr. Mattocks:     I guess what I would say that person could reach out and contact the local VA there. I am sure they could set them up with some resources or information that would be more local and more appropriate. I would encourage them to do that. Whoever is receiving VA, there is someone there to connect with. 

Molly:     Thank you. The reaction to my statement that reassignment should not be considered service connected was interesting. I do not see how a pre-existing condition can be considered service connected. Can you educate me better on this? 

Dr. Mattocks:    I think it is an interesting question. I would defer to Jillian on this, because she has done so much more. My guess, and it is just a guess, is that not all people are probably suggesting that their assignment is related to a service connected issue. That is just speaking off the top of my head. Perhaps in some cases there are, but it is not a service connected issue. It is just an issue that the Veteran has. I am not sure I have anything else to say on that. I do not see why it has to be a service connected issue necessarily. 

Molly:     Thank you. I understand. We have a couple people writing out. A couple people in California want to know what area of California. They are located there and can provide resources. The APA-DIV-44 list sometimes serves as a helpful resource for the person relocating. That is the APA-DIV-44 list. Thank you to those colleagues out in California for reaching out. Okay. Let’s see. In your experience, what is the best way to assess sexual orientation, given that some research focuses not only on identity, but also behavior and attraction? 

Dr. Mattocks:     That is very important. I think the best way to do it is not to just ask one question, but to ask a series of two or three questions that focus on those three important things, on identity, attraction and behavior. When Gary Gates presented to us a month ago, he gave a really great breakdown about how across those three categories, identity, attraction and behavior, how the percentages of people that you have who will agree with each of those categories is very different. Perhaps not surprisingly, the fewest amount of people will probably agree with the identity. The fewest amount of people will say they are actually gay. Slightly more people will say they have had sexual relationships with another man. Even more people will say they find that they are attracted to men on occasion. 

I think it is really important to be sure to ask those three questions separately. I think if you just ask any one of them, you probably would not get an accurate representation of what is really going on. I think the challenging decision at that point will be to how to use that data to go forward with what you want to do. Most people I have seen in papers focus on the identify and the behavior, less so on the attraction. 

Molly:     Thank you. 

Dr. Mattocks:     I was going to say for that follow-up, I have been able to find some good questions that look at those three things. If that person wants to contact me, I can send them the questions we have used. 

Molly:     Excellent. The Greater Los Angeles VA wants to announce that they held their fourth LGBT Pride celebration featuring L.A.’s deputy mayor and elected district councilman. The GLA also marched in the L.A. Pride parade for the first time. Congratulations to the GLA. Okay. Can I get info for the program lacking grant proposal she mentioned? 

Dr. Mattocks:     Can you reread that Molly? I did not understand that. 

Molly:     It is not exactly a complete sentence. Can I get info for program lacking grant proposals that she mentioned? They can also write in to clarify. 

Dr. Mattocks:    I mentioned HSR&D. I would say to go onto the ORD website. Look up HSR&D. You will not see anything there that specifically says they are looking for grants about LGBT populations. I think that you could submit grants in their regular cycles. Those are June and December. You can submit as a merit award or as a pilot grant. That information is all available on the ORD HSR&D website. 

The other one I mentioned, the NIH one, if you go to the NIH grants website and you type in LGBT QI, I think you will find that program announcement too. 

Molly:      Thank you. I believe you referenced him in this presentation, William Byne. He wrote in and said that your article on needs of LGBT vets is available online today. You can get it online at www.liebertpub.com. There is a whole lot more of the reference here. I am not going to read the entire website. If you want that information, feel free to email Cyberseminar@VA.gov. They can send you the entire citation. Thank you very much Dr. Byne. 

Dr. Mattocks:     Thank you. 

Molly:     As an EEO LGBT SEPM, one of my goals has been to provide resources to young Veteran parents who may have children who identify as LGBT. 

Dr. Mattocks:     Okay. That is great. Is that the question? 

Molly:     No, I think it was just a comment. 

Dr. Mattocks:     Okay, good. I am happy to hear that. That is wonderful. 

Molly:     Great. Okay. I am going to ask the remaining question and then we can go back to the hot topic of reassignment surgery, which is a continued debate right now. We do not only treat service connected illnesses. Service connected only determines access to care, VA benefits, etc. For example, we treat hypertension, hypercholesterolemia, and erectile dysfunction; perform cardiac surgeries, gastric bypasses, etc. These are not service connected. Why would we not cover gender reassignment surgery, if it improves the life for a Veteran? 

Dr. Mattocks:     I think that is a really nice response. That was said much more eloquently than what I said. I agree completely. Certainly part of what we do is related to service connected status. That is not the only thing we do. My guess, going back to that question, is that most people going out on a ledge are not interested in gender reassignment surgery related at all to service connected status. That would be my guess. Thank you for that. That was a really great answer. 

Molly:     Thank you. Is there a greater percentage of PTSD among LGBT Veterans who lack community support after service? 

Dr. Mattocks:     In the paper that we put out recently that’s in JGIM, I think we looked at PTSD. I do not think there was any kind of statistically significant difference when we looked at lesbian and bisexual women and compared them to heterosexual women. I have to say the sample size was pretty small. At least in that paper I do not believe it was statistically significant. I will have to dig the paper up again and look at it. It was not one of the major findings of the paper. I am sure that in some of those other papers I put out on the bibliography, others have looked at that too. It is a good question. 

Molly:     Thank you. This one starts with a comment and ends with a question. We here in Reno are about to go through [inaud.] training. In addition, they are sending me to the Gay and Lesbian Medical Association’s 31st annual conference in Denver. I am a nurse educator and the manager of the Women Veterans’ program. My master’s thesis was on LGBT healthcare in the Veteran population. We also have the movie “Tran” and are showing it, as well as having the director here to answer questions. How do I facilitate access to your research findings? 

Dr. Mattocks:     That is great. You can start out by sharing the PowerPoint presentation with them, if you would like to. I am happy to have that shared. I would also download what Dr. Byne mentioned, the paper. Definitely download that paper. It is what I presented here, except more written out. That might be helpful. If there are any other things I can pass along, please let me know. I am delighted that you are going to GLMA I think that is wonderful. 

I cannot believe I forgot to mention this. There is a group out there called The Lesbian Health Fund. I should have mentioned this earlier. The Lesbian Health Fund, which is loosely tied to GLMA, offers grants for lesbian and bisexual health. People should apply. The only downside is that the grants are not huge. If I remember correctly, it is something like a $5,000 or $10,000 cap. It is not a ton of money. It is definitely a place to look for grant funding, if you want to do a small program. I think the peer review is pretty good too. Look it up at LesbianHealthFund.org or something like that. You can see when their call for proposals is. 

Molly:     Thank you for that additional information. Regarding the credit question, there is also The Transgendered Veterans of America website and local chapters. CTTranAdvocacy may also be able to address this. Thank you for that advocacy information. We have a two more comments about the gender reassignment. I did mention to both people that it seems like a very hot topic. It could be an interesting debate. I am pushing them to go to join your research group. SharePoint seems like another venue to continue this. 

Dr. Mattocks:     That is great. 

Molly:     In regard to the cruel comment, please remember that not all individuals who are transitioning want surgical intervention. Many do, but not all. For some people within transition, hormones are the final step for them. 

Dr. Mattocks:     Yes. That is great, thank you. 

Molly:     There is a final comment regarding that. Regarding “service connected,” let us recall that Veterans with 50%+ service connected are priority one and cared for fully, even for issues that are not rated for service connected disability. Let us please maintain the big picture here. OB/GYN prenatal is not a service connected disability either. It is my understanding that some Veterans are also eligible for this care. 

Dr. Mattocks:     That is true. That is an interesting point. We did some research in that area too. With the OB/GYN thing, you will have a copay if you are not service connected and you are having a baby. You can still get the benefit. It is pretty expensive with the copay. It might be cheaper for you to do your private insurance if you have private insurance. 

Molly:     We have had several people write in, not only to our cyberseminar address but also to the write-in section of this webinar. Thank you so much. This was a very concise and well put together presentation. That was repeated multiple times. Thank you for sharing your expertise with the field. I would like to give you the opportunity to make any concluding comments now. 

Dr. Mattocks:     I am just delighted that everyone has joined and stayed on with us for well past the hour. I really do encourage people to send emails if there is anything else I can help with. If I do not know the answer, I will connect you to the person who does know the answer. There is a great group of people in the VA working on this. I have to say I am pretty proud of what we have done so far. Keep up the good work everybody. 

Molly:     Great. I also want to thank our attendees for joining us and for the large number that stayed on past the top of the hour. I want to thank Dr. Mattocks. I want to mention that. One person wrote in to the person interested in LGBT vets’ alcohol and drug use. The Cochran et al, 2013 reference is a good starting point. Thank you to that person. As I was saying, I do want to direct you to the survey that is going to pop up as you exit the session. We have gotten such great feedback for Kristin. I think that should be documented. Thank you everybody. When you exit, please wait a moment. The survey will pop up. Remember it is your feedback that guides the topics we present here. Please enjoy the rest of your day. There is one more question. What was the website for the transgendered Veterans? Do you know that Kristin? 

Dr. Mattocks:     Not off the top of my head. 

Molly:     What is the website for the transgendered Veterans?

Dr. Mattocks:     I think it was Transgendered Veterans of America. I do not remember. 

Molly:     They can write into Cyberseminar@VA.gov. I will review the questions and get that information. Thank you to everybody for joining us. Have a wonderful rest of your day. 

Dr. Mattocks:     Thank you. 

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