VA Studies Barriers to Receiving Hormone Therapy for Transgender Veterans

Report finds a variety of factors associated with successful treatment

with Guneet K. Jasuja PhD

A figure running on a road with bumps, another on a flat path

The Department of Veterans Affairs (VA) has been treating transgender patients since 2011, and since then has also been tracking aspects of care, satisfaction, and various traits of those they treat in effort to understand how to provide the most effective quality care.

There is ample evidence showing that transgender patients in general experience higher levels of:  

  • health disparities
  • barriers to care
  • inadequate care
  • greater rates of suicide, depression, and other mental disorders (1-2). 

One study (3) reported that the suicide rate in the transgender veteran population is 20 times the rate observed in the general VA population.

A very small study (4) from 2016 selected 11 transgender veterans in order to study their experiences navigating trans-related services at the VA. From semi-structured interviews, the authors found five themes:

  • Long delays in receiving care
  • Needing to travel to receive care
  • Lack of patient knowledge about what trans-related care is covered
  • Providers can be insensitive, harassing or violent towards transgender patients
  • Lack of provider knowledge about trans patient issues and care.

The researchers concluded that just knowing that trans-specific services are covered and available isn’t enough; “additional patient-centered and healthcare system-led interventions are needed.”

What has been missing from VA research is an understanding of the particular aspects of transgender patients who access their services. At the most recent ENDO2021 virtual conference, researchers from the VA presented their findings (5) about factors associated with trans patients “which are critical to identify areas of improvement in care for transgender patients.” The study looked specifically at patients who received hormone therapy.

“I think potentially the reason why this hasn't been done before is that attention to transgender health research in general has increased dramatically in the last decade or so, due to the growing prevalence of transgender individuals,” says Guneet K. Jasuja MD, Research Health Scientist, Center for Healthcare Organization and Implementation Research at the Bedford (MA) VA and senior author of the study. “This growing prevalence has been attributed to increased awareness and acceptance of transgender identities, which has allowed more individuals to be willing to open up about how they identify.”

Who is accessing care at the VA?

Dr. Jasuja and her colleagues looked at those who received care for gender identity disorder through the Veteran’s Health Administration (VHA) between January 2006 and December 2018. A total of 9506 records were reviewed, and 5,487 received hormone therapy from the VHA. More younger people received hormone therapy than older patients.

Along with hormones received, they examined:

  • socio-demographics
  • comorbidities
  • social stressors (such as homelessness)
  • military sexual trauma
  • documented suicide attempts.

There were significant associations between hormone therapy and comorbidities, social stressors and being African American. More than 22% of those getting hormone therapy had documentation of military sexual trauma.

“Not much is known about the patient profiles of transgender veterans who are receiving gender affirming hormone therapy in the VA,” says Dr. Jasuja. “Understanding the patient characteristics of [those] receiving this treatment is key to optimizing it in the VA.”

Some surprises in the results

She says the findings included both expected and unexpected elements. For example, he expected that more trans veterans would experience social stressors such as housing or job instability or financial strain than their cis-gendered counterparts. “These social stressors would limit access to and receipt of therapy,” says Dr. Jasuja.

They then looked at the relationship of each of the identified social stressors individually and found something surprising. Those experiencing housing instability specifically were more likely to receive hormone therapy. The researchers suggest that those in this situation are more likely to have closer contact with other VA services, and thus more information on accessing trans-related health care.

“Another unexpected finding was that transgender veterans with a documented military sexual trauma were more likely to receive gender affirming hormone therapy,” Dr. Jasuja says. She calls this positive association “significant” and suggests that, like those with housing instability, this cohort may have closer contact with VA resources. Better communication with physicians about sensitive topics such as military sexual trauma and gender minority identity may increase the likelihood of patients asking for and receiving hormone treatment.

Dr. Jasuja points out that other social stressors—aside from housing instability—were negatively associated with access to hormone therapy. This is an important finding because it poses the question of whether trans veterans lack access or are some choosing to not access hormone therapy. It is true that not every trans person wants hormone therapy. 

Dr. Jasuja hopes the next steps in this line of research will result in efforts to develop a deeper understanding and intervention efforts targeted to increase access to the therapy, and receipt of it for transgender veterans who want it. “It is important to know patient preferences, needs, barriers, and the facilitators around this treatment.”

While this work is related only to the trans community of veterans in the United States, Dr. Jasuja points out that elements of their findings would probably hold true in the wider transgender population. “For example, transgender individuals in general experience a high burden of social stressors, so the general population of transgender patients experiencing those stressors may also be less likely to receive this therapy.”

Racial barriers to hormone therapy 

The study also found that Black non-Hispanic trans veterans were less likely to receive hormone treatment. This likely reflects the wider population, where African-Americans often experience discrimination in health care. Dr. Jasuja says that this trend could be more about the avoidance of medical care rather than a lack of access, though either way it would result in lower treatment rates in transgender people of color.

There is still more work to be done, as Dr. Jasuja points out, “and because this was a study based on structured VA data, it was not possible to ascertain patient needs and preferences around this gender-affirming treatment, nor the barriers and facilitators to receiving or accessing this treatment. Additional research could help us understand where we should target efforts to improve receipt of hormone therapy among those who want it.”

Continue Reading:
Cultivating More Inclusive Medical Care for Transgender Patients
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