Caring for transgender & gender-diverse veterans

• 1994 — "Don't Ask, Don't Tell" was put into motion by then-President Bill Clinton, which prohibited openly lesbian, gay, and bisexual service members from serving (Franklin, 2021).
• 2011— The Veterans Health Administration Transgender Directive (now VHA Directive 1341(3)) was established. This directive helps provide equal access to non-discriminatory health care for transgender and intersex veterans (National Center for Transgender Equality, 2011).
• 2011 — "Don't Ask, Don't Tell" was repealed by the Obama administration, which allows openly lesbian, gay, and bisexual people to enlist but excludes transgender individuals (Keuroghlian et al., 2022).
• 2012 — The VHA established an LGBT Health Program (Keuroghlian et al., 2022)
• 2016 — The military lifted its ban on transgender services for TGD individuals already in the military (Keuroghlian et al., 2022).
• 2018 — The military allowed transgender people to enlist (Keuroghlian et al., 2022).
• 2018 — A military ban on transgender personnel was issued by the Trump administration but was put on hold by courts (Keuroghlian et al., 2022).
• 2019 — The ban was adapted so that only TGD veterans with a waiver stating that they have been "stable" in their gender identity for 18 months can enlist with their authentic gender identity. If not, they had to enlist under their sex assigned at birth (Keuroghlian et al., 2022).
• 2020 — The VHA Directive 1341(2) included gender-affirming treatment of TGD Veterans, which includes addressing individuals by their authentic gender identity and providing access to gender-affirming treatments (gender-affirming surgeries are excluded unless there is a medical need) (Powell et al., 2022).
• 2022 — The Department of Veteran Affairs devised the "Agency Inclusion, Diversity, Equity, and Access (I-DEA) Strategic Plan 2022," which states a commitment to the expansion of non-binary facilities and practices, gender marker and pronoun usage, and respecting transgender, gender non-conforming, and nonbinary employees. In addition, the plan involves delivering more "LGBTQ+ cultural competency, unconscious bias, gender diversity, and other relevant D&I [diversity & inclusion] training to VA workforce" (Department of Veteran Affairs, 2022, p. 10).

• TGD veterans can experience chronic minority stress due to fear of being discovered, rejected, and dishonorably discharged due to their gender identity, which is associated with increased levels of suicidality (Keuroghlian et al., 2022).
• TGD veterans can experience high rates of sexual assault, exacerbating mental health issues such as depression, posttraumatic stress, and substance abuse (Keuroghlian et al., 2022).
• Many TGD veterans avoid health care services due to fear of discrimination, micro-aggressions, invalidation, and providers' lack of knowledge in culturally responsive care based on gender identity (Powell et al., 2022). This can come from providers as well as peers, subordinates, and authority figures.
• Although the VHA Directive 1341 is in place, provider competency and training can be inconsistent and lacking; thus, many TGD clients can suffer as they may not be accurately referred to the services they need.
• TGD veterans can have higher rates of cardiac arrest, diabetes, hypertension, breast cancer, chronic pulmonary disease, HIV, and prostate cancer than their cisgender veterans while utilizing VA services (Brown & Jones, 2016).
• TGD Veterans can die by suicide at twice the rate as their cisgender counterparts when accessing VA services due to discrimination they face based on their gender identity (Blosnich et al., 2013).

• Vocal coaching
• Hormone Therapy
• Fertility Preservation
• Prosthetics
• Diagnostic evaluations
• Psychotherapy services
• Support letters
• Gender-affirming surgeries if there is a medical need (e.g. if a non-binary individual receives a double mastectomy due to breast cancer)
• Pre- and post-operative care

(U.S. Department of Veteran Affairs, 2018)

• Minimize barriers for TGD Veterans to access gender-affirming services as it is linked to improvements in mental health (Tomita et al., 2019).
• The LGBT Veteran Care Coordinators (LGBT VCC) is the designated point of contact program at every facility that is responsible for the dissemination of inclusive signage (i.e., "We Serve All Who Served"), lanyards, and other items.
• If there is a lack of inclusive signage within the facility OTPs can connect with the LGBT VCC and advocate for more inclusive signage to help TGD Veterans feel safer and affirmed (Keuroghlian et al., 2022).
• Work with the LGBT VCC to educate veterans and additional VHA staff on culturally responsive care for TGD Veterans (Keuroghlian et al., 2022).
• Work with the LGBT VCC to assist in partnering with community organizations to help create healthy and healing environments for TGD Veterans (Keuroghlian et al., 2022).

• Understand that military service is a social determinant of health and cultural experience. It is important to educate oneself on the military culture and how it correlates with TGD veterans' experiences (Keuroghlian et al., 2022).
• Stay up to date with current military policies that may cause stress to TGD Veterans (Powell et al., 2022).
• Understand that TGD Veterans may have negative experiences in healthcare due to historical maltreatment towards them due to their gender identity (Powell et al., 2022).
  • Trauma can be experienced at the individual, cultural, community, and historical levels and can negatively impact one's health (Lynch et al., 2021).
  • Apply the collaborative approach of trauma-responsive and trauma-informed interventions can assist the TGD veteran in participating in more meaningful occupations and decrease the likelihood of retraumatization (Lynch et al., 2021).
• Consider utilizing a frame of reference such as the gender minority stress model (e.g., gender-based discrimination, internalized transphobia, non-disclosure of one's identity, and community connectedness) (Testa et al., 2015) and the Socio-ecological framework (Bronfenbrenner, 2000). More detail on utilizing the frame of reference can be found in the frame of reference document.