LGBT Cultural Competence and Veteran Homelessness

1. LGBT Cultural Competence and Veteran Homelessness Michael R. Kauth, PhD and Jillian C. Shipherd, PhD Directors of the Lesbian, Gay, Bisexual, and Transgender (LGBT) Health Program Office of Patient Care Services, Washington DC Presented February 21, 2018 to Homeless Program Coordinators

2. Dr. Michael Kauth and Dr. Jillian Shipherd http://www.patientcare.va.gov/LGBT/index.asp

3. Overview • Definitions • Prevalence of LGBT Veterans and health disparities • DoD and VHA culture and impact on LGBT Veterans • Presence of LGBT Veterans outside Veterans Health Administration (VHA) • VHA LGBT Health Program activities and resources • Some suggested Do’s and Don’ts in your settings • Q&A

4. What LGBT Means LGBT = Lesbian, Gay, Bisexual, and Transgender.* • Acronym for diverse groups of sexual and gender minorities, with similar experiences of social stigma, victimization, and discrimination. • Lesbian, gay, and bisexual groups related by sexual orientation. • Transgender groups related by gender identity; only a subset meet criteria for a Gender Dysphoria diagnosis. *VA uses LGBT in an inclusive way (groups use other letters)

5. Sex, Gender, and Gender Identity • Gender • Behavioral, cultural, and psychological traits socially associated with one’s sex • Man, woman, transman, transwoman, genderqueer, etc. Cisgender

6. Sexual Orientation and Identity Sexual orientation– global term referring to the sex(es) one is attracted (same-sex, other-sex, both sexes, or the absence of attraction). Multi-dimensional. • Sexual attraction – who turns you on (feeling) • Romantic attraction – who you fall in love with (feeling) • Sexual fantasies – who you fantasize about (thoughts) • Sexual behavior – who you have sex with (behaviors) • Sexual identity – how you identify yourself (social identity) • Gay/lesbian, bisexual, straight/heterosexual, queer, asexual, something else

7. Unique Context of LGBT Veterans • DoD policy: Previous bans on gay and transgender Service Members. • “Don’t Ask, Don’t Tell” (1993-2011) – LGB • Eliminated enlistment questions, allowed gay service in secret. Progressive? • Discharged if LGB sexual orientation is discovered. • No one was discharged for “asking”. • DoD policy: Allowed open transgender service beginning June, 2016. • White House (July 2017) orders DoD to ban transgender enlistment (and serviceby current personnel).

8. Unique Context of LGBT Veterans • VHA never had a ban on LGBT Veteran care • But research says LGBT Veterans anticipate discrimination from VHA providers.1-2 • 2011 – national transgender Directive issued guaranteeing care. • 2017 – national LGB Directive issued. 1Sherman, Kauth, Ridener, Shipherd, Bratkovich & Beaulieu, 2014; 2Sherman, Kauth, Shipherd, & Street, 2014

9. Prevalence of LGBT Veterans • Conservative estimates - there are well over 1 million LGBT Veterans.1-6 • Exact number of LGBT Veterans is unknown. • VHA demographic data-collection systems do not identify sexual orientation or gender identity. • VA databases have begun recording Birth Sex and Self-Identified Gender Identity (SIGI) - more later. • Sexual orientation field request pending. 1Gates & Newport, 2012; 2Gates, 2010; 4Elders & Steinman, 2014; 5Gates & Herman, 2014; 6Shipherd,Mizock, Maguen & Green, 2012

10. LGBT People: Health Disparities Overview • LGBT people experience increased rates of some physical and mental health conditions and barriers to accessing healthcare.1-9 • Like other minority groups (e.g., racial and ethnic minorities). • Local and state policies on non-discrimination vary. Housing protections not always afforded to LGBT people. 1Blosnich et al., 2016; 2Gonzales, Przedworski, & Henning-Smith, 2016; 3Herek, Gillis, Cogan, 2009; 4Hatzenbuehler, et al., 2010; 5Hendricks & Testa, 2012; 6Institute of Medicine, 2011; 7Makadon, Mayer, Goldhammer & Potter, 2007; 8Meyer, 2003; 9Shipherd, Green & Abramovitz, 2010

11. LGBT People: Health Disparities Overview • Minority Stress Theory can explain elevated rates of most health conditions elevated in LGBT people (e.g., depression, drug abuse, drinking, smoking, heart disease, cancer, etc.). • Also explains difficulty accessing healthcare. • Less training available about LGBT needs. • Bottom line: Sexual orientation and gender identity are social determinants of health.

12. Intersection of LGBT and Veteran Identities LGBT identity Veteran status Higher risk of poor mental health and suicidal ideation and attempts; higher risk of some physical health issues. Higher prevalence of poor mental health and suicidal ideation and attempts; higher rates of gun ownership and risk of firearm suicide1; higher risk of many physical conditions *Adapted from J. Blosnich 1Miller, Barber, Young, Azrael, Mukamal & Lawler, 2012

13. LGBT Veteran Identities and Mental Health LGBT identity Veteran status • Higher prevalence of trauma (including MST for LB women and transgender Veterans), PTSD, substance abuse (including smoking), poorer mental and physical health outcomes, increased suicidal ideation and homelessness. • Blosnich, Farmer, Lee, Silenzio & Bowen, 2014; Blosnich & Silenzio, 2013; Brown & Jones, 2014; Brown & Jones, 2016; Cochran, Balsam, Flentje, Malte & Simpson, 2013; Kauth, Barrera, Denton & Latini, in press; Lehavot & Simpson, 2014; Mattocks et al., 2013; Monin, Mota, Levy, Pachankis, Pietrzak, 2017; Ray-Sannerud, Bryan, Perry, Bryan, 2015; Shipherd, Mizock, Maguen & Green, 2012

14. Homelessness among transgender Veterans • 5,135 transgender Veterans in VHA (by diagnostic codes) compared to matched sample of non-transgender Veterans:1 • 30% of transgender Veterans had experienced homelessness; 3x more likely to have been homeless than Veterans generally! • 47% of transgender Veterans had a service-connected disability vs. 42% of Veterans generally. • Sample of 6,308 transgender Veterans in VHA (by diagnostic codes):2 • Urban Veterans more likely than rural Veterans to experience housing instability. • Housing instability associated with worse health outcomes. 1Brown & Jones, 2015; 2Bukowski, Blosnich, Shipherd, Kauth, Brown, & Gordon, 2017

15. Minority Stress Theory Offers Solutions! Goal: Decrease stigma, stress and discrimination • Establish supportive policies for LGBT clients and staff. • Improve systems of care: Include routine assessment of sexual orientation and gender identity. Assess Veteran status. • Validating everyone has sexual orientation and gender identity. • Providers know risk factors are present. • Supports examination of risk and resilience in your setting.

16. Minority Stress Theory Offers Solutions! Goal: Decrease stigma, stress and discrimination • Train staff and provide resources. • Create a more welcoming environment for LGBT Veterans to overcome expectations of stigma. • Promote good patient-provider communication; help providers ask about sexual orientation, gender identity, and intersection with Veteran identity. • Offer culturally-competent and affirming treatment.

17. Do Ask! People Will Tell (If Provided Context) • General population study of 1516 LGBT & non-LGBT patients and 429 medical providers1 • 80% of providers thought patients would be offended if asked about sexual orientation. • 11% of patients reported that they might be offended. • Veterans answer these questions on state surveys • Low rates of refusing to answer gender (same as non-Veterans) • Lower rate of refusing to answer sexual orientation2 • 1 Maragh-Bass, Torain, Adler, Schneider, et al., 2017 • 2Ruben, Blosnich, Dichter, Luscri, & Shipherd, 2017

18. Birth Sex & Self-identified Gender Identity in VHA Birth Sex: “What sex was listed on your original birth certificate?” (Male, Female) SIGI: “Do you think of yourself as”: (correct answer is Veteran’s response) Training has been essential to the release of this field. Help your staff feel prepared if they are asking these questions. http://go.va.gov/SIGI

19. Explain Why You Need To Know • Possible that there may be additional homelessness resources available through LGBT community programs. • Assessing for identity and community: Sexual Orientation:“Do you think of yourself as . . .” □ Lesbian, gay, or homosexual □ Straight or heterosexual □ Bisexual □ Something else, please describe _ _ _ _ _ _ __ □ Don’t know

20. Relevant Policies in VHA • Rights and Responsibilities of VA Patients and Residents of Community Living Centers: http://www.va.gov/health/rights/patientrights.asp “You will be treated with dignity, compassion, and respect as an individual….. you will not be subject to discrimination for any reason, including for reasons of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression”

21. Relevant Policies in VHA • Rights and Responsibilities of Family Members of VA Patients and Residents of Community Living Centers: http://www.va.gov/health/rights/familyrights.asp “When a loved one is involved in support and care of a VA patient or CLC resident, VA considers a patient or CLC resident's family to include anyone related to the patient or CLC resident in any way (for example, biologically or legally) and anyone whom the patient or CLC resident considers to be family.”

22. Relevant Policies in VHA • VHA Directive 2011-024/2013-003: Providing Health Care for Transgender and Intersex Veterans: http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2863 “Veterans are treated based upon their self-identified gender. Care can include: Hormonal therapy, mental health care, preoperative evaluation, and medically necessary post-operative and long-term care following sex reassignment surgery.” VHA does not pay for nor perform Gender Confirming Surgeries.

23. Relevant Policies in VHA • VHA Directive 1340: Provision of Health Care for Veterans who Identify as Lesbian, Gay or Bisexual (2017) https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=5438 “It is VHA policy that all staff members provide clinically appropriate, comprehensive, Veteran-centered care with respect and dignity to LGB Veterans. Clinically appropriate care includes assessment of sexual health as indicated with all patients, and attention to health disparities experienced by LGB people. It is VHA policy that any attempts (formal or informal) by VA staff to convert or change a Veteran’s sexual orientation are prohibited.”

24. Creating An Affirming Environment • Assess the physical and social environment • What signs / signals in the environment communicate that LGBT people are expected? Welcome? • Pictures / images on the walls • Magazines (e.g., LGBT community magazine) • Resourcesavailable (e.g., support groups, etc.) • Greetings / comfort of staff (e.g., use preferred names and pronouns)

25. Creating An Affirming Environment in VHA Assessing Sexual Health poster LGBT awareness poster Pride month poster with the Women’s Health Program

26. LGBT Veteran Health Fact Sheets https://www.patientcare.va.gov/LGBT/VA_LGBT_Outreach.asp

27. VHA LGBT Veteran Point of Contact Program • LGBT Veteran Care Coordinator (VCC) at every facility. • Assess clinical needs for LGBT-specific services. Develop clinical services for LGBT Veterans (e.g., support groups, hormone evaluations, etc.). • Publicize community LGBT resources in VHA. • Support development of a welcoming environment. • Outreach to LGBT community organizations and providers outside VHA; share information and collaborate. • LGBT VCC locater: http://go.va.gov/LGBTVCC

28. Education, Training, and Resources • Transgender Veteran online trainings • An Introduction to Transgender Care • Transgender Mental Health Services • Transgender Health: Prescribing Cross-Sex Hormones • LGB Veteran care trainings • Do Ask, Do Tell: 5 Awkward Minutes to Better Patient Care • Do Ask, Do Tell: Assessing Sexual Health of LGBT Veterans (and Everyone Else) • Do Ask, Do Tell: LGB Veteran Health Care https://www.train.org/vha/welcome Public Health Foundation (free, CEs, must create account)

29. Clinical Consultation Programs In VHA : Two clinical consultation programs in transgender health 1) Training teams of providers in transgender care1,2 • Brief didactic on transgender care (14 modules) – 7 months. Twice per month meetings via teleconference and receive continuing education. 75 teams of nearly 600 providers trained. • New briefer format (6 modules) – 3 months. Target learners are rural VA clinicians. Content is all case-based. • 1 Kauth, et al., 2015; 2 Shipherd, et al., 2016

30. Clinical Consultation Programs In VHA : Two clinical consultation programs in transgender health 2) Nationwide transgender e-consultation1 • Case-specific consultation through the Electronic Medical Record. • Over 900 consults completed. • 1Shipherd, Kauth & Matza, 2016

31. A Few Don’ts • DON’T:Expect the Veteran to teach you about LGBT people – do your own homework! • DON’T: Assume that you know what their treatment goals are unless you’ve asked. • DON’T: Assume that because you are LGBT you understand their challenges. • NEVER:Ask “have you had THE surgery yet?” • DON’T: Ask about status of body parts unless you need to know. • DON’T: Forget to apologize when you misgender someone.

32. A Few Do’s • DO:Create a welcoming / supportive environment (debunk their expectation of discrimination). • Add your preferred pronouns to your email signature block. • Add LGBT-friendly signs to the community (especially bathrooms). • Review forms / paperwork for inclusivity.

33. Resources • VHA TRAIN Education System: https://vha.train.org/ • Kauth, M.R. & Shipherd, J.C. (Eds., 2018). Adult transgender care: An interdisciplinary approach for training mental health professionals. New York: Routledge.