“You want people to listen to you”: Patient experiences of women's healthcare within the Veterans Health Administration

Abstract

Objective

To identify constructs that are critical in shaping Veterans' experiences with Veterans Health Administration (VA) women's healthcare, including any which have been underexplored or are not included in current VA surveys of patient experience.

Data Sources and Study Setting

From June 2022 to January 2023, we conducted 28 semi‐structured interviews with a diverse, national sample of Veterans who use VA women's healthcare.

Study Design

Using VA data, we divided Veteran VA‐users identified as female into four groups stratified by age (dichotomized at age 45) and race/ethnicity (non‐Hispanic White vs. all other). We enrolled Veterans continuously from each recruitment strata until thematic saturation was reached.

Data Collection/Extraction Methods

For this qualitative study, we asked Veterans about past VA healthcare experiences. Interview questions were guided by a priori domains identified from review of the literature, including trust, safety, respect, privacy, communication and discrimination. Analysis occurred concurrently with interviews, using inductive and deductive content analysis.

Principal Findings

We identified five themes influencing Veterans' experiences of VA women's healthcare: feeling valued and supported, bodily autonomy, discrimination, past military experiences and trauma, and accessible care. Each emergent theme was associated with multiple of the a priori domains we asked about in the interview guide.

Conclusions

Our findings underscore the need for a measure of patient experience tailored to VA women's healthcare. Existing patient experience measures used within VA fail to address several aspects of experience highlighted by our study, including bodily autonomy, the influence of past military experiences and trauma on healthcare, and discrimination. Understanding distinct factors that influence women and gender‐diverse Veterans' experiences with VA care is critical to advance efforts by VA to measure and improve the quality and equity of care for all Veterans.

What is known on this topic

• There is wide variation in Veterans' experiences with Veterans Health Administration (VA) women's healthcare across VA facilities.

• Experiences with VA women's healthcare inform decisions to seek or continue to use VA care, with up to 30% of women Veterans discontinuing VA care use within 3 years.

• There is not a VA women's healthcare‐specific measure of patient experience.

What this study adds

• We identified constructs salient to women's healthcare that have been underexplored/unexplored in VA surveys of patient experience: feeling valued/supported, autonomy, discrimination, past military experiences and trauma, and accessible care.

• Our findings call attention to the importance of ongoing efforts within VA to increase proficiency in women's healthcare, reduce gender‐based harassment within VA, and improve experiences of inclusion.

• Our findings suggest the importance of supporting and increasing providers' use of gender‐responsive and trauma‐informed care approaches.

1. INTRODUCTION

Given the rapidly growing number of women Veterans, ensuring comprehensive, high‐quality, equitable, patient‐centered women's healthcare is a national Veterans Health Administration (VA) priority. ¹ In VA, the majority of women's primary healthcare and basic sex‐ or gender‐specific care, such as cervical cancer screening and contraceptive care, are delivered by designated women's health primary care providers (WH‐PCPs) either within general primary care or separate women's health clinics. ² , ³ , ⁴ , ⁵ Sex‐ or gender‐specific specialty care are also increasingly available at VA, including gynecology care and women's mental healthcare. ⁶ , ⁷ Past qualitative studies suggest wide variation in women Veterans' experiences with primary care across VA facilities, depending on the organization of women's healthcare. ⁸ , ⁹ These experiences may inform women Veterans' decisions to seek or continue to use VA care. Outside VA, negative patient experiences are key contributors to decreased utilization, poor outcomes, and inequities in multiple areas of healthcare including primary care, reproductive health, and mental health. ¹⁰ , ¹¹ , ¹² , ¹³ Thus, there is a clear need for a greater understanding of women Veterans' experiences with VA healthcare.

Women Veterans using VA healthcare are increasingly diverse in terms of race/ethnicity and sexual orientation; have complex medical and mental healthcare needs; and up to 50% have a lifetime history of sexual trauma, including military sexual trauma (MST). ¹ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ Approximately 30% of women Veterans using VA healthcare identify as African American or Black, and there is a growing proportion who identify as Latina or Hispanic; thus, it is important to consider the intersection of racism and sexism in the context of women Veterans' experiences of VA care. ¹ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ For example, approximately 11% of Black or other racialized women Veterans using VA healthcare report experiences of racial discrimination by providers. ²² , ²³ , ²⁴ Additionally, women Veterans continue to report experiences of judgment, dismissal, and lack of sensitivity by VA providers across a variety of care settings, including specialty and primary care. ²² , ²⁵ , ²⁶ , ²⁷ The complexity of healthcare needs of women Veterans also means that effective patient–provider communication and care coordination are critical determinants of experiences of VA healthcare. ¹⁵ , ²² , ²⁸ , ²⁹ , ³⁰ Finally, given the high prevalence of sexual trauma among women Veterans, trust, privacy, and safety concerns are particularly salient issues and may be exacerbated in the context of VA's physical spaces where women Veterans, particularly those who are gender or sexual minorities, frequently face harassment from other Veterans. ³¹ , ³² , ³³

As part of a larger project to develop and validate a patient‐reported experience measure for women Veterans, we conducted a series of semistructured interviews with a diverse sample of women Veterans to identify constructs salient to their experiences of VA healthcare. Specifically, we sought to identify constructs that have either been underexplored or are not included in the most commonly used VA surveys of patient experience (such as the Survey of Healthcare Experiences of Patients [SHEP] and the VA Healthcare Visit Survey) but shape Veterans' experiences with VA women's healthcare. ³⁴ , ³⁵

2. METHODS

2.1. Positionality statement

The research team consists of VA researchers and clinical practitioners committed to investigating and improving the care experiences of women and gender‐diverse Veterans. Most of our research team identify as women and have conducted other qualitative work focused on women and gender‐diverse Veteran patients. All authors are users of non‐VA healthcare in the United States. None of the authors of this work are Veterans. Among the three researchers directly involved in conducting interviews and coding data, all three identify as cisgender women, one identifies as non‐White, and all three identify as queer.

2.2. Recruitment and sampling

VA administrative data were used to identify potentially eligible Veterans who were female; had received VA outpatient care, inpatient care, or non‐VA (community) care paid for by VA in the past 12 months; had a mailing address and phone number; did not have a diagnosis of dementia according to International Classification of Diseases (ICD‐10) codes; and were not deceased. Veterans were then sorted into four a priori recruitment strata based on age and race/ethnicity (Table 1). Veterans within each stratum were randomly selected, sent study information, and given an opportunity to opt‐out of further contact from study staff. Those who did not opt‐out were called up to three times to gauge their interest in the study.

TABLE 1.

Demographic categories defining recruitment strata and quoted interviews.

Participant recruitment strata	Interview participants quoted
Non‐Hispanic White, <45 years old	A13, A14, A20, A21, A29
Non‐White and/or Hispanic, <45 years old	B12, B13, B20, B21, B22, B25
Non‐Hispanic White, ≥45 years old	C13, C15, C18, C19, C22
Non‐White and/or Hispanic, ≥45 years old	D14, D16, D27, D28

Telephone screening was used to confirm Veteran self‐report of receipt of VA care within the past 12 months. Because the variable capturing sex in the VA record does not consistently distinguish birth sex from gender identity, particularly for transgender Veterans, we also screened participants to verify that they either identified as women (irrespective of birth sex) or were assigned female sex at birth (irrespective of gender identity). ⁶ Interviewers obtained consent for audio recording from Veterans at the start of interviews.

Recruitment was conducted on a rolling basis within each recruitment stratum until the analytic study team deemed that we had reached thematic saturation and adequate representation across strata.

This study was reviewed and determined to be exempt by VA Puget Sound and VA Greater Los Angeles Institutional Review Boards.

2.3. Data collection

Our team crafted the interview guide to elicit positive, negative, and otherwise memorable experiences with VA care, including asking about a priori domains of trust, safety, respect, privacy, communication, and discrimination (see Supplementary File 1), which were selected based on a literature review of women Veterans' healthcare and the broader literature on patient‐reported experience. ²² , ³⁶ , ³⁷ , ³⁸ Specific probes, grounded in verbatim participant language and informed by the a priori domains, were used to solicit rich, descriptive data. ³⁹

Two trained qualitative interviewers conducted semistructured telephone interviews from June 2022 to January 2023. Interviews were audio‐recorded and professionally transcribed. Following the interview, each participant completed a brief demographic questionnaire to provide sample descriptors.

2.4. Analysis

Analysis occurred concurrently with interviews. We ensured transcripts matched the audio recording before coding. We analyzed transcripts using inductive and deductive content analysis. ⁴⁰ , ⁴¹ Using ATLAS.ti version 8, we categorized the data, utilizing a combination of deductive codes based on interview guide questions and a priori domains alongside inductive coding to identify emergent concepts. Two analysts coded all transcripts independently after co‐coding four transcripts to reach consensus over the initial codebook and coding style. The coders took analytic memos, noting observations, questions, and assumptions while coding. Coders met weekly with the larger qualitative team to discuss interviewer reflections, review analysis memos, refine the codebook and reach consensus over code meaning, discuss findings, and assess when thematic saturation was achieved to ensure trustworthiness and credibility of findings. ⁴² We determined saturation when we reached a deep understanding of identified themes, finding no new concepts arising from the data, and no new codes being created. ⁴³ We maintained detailed records of analytic and reflexive discussions to establish an audit trail for dependability and confirmability. ⁴² , ⁴⁴

3. RESULTS

We completed 28 interviews, with an average duration of 42 min. Demographic characteristics of the sample are summarized in Table 2; a list of all quoted interviewees, organized by the characteristics defining our recruitment strata, are shown in Table 1. We identified five themes illustrating key factors that influence women Veterans' experiences of VA healthcare (Table 3). Themes included (1) feeling valued and supported, (2) bodily autonomy, (3) discrimination, (4) past military experiences and trauma, and (5) accessible care. Several of our a priori domains were described by participants as influenced by or associated with multiple of these emergent themes, and discrimination, as an a priori domain, became a theme because of its salience to our interviewees, most often arising before we asked directly about it (Figure 1). When we reference an a priori domain such as trust, this indicates that the participant used that phrasing either when asked about experience with care or when replying to interview questions about trust. These themes are derived from interpersonal experiences Veterans had within healthcare settings and systemic factors stemming from VA policies.

TABLE 2.

Self‐reported characteristics of interview participants.

Veteran characteristics	Total, N = 28
Interview length (min), average (SD)	42	(11.6)
Hispanic/Latina ethnicity, n (%)	6	(21%)
Race, n (%)
Black	8	(28%)
White	15	(53%)
White and Native American/Alaska Native	2	(7%)
White and Asian/Pacific Islander	1	(4%)
White and Brazilian	1	(4%)
Only Latina	1	(4%)
Age, n (%)
≤34	6	(21%)
35–49	13	(46%)
50–64	7	(25%)
≥65	2	(7%)
Gender identity, n (%)
Woman	27	(96%)
Nonbinary	1	(4%)
Sexual orientation, n (%)
Straight or heterosexual	21	(75%)
Lesbian or homosexual	2	(7%)
Bisexual	2	(7%)
Asexual	2	(7%)
Prefer to self‐describe	1	(7%)
Ever deployed, n (%)	13	(46%)
VA care ever received, n (%)
Primary care	27	(96%)
Mental health care	23	(82%)
Reproductive health care	19	(68%)
Specialty care	25	(89%)

TABLE 3.

Definitions of identified themes regarding women Veterans' experiences.

Theme	Definition
Feeling valued and supported	Feeling listened to and taken seriously by providers when bringing up health concerns, supportive interactions with providers including informational support (medical advice/education, able to explain treatments clearly, etc.) and emotional support (feeling like your provider cares about you), and being welcome (feeling welcome at VA, feeling like VA staff and providers want to treat you and value you)
Bodily autonomy	Being able to have control of healthcare and healthcare interactions/treatment decisions (exams, medication, procedures) or not (feeling coerced or pressured by a provider to do something they do not want to), being treated by an expert on your own body
Discrimination	Being seen as a “real Veteran” as a woman by VA staff and providers, Interpersonal discrimination (experiencing bias from clinicians like sexism, racism, queerphobia, ableism, sizeism, and harassment/bias from other Veterans)
Past military experiences and trauma	How past military experiences or trauma impacted their perceptions and experiences of VA care, including harmful experiences with military care, experiences of MST impacting trust in VA as an extension of the military, and past experiences of violence impacting wanting to access care at all
Accessible care	Care that is accessible to the Veteran and convenient, including ease of scheduling appointments or not, ability to navigate bureaucratic systems with VA staff help or not, and ability to contact care team or not

Abbreviations: MST, military sexual trauma; VA, Veterans Health Administration.

FIGURE 1.

Identified themes regarding women veterans' experiences with Veterans Health Administration healthcare shaped by interpersonal and system factors. ^aPrivacy was not found to be consistently related to any themes and did not independently resonate with interviewees apart from connections with safety. ^bOriginally an a priori domain but was identified as a theme.

3.1. Feeling valued and supported

Our participants often discussed whether they were listened to and believed, were supported by their healthcare team, and had a sense of belonging at VA. These factors influenced whether participants felt valued and supported during healthcare experiences.

3.1.1. Being listened to

One of the most salient themes to emerge from our interviews was the importance of being listened to during healthcare encounters, including the value participants placed on feeling heard, being believed, and having their concerns taken seriously.

She listened very well, first of all, which is huge. And really understood what I was saying, and where it was hurting. She'd try this, try this, to confirm what I was saying. C18

Such experiences made Veterans feel respected and built a sense of safety. Participants with past histories of sexual trauma particularly stressed the importance of listening (“as a rape survivor it's important that I believe that those people are listening to me” C19). When participants were not listened to, it undermined their trust in providers and sense of safety.

I didn't trust him because he wasn't listening. He kind of just blew me off, like I don't know what I'm talking about. A20

In addition to not feeling heard about medical concerns, participants often associated providers not listening to them with feeling rushed during appointments and further undermined feeling safe.

Sometimes I just feel like they try to get people in and out as quickly as possible. They don't listen to you… how am I supposed to feel safe when you don't even make sure that I'm good? B25

3.1.2. Supportive provider interactions

Participants appreciated providers who offered helpful medical advice, health education, and clear explanations of medical diagnoses, tests, and procedures. This reinforced trust in their medical team.

The doctor was trying to help me and give me recommendations of ways to be preventive. Managing stress, diet, and ideas of how to kind of manage the headaches, and if they were migraines. The doctor gave me a really good informational piece that I could read over, and it really explained the difference between a migraine headache and just a regular headache. D16

Some participants recounted times when there was a lack of informational support from providers such as one Veteran who did not receive adequate explanations about her hysterectomy before having the surgery:

…just explaining, ok, this is what we're going to keep, this is what's going to be taken out, this we're going to take out, this is for this, so if you don't have this, you won't be able to do this or do that…I did not get a good explanation. D14

Many participants described feeling safe and supported when they perceived their healthcare team to be knowledgeable (“they know what they're talking about” D28), whereas trust and feelings of safety were undermined when providers came across as uninformed or inexperienced:

This nurse had no clue who I was, my medical records, or anything. Nothing. So, she decides to do her exam. In her exam findings she said, you're good to go, your ovaries and stuff look good. But all you did was feel my stomach, and you didn't look. If you had looked at my file you would have known I had a hysterectomy at 30, so I don't have ovaries. D27

Participants felt respected and supported when providers were open and transparent about treatment options (“they'll be honest with me on what we can do, what our options are.” C22) and when providers offered to help them obtain a second opinion or refer them to more specialized providers.

I was really nervous about getting the surgery as it was, and they were just forthcoming and honest, and told me, like we would rather refer you out for this advanced kind of surgery instead of doing it ourselves. So I thought that was excellent. A13

Finally, Veterans described the importance of emotional support from healthcare staff, particularly in vulnerable situations, such as during hospital stays or when isolating due to a COVID infection.

The nurses there [in the hospital] …would come in and they would bring in little, tiny mints that I could suck on, I mean, just little things. The little things really make a difference. They'd come in and they were all smiles, and they'd raise my spirits, and tried to keep my mental health going as well as my physical health. C13

3.1.3. Feeling welcome

Veterans felt a sense of belonging at the VA when they encountered providers and staff who were “friendly,” “welcoming,” “hospitable,” or had “good bedside manner.” Small gestures, such as greeting the Veteran or asking about their family, made them feel included and respected.

You knew they cared. It wasn't like we were an assembly line, type of thing. They came in, introduced themselves, we're going to take care of you. Good bedside manner, that type of thing. C15

On the other hand, experiences of disrespect—such as providers or staff who were “rude” or “impersonal”—undermined this sense of belonging.

[W]hen you're a patient you want to feel like you're welcome and want to feel like they appreciate you coming here. It's just her attitude overall … she's just more on the rude side. So if you come in and say hi, she'll greet you, but it's not a welcoming greeting. B20

Participants also stressed the importance of relationships built with healthcare teams over time. Provider continuity helped foster a sense of belonging within the VA (“It just feels like family, it's always the same people” D16), while frequent provider turnover resulted in Veterans feeling disconnected from their VA care.

I never saw the same person. So it was really hard to, I don't know, build a rapport with any of the providers. A14

3.2. Bodily autonomy

Bodily autonomy emerged as a powerful and salient aspect of Veterans' experiences with VA healthcare. Consent, which they often framed as having “control” of healthcare, was crucial for those with a history of sexual trauma to build a sense of safety and respect during exams.

It was a gynecology appointment. I've had sexual trauma in the past. He was very, very calm and patient with me. He walked me through everything during the appointment… He let me say stop at any time that I wanted to. I felt like I had control over the appointment… And he explained everything that was happening to me before he did it. A20

Providers also supported patients' sense of bodily autonomy by seeking Veteran input during treatment decisions and trusting them as experts on their own body.

Just this past week at my gynecologist. When I asked her if I can get my Implanon removed, she was like, of course, this is what I'm here for. And then when I said I wanted to get my tubes tied, she was like, it's your decision, of course you can, you're a grown woman. Why couldn't you? And I was like, oh ok. Because I thought there was going to be pushback. I thought they were going to say no or something like that… She respected what I wanted. She listened to what I wanted. B25

Several Veterans also described feeling pressured or coerced by providers during healthcare interactions, which undermined trust and safety. For example, being pressured to allow medical trainees to participate in their care, to take medications, or to undergo unwanted treatments.

I think he kept trying to push a lot of medication on me. Which, I understand that's part of the treatment and stuff, but I didn't like the way I was feeling when I was on the medication… I mentioned that to him, and it almost seemed like he wasn't listening to me. He wasn't trying to find a different solution besides the medication or providing me outlets. B22

3.3. Discrimination

Discrimination when receiving VA healthcare, though not reported by all Veterans, was a consistent theme. Veterans frequently mentioned these experiences, usually raising these issues before being asked directly about discrimination.

Many Veterans noted that, as women, they were not seen as “real” Veterans. Some cited instances of staff assuming they must be a Veteran's spouse or caretaker rather than a patient. Another Veteran described being ignored by a provider because she was not seen as a Veteran:

He didn't see me as a soldier or as a Veteran, or anything, in the waiting room. He overlooked me multiple times. A29

Veterans also described experiencing other forms of interpersonal discrimination from clinicians, including racism, queerphobia, and ableism. Several Veterans described discriminatory experiences based on their body size.

I just felt she was a little rude. She was like, it sounded like she was making snide comments when we took my weight and my blood pressure. She was like, oh, a little heavy there. B13

Veterans also recounted experiences of gender discrimination and harassment from other Veterans in VA. Experiencing discrimination and harassment can undermine Veterans' trust and sense of safety when seeking VA healthcare:

They would say things to women coming into the VA, or follow them around, and stuff like that… this was important because a lot of women have this same complaint, and that's the reason they don't seek services at the VA. B12

Moreover, as one Veteran noted, having multiple marginalized identities adds to the systemic barriers that Veterans face.

it's one thing being a woman in the VA system, but when you're a blind woman you realize that's even rarer. And they just don't know what to do with you. C19

3.4. Past military experiences and trauma

Some Veterans described how past military experiences or trauma impacted their perceptions and experiences of VA care. One Veteran discussed a healthcare experience during her military service, which later impacted her desire to seek care at VA.

This older doctor… he was very mean, and it was uncomfortable for me. I was 21 years old and probably only ever had 2 pap smears in my entire life, and for an old man to basically tell me to lay down and put my feet in the stirrups, I was in Basic, so his job was to treat me like shit, excuse my language…. I think I've always been kind of skeptical because, from going from like the military providers to the VA providers, I figured they would be just like the military doctors were, but they're not. It took me some time, like I had some PTSD and stuff that I had to work through. A13

Non‐healthcare‐related traumatic experiences while serving in the military, such as MST, also discouraged some Veterans from initially engaging with care at VA and shaped their specific healthcare needs. For example, some Veterans shared their preference for women providers.

I was brutally raped while I was in the military. So, I just wanted nothing to do with it ever again in my entire life. So, starting with [VA] healthcare was a concession I made just because of poverty. And it's something I'm really glad I did… Right away I had a woman doctor, sometimes there's Nurse Practitioners and stuff, but I've always been able to find female care, and that's meant so much to me. Because I am so uncomfortable around men in positions of power. A21

Finally, not all traumatic healthcare experiences recounted in the interviews predated our participants' time as VA patients. One participant described being sexually assaulted at a VA hospital, after which they recalled “trying to stay away” (C18) from VA healthcare and moving to another state to avoid returning to the same VA hospital.

3.5. Accessible care

Veterans stressed the importance of care being accessible and convenient. Some participants had positive experiences accessing care, noting that scheduling appointments was easy or that VA staff went out of their way to help them navigate processes (“they took care of everything. So that was wonderful.” C13).

Many participants described encountering frequent barriers to care, such as being unable to contact their healthcare team (“I could never get in touch with my doctor” B21), delays or difficulties scheduling appointments (“it's very hard to get an appointment with this VA here” B20), or having to navigate complex bureaucratic processes alone (“you have to just be persistent” A14).

3.6. Interrelation of domains and themes

We designed our interview guide around a priori domains of trust, safety, respect, privacy, communication, and discrimination; however, during analysis, we found most of the domains to be interrelated concepts and our themes arose directly from the ways that participants' described and conceptualized their experiences (Figure 1). For example, the extent to which Veterans' bodily autonomy (an emergent theme) was supported during healthcare experiences influenced their trust in their provider and sense of safety receiving care at VA (both a priori domains). The a priori domain discrimination was an exception; it emerged as a salient theme affecting participants' experiences in its own right. In addition, the a priori domain of privacy was rarely considered a salient contributor to healthcare experiences by our participants, even when asked directly about it. While we identified five distinct themes, it is important to note that they do not operate independently. For example, feeling valued and supported (an emergent theme) was an important construct in its own right as well, contributing in important ways to whether healthcare interactions were supportive of bodily autonomy.

4. DISCUSSION

In this study, we sought to identify constructs salient to the experiences of women Veterans who use VA healthcare to inform development of a patient‐reported experience measure specific to VA women's healthcare. We identified five themes influencing participants' experiences of VA women's healthcare: feeling valued and supported, bodily autonomy, discrimination, past military experiences and trauma, and accessible care. Several of our identified themes—including the importance of accessible care ²⁷ , ³⁷ , ⁴⁵ , ⁴⁶ ; being listened to ²⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ ; and being supported with adequate, understandable information ²² , ³⁷ , ⁴⁶ , ⁵⁰ —are consistent with a robust body of literature on VA patient experiences broadly and are measured by existing healthcare experience surveys such SHEP. On the other hand, some of the other emergent themes—including the importance of bodily autonomy, the influence of past military and traumatic experiences, and discrimination—may be particularly relevant to women Veterans within the unique context of VA healthcare, suggesting a tailored patient experience measure could be particularly useful within this population. From our data, we cannot determine whether our finding about privacy not being salient to participants is because of VA system improvements or because it was not as relevant compared with the other questions we asked. There are ongoing questions about the importance of privacy for women's healthcare, especially in relationship to reproductive healthcare and the current legal abortion landscape, a topic that should be further explored in future research. ⁵¹ , ⁵² , ⁵³

As with prior studies of women Veterans' experiences in VA, our findings highlight the importance of gender‐responsive and trauma‐informed care approaches for women Veterans. ⁵⁴ , ⁵⁵ Trauma‐informed care involves healthcare providers and systems working to create safe and trusted environments and interactions for patients with sexual or other trauma histories. Consistent with other studies of women utilizing VA care, many participants disclosed histories of sexual assault, including MST, and other gender‐based violence. ³³ , ⁵⁶ , ⁵⁷ These participants highlighted their desire for care that is sensitive to these histories, and which actively affirms their bodily autonomy, through communication practices like gaining active consent throughout healthcare procedures and engaging in shared decision‐making. Other participants discussed how harassment at VA facilities, past trauma within the military, or past traumatic healthcare experiences led them or others to avoid VA care altogether. Past gender‐based violence and harassment may be particularly salient to perceptions of VA because women and gender‐diverse Veterans remain minorities within the VA, a demographic imbalance that can reflect and remind them of environments when they have been unsafe in the past.

VA continues to engage in efforts to combat sexual harassment and support the visibility of women as Veterans through a variety of campaigns and trainings. ⁵⁸ , ⁵⁹ These efforts are beginning to show promising results with reported decreases in gender‐based harassment. ⁶⁰ Other national efforts are seeking to improve the quality of care for other minoritized groups, such as the work of VA Pride to enhance the use and completeness of new gender identity and sexual orientation fields in the VA electronic health record. ⁶¹ Our work also highlights new areas deserving of research, evaluation, and quality improvement efforts. Several participants described experiences of healthcare discrimination based on their body size (i.e., fatphobia or anti‐fat bias), including snide remarks and dismissal of their symptoms and concerns. Anti‐fat bias among medical professionals is well documented outside of the VA, as are interventions that attempt to reduce this bias. ⁶² , ⁶³ , ⁶⁴ , ⁶⁵ , ⁶⁶ , ⁶⁷ , ⁶⁸ Veterans' experiences of anti‐fat bias within VA have not been well explored, although studies suggest women Veterans with body mass indexes (BMIs) of 25 or more receive similar or better quality care for some services (e.g., preventative care) compared with women Veterans with BMIs less than 25. ⁶⁹ , ⁷⁰ , ⁷¹

While our data provide information on Veterans' experiences of VA care broadly, one limitation of these data is that our interviews do not offer detailed insight into specific types of care (e.g., reproductive health, specialty care). Moreover, we asked participants to share any relevant care experiences that they wanted to speak about, which could include experiences that happened in the distant past. Our participants' experiences therefore may or may not be representative of women Veterans' most recent VA healthcare experiences, and we are not able to evaluate whether VA efforts to address known problems (e.g., sexual harassment) have improved patient experiences. We did not engage in member checking with participants. In addition, all but one participant in our study identified as a woman (one participant identified as nonbinary), meaning our results may or may not adequately capture experiences of transgender men Veterans, nonbinary Veterans, and other gender‐diverse Veterans who may need to access VA women's healthcare services. Finally, we acknowledge that although our team is experienced with research about women Veterans, none of us are Veterans and we do not access VA care ourselves, which may influence our interpretations of these data.

5. CONCLUSION

Our findings underscore the need for a measure of patient experience tailored to VA women's healthcare. Existing patient experience measures used within VA, including SHEP and the brief VA Healthcare Visit Survey fielded by the VA Patient Experience Office, ³⁵ fail to address several aspects of experience highlighted by our study (such as bodily autonomy, the influence of past military experiences and trauma on healthcare, and discrimination). A tailored patient experience measure would allow VA to better characterize current variations in healthcare experience among women and gender‐diverse Veterans, identify potential disparities in experience, and allow VA to evaluate the impact of efforts to improve care for women and gender‐diverse Veterans over time. Our findings highlight the importance of ongoing efforts within VA to increase the availability of providers proficient in women's healthcare, reduce gender‐based harassment within VA, and improve experiences of inclusion. Our findings suggest efforts to increase VA providers' use of gender‐responsive and trauma‐informed care approaches may be warranted. Finally, several participants described experiencing anti‐fat bias within VA. This is an understudied area of patient experience within VA, suggesting more research and evaluation are needed. Understanding the distinct factors that influence women and gender‐diverse Veterans' experiences with VA care is critical to advance efforts by VA to measure and improve the quality and equity of care for all Veterans.

CONFLICT OF INTEREST STATEMENT

The authors report no conflicts of interest.

Supporting information

Data S1. Supporting information.

Mog AC, Benson SK, Sriskantharajah V, et al. “You want people to listen to you”: Patient experiences of women's healthcare within the Veterans Health Administration. Health Serv Res. 2024;59(6):e14324. doi: 10.1111/1475-6773.14324