Abstract
Background:
Transgender individuals are overrepresented among Veterans. However, little is known regarding their satisfaction with Veterans Administration (VA) care and unmet health needs.
Objectives:
This study examined transgender Veterans’ satisfaction with VA medical and mental health care, prevalence of delaying care, and correlates of these outcomes.
Research Design:
We used data from transgender Veterans collected in 2014 through an online, national survey.
Subjects:
In total, 298 transgender Veterans living in the United States.
Measures:
We assessed patient satisfaction with VA medical and mental health care and self-reported delays in seeking medical and mental health care in the past year. Potential correlates associated with these 4 outcomes included demographic, health, and health care variables.
Results:
Over half of the sample used VA (56%) since their military discharge. Among transgender Veterans who had used VA, 79% were satisfied with medical care and 69% with mental health care. Lower income was associated with dissatisfaction with VA medical care, and being a transgender man was associated with dissatisfaction with VA mental health care. A substantial proportion reported delays in seeking medical (46%) or mental (38%) health care in the past year (not specific to VA). Screening positive for depression and/or posttraumatic stress disorder was associated with delays in seeking both types of care.
Conclusions:
Although the majority of transgender Veterans are satisfied with VA health care, certain subgroups are less likely to be satisfied with care. Further, many report delaying accessing care, particularly those with depression and/or posttraumatic stress disorder symptoms. Adapting health care settings to better engage these vulnerable Veterans may be necessary.
Keywords: transgender, gender identity, Veteran, patient satisfaction, unmet needs
Transgender individuals experience high rates of discrimination, social and economic instability, and adverse health outcomes.1–3 They are also overrepresented in the Veteran population,4 with transgender-related diagnoses in the Veterans Administration (VA) being 5 times more prevalent than in the general population.5 In 2011, VA outlined a policy on transgender health care that provides nonsurgical medically necessary care to transgender Veterans, including hormone therapies.6 It is likely that since the VA’s announcement of this directive, use of VA by transgender Veterans has increased.7
Patient satisfaction is an important patient-centered goal that has implications for patient-provider relationships, health care utilization, and treatment outcomes. It is also a marker through which to evaluate whether VA, likely the largest provider of lesbian, gay, bisexual, and transgender health care in the world,8 is providing high-quality care to this population. Nonetheless, little is known about transgender Veterans’ satisfaction with VA care. Among Veterans overall, satisfaction with VA care tends to be fairly high. A 2007 survey of a representative sample of VA outpatients found that 72% of women and 79% of men reported very good or excellent satisfaction with VA care.9 In the general population, patients tend to be less satisfied with care if they are younger, sicker, members of racial/ethnic minority groups, and more highly educated.10,11 Similar associations are evident with respect to satisfaction with VA care.9,12 Examining transgender Veterans’ satisfaction with care and relevant correlates will help clarify whether they are similar to their nontransgender peers in their experiences of VA, or whether targeted health care interventions to improve care may be necessary.
In addition to evaluating satisfaction with health care, delays in seeking care are an important facet of the patient experience. Among nearly 28,000 transgender participants from the general US population who took part in the 2015 US Transgender Survey, 23% delayed or did not seek needed health care due to perceived discrimination.13 A recent study from the general population further demonstrated that those who felt they had to teach providers about transgender people were 4 times more likely to delay health care.14 The most frequently endorsed barriers related to seeking mental health services among transgender individuals in the general population were treatment cost, previous negative experiences, fear of treatment, and stigma concerns.15 Transgender Veterans from the community endorsed more reluctance to seek medical than mental health treatment, citing concerns about medical providers’ reactions to their gender identity or sexual orientation.4 Further evaluation of transgender Veterans’ level of unmet need and its correlates may help health care systems address these concerns and improve access to care.
The current study evaluated (1) satisfaction with VA medical and mental health care and correlates of dissatisfaction, and (2) patient-reported delays in seeking medical and mental health care, reasons reported for delaying or going without care, and correlates associated with delaying care in a national sample of transgender Veterans.
METHODS
Procedure
An online survey was used to collect the data between February and May 2014. Participants were recruited using online methods, with announcements sent to listserves, groups, and organizations serving transgender Veterans. Ads were also disseminated via Facebook using target words such as “Veteran” and “transgender.” The survey link in the ads led to an information statement that explained the purpose (eg, to “learn more about the health and life experiences of transgender Veterans”), eligibility criteria [age 18 y or older, Veteran defined as prior service in the US armed forces, identify as transgender (eg, your current gender identity is not the same as your birth sex), living in the United States], the anonymous nature of the survey, and risks and benefits. The survey took ~1 hour to complete. Participants were not compensated.
Measures
VA Use
Participants were asked if they had ever used any VA health care services since being discharged from the military (yes/no). Those who had enrolled in VA but never used it were classified as not using any services (n = 34, 11%), and those who reported lifetime VA use were asked whether they had used these services in the past year. Similarly, participants were asked if they had ever received any mental health or substance abuse treatment in the VA (yes/no).
Satisfaction With VA Health Care
Participants who had used VA were asked separately how satisfied on average they had been with medical (non–mental health) services they received, and how satisfied on average they had been with mental health or substance abuse services they received. Responses were dichotomized as satisfied (very satisfied, somewhat satisfied) or dissatisfied (neither satisfied nor dissatisfied, somewhat dissatisfied, very dissatisfied).
Veteran Delayed or Missed Care
All participants were asked if they delayed or went without medical care they thought they needed in the past 12 months. The same was asked for mental health or substance abuse services. Those who answered affirmatively were asked if they delayed needed medical or mental health care for the following reasons (not mutually exclusive): unable to afford care; transportation difficulties; unable to take time off work; disrespect or discrimination from doctors or other health care providers; or some other reason.
Demographic Variables
Veterans provided information on their birth sex and current gender identity. Those who were male at birth and currently identified as female, male-to-female, or transgender were classified as transgender women, and those who were female at birth and currently identified as male, female-to-male, or transgender were classified as transgender men. Age, race/ethnicity, income, marital status, and history of homelessness were also assessed.
Health Variables
Veterans were screened for depression, posttraumatic stress disorder (PTSD), and alcohol misuse. The 8-item Patient Health Questionnaire (PHQ-8) was used to assess the frequency of being bothered by depressive symptoms over the last 2 weeks, with a cut score of 10 used to indicate likely depression.16 The 17-item PTSD Checklist-Civilian version 4 (PCL-4) was used to assess PTSD symptoms consistent with Diagnostic and Statistical Manual of Mental Disorders-IV criteria over the past month, with a cut score of 50 used to indicate likely PTSD.17,18 Because of the high co-occurrence of depression and PTSD symptoms (r = 0.50), a composite variable was created for presence of symptoms of either depression or PTSD. The 10-item alcohol use disorders identification test (AUDIT) was used to assess past year alcohol consumption and alcohol-related consequences, with a cut score of 8 indicating likely alcohol misuse.19 General health was assessed with the first item of the 12-Item Short Form Survey, and was dichotomized with responses of fair, poor, and very poor indicative of poor health compared with responses of excellent, very good, and good.20
Health Care Variables
Participants were asked whether they were “out” about their gender identity to any health care providers (yes/no), and whether they ever “experienced verbal harassment in a medical setting” (yes/no).
Data Analysis
Descriptive information on VA utilization is provided and among those who had ever used VA health care, correlates of dissatisfaction with VA medical and mental health care at the bivariate level were evaluated using w2 tests with a predetermined a level of 0.05. Those who either never enrolled or used VA health care (n =91, 30%) or those who enrolled in VA health care but never used it (n=34, 11%) were excluded from analyses on VA dissatisfaction. The entire sample, regardless of VA use, was included in analyses regarding delaying medical and mental health care.
Multivariable regressions were used to examine associations of demographic, health, and health care characteristics with dissatisfaction with VA care and delaying care. All potential correlates were simultaneously entered into separate models for each of the 4 outcomes (dissatisfaction with VA medical care, dissatisfaction with VA mental health care, delaying medical care, delaying mental health care). Given the nonrare nature of the outcomes, we used general linear models with a log-link and Poisson variance distribution. This approach directly estimates relative risks (RRs), which would be overestimated by odds ratios when the outcome is not rare.21 Use of VA was included as a health care correlate in these models.
Although there were little missing data on demographic variables (< 5% for any variable), there was substantial missing data for depression and PTSD symptoms and alcohol misuse (~20%). As these scales were placed at the end of a long survey, this was hypothesized to be an artifact of survey layout and length and therefore missing at random. To decrease the chance of bias and increase efficiency, we used multiple imputation to create 15 complete datasets before the multivariable regression.22 The imputation equations used all variables from the analysis, including outcome variables.23 Mean values for the PHQ, PCL, and AUDIT were imputed along with any other missing values. Regression coefficients were combined according to the rules described by Little and Rubin.22 RRs and 95% confidence intervals (CIs) are reported for all potential correlates for each of the 4 outcomes. Results from the complete case analysis (available on request) were similar to those from the multiple imputation. All analyses were completed using STATA 14.
RESULTS
Overall Descriptives
A total of 316 Veterans participated in the survey. Those identifying with nonbinary terms (eg, cross-dresser, two-spirit, gender fluid, gender queer; n = 18) were excluded from this analysis due to small numbers. Among the 298 transgender Veterans, the average age was 48 (SD = 15.23), 85% were transgender women, and 89% were white. In total, 45% reported a yearly income of ≤$35,000/year and 34% had a history of having been homeless. In addition, 50% screened positive for depression, 41% for PTSD, and 58% for either depression and/or PTSD. Finally, 13% screened positive for alcohol misuse and 22% reported poor health.
Verbal harassment in health care settings was relatively common with 11% reporting harassment in VA only, 20% reporting harassment outside VA only, and 9% reporting harassment both in and outside VA. Most of the Veterans in the sample were out with respect to their transgender status to at least 1 provider (73%), though whether they shared this information with a VA provider specifically is unknown.
Over half the sample used VA health care services since discharge (56%) and of those who had, 82% used VA health care in the past year. In total, 69% of participants reported ever receiving any mental health treatment, including treatment for substance use problems; of these participants, 51% reported that their mental health or substance use treatment was in VA.
Bivariate Analyses
Dissatisfaction With VA Care
Table 1 shows the results of the bivariate analysis, with 21% being dissatisfied and 79% satisfied with VA medical care. Being a racial/ethnic minority and having an income ≤$35,000/year were each associated with greater likelihood of being dissatisfied with VA medical care.
TABLE 1.
Demographic, Health, and Health Care Characteristics of Transgender Veterans by Dissatisfaction With VA Health Care and Delaying Any Type of Care (VA and Non-VA)
| Dissatisfaction With VA Health Care* [n (%) Dissatisfied] † | Delaying Any Health Care‡ [n (%) Delayed]† | |||
|---|---|---|---|---|
| Medical Care (N = 163) | Mental Health Care (N = 114) | Medical Care (N = 278) | Mental Health Care (N = 279) | |
| Gender | ||||
| Trans women | 143 (19) | 96 (26) | 242 (44) | 242 (37) |
| Trans men | 20 (35) | 18 (56) | 36 (58) | 37 (43) |
| Age (y) | ||||
| 18–34 | 30 (30) | 24 (46) | 66 (61) | 67 (48) |
| 35–49 | 35 (17) | 29 (17) | 63 (54) | 61 (56) |
| 50–64 | 70 (20) | 45 (24) | 108 (39) | 109 (31) |
| ≥ 65 | 28 (18) | 16 (50) | 41 (27) | 42 (12) |
| Race/ethnicity | ||||
| White | 144 (17) | 101 (30) | 250 (44) | 250 (37) |
| Nonwhite | 19 (53) | 13 (38) | 28 (61) | 29 (45) |
| Married/domestic partner | ||||
| Yes | 66 (14) | 37 (27) | 120 (43) | 119 (32) |
| No | 97 (26) | 77 (32) | 158 (48) | 160 (42) |
| Income | ||||
| > $35,000 | 83 (10) | 56 (27) | 153 (38) | 152 (35) |
| ≤ $35,000 | 79 (33) | 58 (34) | 124 (55) | 126 (41) |
| Ever homeless | ||||
| No | 99 (16) | 62 (32) | 181 (35) | 182 (32) |
| Yes | 64 (28) | 52 (29) | 97 (66) | 97 (48) |
| PTSD/depression | ||||
| No | 50 (16) | 23 (22) | 91 (27) | 93 (19) |
| Yes | 86 (27) | 71 (35) | 135 (65) | 134 (54) |
| Alcohol misuse | ||||
| No | 110 (22) | 72 (25) | 182 (48) | 183 (37) |
| Yes | 22 (23) | 19 (58) | 38 (55) | 38 (50) |
| Poor health | ||||
| No | 81 (21) | 54 (24) | 154 (45) | 154 (36) |
| Yes | 49 (24) | 36 (42) | 63 (62) | 64 (47) |
| Out to providers | ||||
| No | 23 (13) | 14 (14) | 51 (35) | 50 (36) |
| Yes | 139 (22) | 100 (33) | 221 (47) | 222 (38) |
| Verbal harassment in medical setting | ||||
| No | 83 (16) | 47 (34) | 158 (37) | 160 (28) |
| Yes | 79 (25) | 66 (27) | 118 (57) | 118 (52) |
| Ever used VA | ||||
| No | 111 (49) | 111 (31) | ||
| Yes | 165 (44) | 166 (43) | ||
Bold values are significant.
Excludes those who did not use VA care (n = 113), those missing responses on VA care (n = 17), and those responding “not applicable.” Dissatisfaction with VA medical care (n = 5) “not applicable,” dissatisfaction with VA mental health care (n = 51) “not applicable,” 3 were missing.
May not add to total due to missing data.
Includes those who used and did not use VA health care. Delayed medical care (n = 20 missing), delayed mental health care (n = 19 missing).
Trans indicates transgender; VA, Veterans Administration.
For VA mental health care, 31% reported dissatisfaction and 69% reported satisfaction. Compared with transgender women, transgender men were more likely to report being dissatisfied (26% vs. 56%). Dissatisfaction with VA mental health care varied with age, with those in the youngest (18–34 y) and oldest (65 y and above) age groups most likely to report dissatisfaction. In addition, relative to those without alcohol misuse, those with alcohol misuse were more likely to report being dissatisfied (25% vs. 58%).
Delaying or Missing Care
With respect to unmet health needs, 46% reported delaying medical care and 38% reported delaying mental health care during the preceding 12 months (not VA-specific). The top reason for delaying both types of care was “unable to afford it” (reported by 43% who delayed medical care and 30% who delayed mental health care). This was followed by fear of disrespect or discrimination from health care providers (reported by 31% who delayed medical care and 25% who delayed mental health care). Being unable to take time off work (20% medical care, 22% mental health care) and transportation difficulties (19% medical care, 23% mental health care) were also commonly reported.
Delaying medical care was associated with several demographic variables, including younger age, lower income, and history of homelessness as well as with health factors including screening positive for depression and/or PTSD and reporting poor health. Finally, compared with those who did not experience verbal harassment in a medical setting, those who did were more likely to report delaying medical care (45% vs. 62%). Similar results were observed for delaying mental health care, with younger age, history of homelessness, and screening positive for depression and/or PTSD being associated with delaying care.
Multivariable Analyses
Dissatisfaction With VA Care
In the fully adjusted model for dissatisfaction with VA medical care, the only correlate that remained significant was income (Table 2). Having an income ≤$35,000/year was associated with a >3 times higher likelihood of being dissatisfied with VA medical care (RR, 3.22, 95% CI, 1.22–8.93). In the fully adjusted model for dissatisfaction with VA mental health care, gender identity was the only significant correlate. Relative to transgender women, transgender men were >3 times as likely to report dissatisfaction with VA mental health care (RR, 3.30; 95% CI, 1.00–10.95).
TABLE 2.
Associations of Demographic, Health, and Health Care Characteristics With Dissatisfaction With VA Health Care
| Dissatisfaction With VA Health Care | ||||
|---|---|---|---|---|
| Medical Care | Mental Health Care | |||
| RR | (95% CI) | RR | (95% CI) | |
| Gender* | ||||
| Transgender men | 2.21 | (0.64–7.60) | 3.30 | (1.00–10.95) |
| Age (y)† | ||||
| 35–49 | 0.68 | (0.20–2.27) | 0.27 | (0.06–1.20) |
| 50–64 | 1.07 | (0.35–3.28) | 0.83 | (0.24–2.83) |
| ≥ 65 | 0.67 | (0.15–2.96) | 1.99 | (0.54–7.39) |
| Nonwhite race/ethnicity | 1.77 | (0.71—4.45) | 0.87 | (0.26–2.88) |
| Not married or living with a partner | 1.74 | (0.70–4.36) | 1.09 | (0.44–2.73) |
| Income ≤ $35,000/year | 3.22 | (1.22–8.33) | 1.33 | (0.54–3.23) |
| History of homelessness | 1.52 | (0.68–3.38) | 0.87 | (0.38–2.02) |
| Depression/PTSD symptoms | 0.87 | (0.35–2.12) | 0.99 | (0.35–2.74) |
| Alcohol misuse | 0.87 | (0.31–2.43) | 2.21 | (0.90–5.43) |
| Poor health | 1.19 | (0.35–1.06) | 3.43 | (0.83–14.22) |
| Out to providers | 1.70 | (0.22–13.03) | 0.56 | (0.05–6.06) |
| Verbal harassment in medical setting | 1.42 | (0.62–3.29) | 0.76 | (0.32–1.82) |
Bold values are significant.
Results are from multiple imputation with M = 15 imputed datasets.
Reference group is transgender women.
Reference group is 18–34 years.
CI indicates confidence interval; RR, relative risks; VA, Veterans Administration.
Delaying or Missing Care
In the fully adjusted model on delaying medical care, the only correlate that remained significant was screening positive for depression and/or PTSD (Table 3). Compared with those without such symptoms, those with symptoms of either diagnosis were 76% more likely to report delaying medical care (RR, 1.76; 95% CI, 1.08–2.85).
TABLE 3.
Associations of Demographic, Health, and Health Care Characteristics With Delaying Health Care
| Delaying Any Health Care | ||||
|---|---|---|---|---|
| Medical Care | Mental Health Care | |||
| RR | 95% CI | RR | 95% CI | |
| Gender* | ||||
| Transgender men | 1.01 | (0.57–1.82) | 0.67 | (0.34–1.33) |
| Age (y)† | ||||
| 35–49 | 0.87 | (0.49–1.54) | 0.95 | (0.51–1.77) |
| 50–64 | 0.59 | (0.33–1.06) | 0.50 | (0.26–0.96) |
| ≥ 65 | 0.59 | (0.26–1.30) | 0.30 | (0.11–0.86) |
| Nonwhite race/ethnicity | 0.89 | (0.49–1.64) | 0.82 | (0.41–1.65) |
| Not married or living with a partner | 0.93 | (0.60–1.43) | 0.96 | (0.60–1.55) |
| Income ≤ $35,000/year | 1.14 | (0.72–1.81) | 0.93 | (0.55–1.56) |
| History of homelessness | 1.50 | (0.96–2.35) | 1.14 | (0.70–1.86) |
| Depression/PTSD symptoms | 1.76 | (1.08–2.85) | 2.40 | (1.36–4.22) |
| Alcohol misuse | 1.00 | (0.59–1.68) | 1.15 | (0.65–2.03) |
| Poor health | 1.11 | (0.49–2.54) | 0.95 | (0.39–2.31) |
| Out to providers | 0.71 | (0.36–1.40) | 0.58 | (0.28–1.19) |
| Verbal harassment in medical setting | 1.19 | (0.78–1.81) | 1.35 | (0.85–2.15) |
| Ever used VA | 0.85 | (0.56–1.30) | 1.52 | (0.93–2.48) |
Bold values are significant.
Results are from multiple imputation with M = 15 imputed datasets.
Reference group is transgender women.
Reference group is 18–34 years.
CI indicates confidence interval; RR, relative risks; VA, Veterans Administration.
Examining correlates of delaying mental health care in the fully adjusted model, older age was associated with a decreased likelihood of delaying mental health care. Compared with those 18–34 years old, those who were 65 years old and above were 70% less likely to report delaying mental health care (RR, 0.30; 95% CI, 0.11–0.86). In addition, screening positive for depression and/or PTSD was associated with a >2-fold increase in the likelihood of delaying mental health care (RR, 2.40; 95% CI, 1.36–4.22).
DISCUSSION
This study examined satisfaction with VA care, reported delays in seeking mental and medical health care, and their correlates among a national sample of transgender Veterans. Our sample of transgender Veterans was significantly economically and socially disadvantaged. Despite their vulnerability, Veterans reported a level of satisfaction with VA medical care (79%) that is similar to rates reported by a representative sample of VA outpatients (79% for men and 72% for women).9 This is an optimistic and promising finding for VA and perhaps reflects the recent advances in transgender health in VA.8 Even so, a significant proportion reported dissatisfaction and many reported delays in seeking care in the past year.
Comparisons to transgender individuals’ satisfaction with care in the civilian sector are difficult to make given lack of research and differences in settings and methodology used. Nonetheless, one informative study with 122 transgender men in the community found that 70% rated their overall quality of health care as “excellent” or “good.”24 Results from our study suggest that VA care is perceived to be as good (69% satisfied with mental health care) or better (79% satisfied with medical care). Nonetheless, we did not assess satisfaction with non-VA health care, an important question and avenue for future research.
In bivariate analyses, demographic variables including minority race/ethnicity, lower income, and younger age were significantly associated with dissatisfaction with VA medical or mental health care, as has been shown in other populations.9–12 In multivariable models, only low income remained a significant correlate of dissatisfaction with VA medical care. This finding is particularly important for transgender Veterans, given the relatively high prevalence of individuals with low incomes. In the US Transgender Survey, transgender participants reported unemployment at 3 times the rate of the general population and 20% resorted to working in the underground economy for income,13 emphasizing the degree of economic insecurity among transgender individuals. Future research that addresses why Veterans with low incomes, both generally and those who are transgender, are more dissatisfied may help VA address this issue.
Transgender men were 3 times more likely than transgender women to be dissatisfied with VA mental health care. Transgender women, who made up 85% of our sample, are more prevalent in VA than transgender men, likely because the majority of the Veteran population is male sex at birth25 and gender dysphoria is estimated to occur more frequently among natal males than natal females at a ratio of 3:1.26 Further research is needed to clarify why more transgender men than transgender women are dissatisfied with VA mental health care; it is possible that this group feels additionally stigmatized due to their extreme minority status, or that VA providers have less experience working with them. These results should, however, be interpreted cautiously due to our small sample of transgender men.
A sizeable proportion of our sample reported delaying or going without medical (46%) or mental (38%) health care that they thought they needed in the past year (not restricted to VA care). These are much higher prevalence rates than have been found with other groups of Veterans; for example, 19% of women Veterans sampled in a population-based national telephone survey reported delaying health care needs in the past year.27 These rates are also higher than those reported by transgender individuals in the community (23%).13 In our sample, the most frequently endorsed reason for delaying both medical and mental health care was affordability. Although low income was not associated with delaying care in adjusted analyses, we suspect small sample size led to the lack of statistical significance. In addition, fear of disrespect or discrimination from health care providers was the second most prevalent reason endorsed. In bivariate analyses, Veterans experiencing verbal harassment in medical settings were more likely to delay medical care than those who did not report such harassment (57% vs. 37%), though this finding did not remain statistically significant in multivariable analysis. In addition, being out to providers was not associated with delays in bivariate or multivariable analyses. We did not, however, assess patients’ perceptions of providers’ acceptance of their gender identity, which may be a better predictor of delaying care and/or satisfaction with care. Greater understanding of transgender Veterans’ experiences in health care systems, for example, at the environmental level (eg, waiting rooms) or provider level, could inform future efforts to improve care.
The most consistent correlate of delaying both medical and mental health care was screening positive for depression and/or PTSD. These findings are similar to studies with other groups of Veterans that have shown that those with depression or PTSD report greater barriers to care and unmet medical needs.28–30 It is unclear, however, what is driving this relationship: greater cognitive or psychological challenges with managing health care (from making an initial appointment to getting to the health facility), avoidance and lethargy (common symptoms of these disorders), concerns about stigma, or other possible mechanisms. In our sample, nearly 60% of Veterans screened positive for these disorders, suggesting that mental health symptoms are a common problem. Our findings are consistent with a study using VA medical records indicating that transgender Veterans were more likely than nontransgender Veterans to have depression and/or PTSD diagnoses.31 Research on transgender Veterans’ mental health needs, and ways in which mental health may interfere with accessing care, is needed.
The current study has several limitations. Use of online recruitment and data collection limits the generalizability of our findings.32 Nonetheless, in the absence of probability sample studies of transgender people or standard collection of gender identity in electronic medical records, innovative approaches that capitalize on the Internet may be necessary. Comparison of our sample to the handful of available samples of transgender Veterans show general similarities across samples. For example, among 336 transgender Veterans who served in Iraq and/or Afghanistan (identified by ICD-9 codes in VA medical records), whereas age was considerably younger (due to the study’s war zone-specific sample), distribution of gender identity (77% transgender women), race/ethnicity (72% white), and PTSD diagnoses (50%) were similar to ours.33 Similarly, in a sample of 5135 transgender Veterans identified via VA medical records, 80% were white, 30% had a history of homelessness, nearly 50% had a depression diagnosis, and 39% had a PTSD diagnosis, similar to the distribution in the current study.31
Another important limitation was use of a single item to assess patient satisfaction. For example, several different dimensions of patient satisfaction have been identified, such as access, continuity, visit coordination, courtesy, education, emotional support, physical comfort, specialist care, and others.34 Use of a single item limits our ability to determine which aspects of their care transgender Veterans are evaluating. Nonetheless, use of a single patient satisfaction item has prior precedence in the literature, where patients are asked to rate the quality of the care they received overall,9,12 and facilitates comparisons across studies.
Transgender Veterans are a marginalized population that has been very rarely studied. The National Institutes of Health recently recognized transgender individuals, along with sexual minorities, as a health population facing wide-spread disparities, stigma, and discrimination. Our online study suggests that, despite their many social and economic disadvantages, transgender Veterans reported relatively high satisfaction with their VA care. Nonetheless, it is those who may be most vulnerable—with lower income, a minority gender identity (transgender men), and depression or PTSD—who experience more dissatisfaction with care or unmet needs. Interventions that target the health care setting or engage these Veterans may be a valuable step to achieving health equity and more satisfying health care experiences.
Acknowledgments
Supported by the Denver-Seattle VA HSR&D Center of Innovation, VA Puget Sound Health Care System, and VA Boston Health Care System. K.L.: supported by a VA Career Development Award from the CSR&D Service of the VA Office of Research and Development (IK2 CX000867). J.K.: supported by the VA Puget Sound Health Services and Development Center of Innovation (COIN) for Veteran-Centered and Value Driven Care, and by a Health Services Research and Development Career Development Award (VA HSRD CDA 13-266). This research was supported by a grant from the Williams Institute Small Grants Program to K.L., T.L.S., and J.C.S. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.
Footnotes
The authors declare no conflict of interest.
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