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Patient Experiences and Provider Perspectives on Accessing Gender-Affirming Surgical Services in the Veterans Health Administration

  • Original Research: Qualitative Research
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

Background

Transgender and gender diverse (TGD) veterans have a greater prevalence of suicide morbidity and mortality than cisgender veterans. Gender-affirming surgery (GAS) has been shown to improve mental health for TGD veterans. In 2021, the Veterans Health Administration (VHA) announced the initiation of a rulemaking process to cover GAS for TGD patients.

Objective

This study explores patients’ and providers’ perspectives about access to GAS and other gender-affirming medical interventions not offered in the VHA including barriers, facilitators, and clinical and policy recommendations.

Participants

TGD patients (n = 30) and VHA providers (n = 22).

Approach

Semi-structured telephone interviews conducted from August 2019 through January 2020. Two TGD analysts used conventional and directed content analysis to code transcribed data.

Key Results

VHA policy exclusions were the most cited barrier to GAS. Additional barriers included finding information about GAS, traveling long distances to non-VHA surgeons, out-of-pocket expenses, post-surgery home care, and psychological challenges related to the procedure. Factors facilitating access included surgical care information from peers and VHA providers coordinating care with non-VHA GAS providers. Pre- and post-operative care through the VHA also facilitated receiving surgery; however, patients and providers indicated that knowledge of these services is not widespread. Respondents recommended disseminating information about GAS-related care and resources to patients and providers to help patients navigate care. Additional recommendations included expanding access to TGD mental health specialists and establishing referrals to non-VHA GAS providers through transgender care coordinators. Finally, transfeminine patients expressed the importance of facial GAS and hair removal.

Conclusions

A policy change to include GAS in the VHA medical benefits package will allow the largest integrated healthcare system in the United States to provide evidence-based GAS services to TGD patients. For robust and consistent policy implementation, the VHA must better disseminate information about VHA-provided GAS-related care to TGD patients and providers while building capacity for GAS delivery.

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Data Availability

De-identified data from this study are not available in a public archive. De-identified data from this study cannot be made available to protect participant privacy according to IRB standards.

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Acknowledgements:

This work was supported by a U.S. Department of Veterans Affairs Health Services Research & Development Career Development Award to JRB (CDA-14-408).

Author information

Authors and Affiliations

  1. Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA

    Taylor L. Boyer MPH, Hill L. Wolfe PhD, MPA & John R. Blosnich PhD, MPH

  2. Pain Research, Informatics, Multi-Morbidities, and Education Center, West Haven, CT, USA

    Hill L. Wolfe PhD, MPA

  3. Biomedical Informatics & Data Science, Yale School of Medicine, New Haven, CT, USA

    Hill L. Wolfe PhD, MPA

  4. Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA

    Alyson J. Littman PhD, MPH

  5. Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA

    Alyson J. Littman PhD, MPH

  6. Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA

    Alyson J. Littman PhD, MPH

  7. Lesbian, Gay, Bisexual, Transgender, and Queer Health Program, Veterans Health Administration, Washington, DC, USA

    Jillian C. Shipherd PhD & Michael R. Kauth PhD

  8. National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA

    Jillian C. Shipherd PhD

  9. Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA

    Jillian C. Shipherd PhD

  10. Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA

    Michael R. Kauth PhD

  11. Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA

    Michael R. Kauth PhD

  12. Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, USA

    John R. Blosnich PhD, MPH

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  1. Taylor L. Boyer MPH
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  2. Hill L. Wolfe PhD, MPA
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Correspondence to Taylor L. Boyer MPH.

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Boyer, T.L., Wolfe, H.L., Littman, A.J. et al. Patient Experiences and Provider Perspectives on Accessing Gender-Affirming Surgical Services in the Veterans Health Administration. J GEN INTERN MED 38, 3549–3557 (2023). https://doi.org/10.1007/s11606-023-08389-9

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