Contextual Frameworks for Addressing Risk and Fostering Resilience Among Sexual and Gender Minority Veterans

  • Rebecca GitlinEmail author
  • Michael R. Kauth


Several hundred thousand sexual and gender minority (SGM) veterans are estimated to seek out healthcare services through the Veterans Health Administration (VHA) each year, though the exact number is unknown. SGM veterans present with many healthcare concerns that are similar to the veteran population at large. They also experience unique risk and resilience factors affecting healthcare and treatment outcomes. Mental health professionals play a crucial role in addressing risk and resilience factors of SGM veterans, whether as solo practitioners, as members of specialty mental health programs, or within integrated care teams in VHA or civilian healthcare systems. Utilizing a minority stress theoretical lens, (Meyer I, Psychological Bulletin. 129:674–697, 2003) this chapter offers mental health professionals a framework through which to identify and address contributors to distress and foster resilience in SGM veterans. This chapter will further outline strategies for developing a welcoming clinical environment for SGM veterans and providing patient-centered, culturally informed, and affirming mental health treatment. Finally, this chapter will review considerations for transgender veterans seeking transition-related care.


Veterans Sexual minorities Transgender LGBTQ Sexual identity Gender identity Mental health Clinical care Health disparities Strength-based treatment Affirming treatment 


  1. 1.
    Meyer I. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674–97.CrossRefGoogle Scholar
  2. 2.
    Kauth MR, Shipherd JC, editors. Adult transgender care: an interdisciplinary approach for training mental health professionals. New York: Routledge; 2018.Google Scholar
  3. 3.
    Gates GJ. How many people are lesbian, gay, bisexual, and transgender? Los Angeles: Williams Institute, UCLA School of Law; 2011.Google Scholar
  4. 4.
    Gates GJ, Herman JL. Transgender Military Service in the United States. Los Angeles: Williams Institute, UCLA School of Law; 2014.Google Scholar
  5. 5.
    Gates GJ. Lesbian, gay, and bisexual men and women in the US military: updated estimates. Los Angeles: Williams Institute, UCLA School of Law; 2010.Google Scholar
  6. 6.
    Hoover KW, Tao KL, Peters PJ. Nationally representative prevalence estimates of gay, bisexual, and other men who have sex with men who have served in the US military. PLoS One. 2017;12(8):E01822222.CrossRefGoogle Scholar
  7. 7.
    Brown GR. Transsexuals in the military: flight into hypermasculinity. Arch Sex Behav. 1988;17(6):527–37.CrossRefGoogle Scholar
  8. 8.
    Kauth MR, Shipherd JC. Transforming a system: improving patient-centered care for sexual and gender minority veterans. LGBT Health. 2016;3(3):177–9.CrossRefGoogle Scholar
  9. 9.
    National LGBT Health Education Center. Glossary of LGBT terms for health care teams. Updated March 2016. Accessed 14 Nov 2017.
  10. 10.
    Bostwick WB, Boyd CJ, Hughes TL, McCabe SE. Dimensions of sexual orientation and the prevalence of mood and anxiety disorders in the United States. Am J Public Health. 2010;100(3):468–75.CrossRefGoogle Scholar
  11. 11.
    McCabe SE, Hughes TL, Bostwick WB, West BT, Boyd CJ. Sexual orientation, substance use behaviors and substance dependence in the United States. Addiction. 2009;104(8):1333–45.CrossRefGoogle Scholar
  12. 12.
    Department of Veterans Affairs. Provision of health care for veterans who identify as lesbian, gay or bisexual (VHA Directive 1340). Accessed 14 Oct 2017.
  13. 13.
    Practitioners Disagree on NHS Recommendation to Ask Patients About Sexual Orientation. Psychiatry advisor Published 30 Jan 2018. Accessed 8 April 2018.
  14. 14.
    Fletcher JB, Reback CJ. Mental health disorders among homeless, substance-dependent men who have sex with men. Drug Alcohol Rev. 2017;36(4):555–9.CrossRefGoogle Scholar
  15. 15.
    Balsam KF, Rothblum ED, Beauchaine TP. Victimization over the life span: a comparison of lesbian, gay, bisexual, and heterosexual siblings. J Consult Clin Psychol. 2005;73(3):477–87.CrossRefGoogle Scholar
  16. 16.
    Testa RJ, Habarth J, Peta J, Balsam K, Bockting W. Development of the gender minority stress and resilience measure. Psychol Sex Orientat Gend Divers. 2015;2(1):65–77.CrossRefGoogle Scholar
  17. 17.
    Crenshaw K. Demarginalizing the intersection of race and sex: a black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. Univ Chic Leg Forum. 1989;1989(1):139–67.Google Scholar
  18. 18.
    Cochran BN, Balsam KF, Flentje A, Malte CA, Simpson T. Mental health characteristics of sexual minority veterans. J Homosex. 2013;60:419–35.CrossRefGoogle Scholar
  19. 19.
    Blosnich J, Foynes MM, Shipherd JC. Health disparities among sexual minority women. J Women’s Health. 2013;22(7):631–6.CrossRefGoogle Scholar
  20. 20.
    Lehavot K, Williams EC, Millard SP, Bradley KA, Simpson TL. Association of alcohol misuse with sexual identity and sexual behavior in women veterans. Subst Use Misuse. 2016;51(2):216–29.CrossRefGoogle Scholar
  21. 21.
    Lehavot K, Simpson TL. Trauma, posttraumatic stress disorder, and depression among sexual minority and heterosexual women veterans. J Couns Psychol. 2014;61(3):392–403.CrossRefGoogle Scholar
  22. 22.
    Mattocks KM, Sadler A, Yano EM, et al. Sexual victimization, health status, and VA healthcare utilization among lesbian and bisexual OEF/OIF veterans. J Gen Intern Med. 2013;28(Suppl 2):S604–8.CrossRefGoogle Scholar
  23. 23.
    Brown GR, Jones KT. Mental health and medical health disparities in 5135 transgender veterans receiving healthcare in the veterans health administration: a case-control study. LGBT Health. 2016;3(2):122–31.CrossRefGoogle Scholar
  24. 24.
    Blosnich JR, Brown GR, Shipherd JC, Kauth M, Piegari RI, Bossarte RM. Prevalence of gender identity disorder and suicide risk among transgender veterans utilizing veterans health administration care. Am J Public Health. 2013;103(10):e27–32.CrossRefGoogle Scholar
  25. 25.
    Harrison-Quintana J, Herman JL. Still serving in silence: transgender service members and veterans in the National Transgender Discrimination Survey. LGBTQ Policy J. 2012;13:1–13.Google Scholar
  26. 26.
    Hatzenbuehler ML, Keyes KM, Hasin DS. State-level policies and psychiatric morbidity in lesbian, gay, and bisexual populations. Am J Public Health. 2009;99(12):2275–81.CrossRefGoogle Scholar
  27. 27.
    Hatzenbuehler ML, McLaughlin KA, Keyes KM, Hasin DS. (2010). The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: a prospective study. Am J Public Health. 2010;100(3):452–9. Scholar
  28. 28.
    Blosnich JR, Marsiglio MC, Gao S, et al. Mental health of transgender veterans in US states with and without discrimination and hate crime legal protection. Am J Public Health. 2016;106(3):534–40.CrossRefGoogle Scholar
  29. 29.
    Department of Veterans Affairs. Providing health care for transgender and intersex veterans (VHA Directive 2013–003). Retrieved from Accessed 14 Oct 2017.
  30. 30.
    Institute of Medicine. The health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding. Washington, DC: The National Academies Press; 2011.Google Scholar
  31. 31.
    James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The report of the 2015 U.S. transgender survey. Washington, DC: National Center for Transgender Equality; 2016.Google Scholar
  32. 32.
    Sherman MD, Kauth MR, Ridener L, Shipherd JC, Bratkovich K, Beaulieu G. An empirical investigation of challenges and recommendations for welcoming sexual and gender minority veterans into VA care. Prof Psychol Res Pract. 2014;45(6):433–42. Scholar
  33. 33.
    Sherman MD, Kauth MR, Shipherd JC, Street RL. Communication between VA providers and sexual and gender minority veterans: a pilot study. Psychol Serv. 2014;11(2):235–42. Scholar
  34. 34.
    Johnson L, Shipherd J, Walton HW. The psychologist’s role in transgender-specific care with U.S. veterans. Psychol Serv. 2016;13(1):69–76.CrossRefGoogle Scholar
  35. 35.
    Simpson TL, Balsam KF, Cochran BN, Lehavot K, Gold SD. Veterans administration health care utilization among sexual minority veterans. Psychol Serv. 2013;10(2):223–32.CrossRefGoogle Scholar
  36. 36.
    Kauth MR, Barrera TL, Latini DM. Lesbian, gay, and transgender veterans’ experiences in the veterans health administration: positive signs and room for improvement. Psychol Serv. 2018;01:25.Google Scholar
  37. 37.
    Fredriksen-Goldsen KI. The future of LGBT+ aging: a blueprint for action in services, policies, and research. J Am Soc Aging. 2016;40(2):6–15.Google Scholar
  38. 38.
    Monin JK, Mota N, Levy B, Pachankis J, Pietrzak RH. Older age associated with mental health resiliency in sexual minority US veterans. Am J Geriatr Psychiatry. 2017;25(1):81–90.CrossRefGoogle Scholar
  39. 39.
    Hoy-Ellis CP, Shiu C, Sullivan KM, Kim HJ, Sturges AM, Fredriksen-Goldsen KI. Prior military service, identity stigma, and mental health among transgender older adults. The Gerontologist. 2017;57(suppl 1):S63–71. Scholar
  40. 40.
    Brown GR, Jones KT. Racial health disparities in a cohort of 5,135 transgender veterans. J Racial Ethn Health Disparities. 2014;1:257–66.CrossRefGoogle Scholar
  41. 41.
    Balsam KF, Molina Y, Blayney JA, Dillworth T, Zimmerman L, Kaysen D. Racial/ethnic differences in identity and mental health outcomes among young sexual minority women. Cult Divers Ethn Minor Psychol. 2015;21(3):380–90.CrossRefGoogle Scholar
  42. 42.
    Spoont MR, Sayer NA, Kehle-Forbes SM, Meis LA, Nelson DB. A prospective study of racial and ethnic variation in VA psychotherapy services for PTSD. Psychiatr Serv. 2017;68(3):231–7.CrossRefGoogle Scholar
  43. 43.
    Dovidio JF, Fiske ST. Under the radar: how unexamined biases in decision-making processes in clinical interactions can contribute to health care disparities. Am J Public Health. 2012;102(5):945–52.CrossRefGoogle Scholar
  44. 44.
    Chang SC, Singh AA. Affirming psychological practice with transgender and gender nonconforming people of color. Psychol Sex Orientat Gend Divers. 2016;3(2):140–7.CrossRefGoogle Scholar
  45. 45.
    Zimmerman L, Darnell DA, Rhew IC, Lee CM, Kaysen D. Resilience in community: a social ecological development model for young adult sexual minority women. Am J Community Psychol. 2015;55:179–90.CrossRefGoogle Scholar
  46. 46.
    Kauth MR, Barrera TL, Denton FN, Latini DM. Health differences among lesbian, gay, and transgender veterans by rural/small town and suburban/urban setting. LGBT Health. 2017;4(3):194–201.CrossRefGoogle Scholar
  47. 47.
    Bukowski LA, Blosnich J, Shipherd JC, Kauth MR, Brown GR, Gordon AJ. Exploring rural disparities in medical diagnoses among veterans with transgender-related diagnoses utilizing veterans health administration care. Med Care. 2017;55(9):S97–S103.CrossRefGoogle Scholar
  48. 48.
    Van Gilder BJ. Coping with sexual identity stigma in the U.S. military: an examination of identity management practices prior to and after the repeal of “Don’t Ask, Don’t Tell”. Identity. 2017;17(3):156–75.CrossRefGoogle Scholar
  49. 49.
    Chen JA, Granato H, Shipherd JC, Simpson T, Lehavot K. A qualitative analysis of transgender veterans’ lived experiences. Psychol Sex Orientat Gend Divers. 2017;4(1):63–74.CrossRefGoogle Scholar
  50. 50.
    Colpitts E, Gahagan J. The utility of resilience as a conceptual framework for understanding and measuring LGBTQ health. Int J Equity Health. 2016;15(1):60.CrossRefGoogle Scholar
  51. 51.
    Rostosky SS, Riggle EDB. Same-sex couple relationship strengths: a review and synthesis of the empirical literature (2000-2016). Psychol Sex Orientat Gend Divers. 2017;4(3):1–13.Google Scholar
  52. 52.
    Maragh-Bass AC, Torain M, Adler R, et al. Is it okay to ask: transgender patient perspectives on sexual orientation and gender identity collection in healthcare. Acad Emerg Med. 2017;24(6):655–67.CrossRefGoogle Scholar
  53. 53.
    Centers for Disease Control and Prevention. A guide to taking a sexual history. Accessed at 2011.
  54. 54.
    Hays PA. Addressing cultural complexities in practice: assessment, diagnosis, and therapy. 3rd ed. Washington, DC: American Psychological Association; 2016.CrossRefGoogle Scholar
  55. 55.
    Brown TNT, Herman JL. Intimate partner violence and sexual abuse among LGBT people: a review of existing research. Los Angeles: The Williams Institute, UCLA School of Law; 2015.Google Scholar
  56. 56.
    Dichter ME, Cerulli C, Bossarte BM. Intimate partner violence victimization among women veterans and associated heart risks. Womens Health Issues. 2011;21(4):S190–4.CrossRefGoogle Scholar
  57. 57.
    Dardis CM, Shipherd JC, Iverson KM. Intimate partner violence among women veterans by sexual orientation. Women Health. 2017;57(7):775–91.CrossRefGoogle Scholar
  58. 58.
    Coolhart D, Provancher N, Hager A, Wang M. Recommending transsexual clients for gender transition: a therapeutic tool for assessing readiness. J GLBT Fam Stud. 2008;4(3):310–24.Google Scholar
  59. 59.
    World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people. Accessed at
  60. 60.
    Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, Rosenthal SM, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869–903.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Los Angeles County Department of Mental HealthLos AngelesUSA
  2. 2.VHA LGBT Health ProgramWashington, DCUSA
  3. 3.VA South Central Mental Illness Research, Education, and Clinical CenterHoustonUSA
  4. 4.Department of PsychiatryBaylor College of Medicine, Michael E. DeBakey Veterans Affairs Medical CenterHoustonUSA

Personalised recommendations