36C77619R0003-0003002.pdf

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Department of Veterans Affairs Veterans Health Administration Washington, DC 20420

VHA DIRECTIVE 1341

Transmittal Sheet

May 23, 2018

PROVIDING HEALTH CARE FOR TRANSGENDER AND INTERSEX VETERANS

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive revises VHA policy for the respectful delivery of health care to transgender and intersex Veterans who are enrolled in the Department of Veterans Affairs (VA) health care system or are otherwise eligible for VA care.

2. SUMMARY OF MAJOR CHANGES: Major changes include:

a. Updates to language and definitions to reflect current nomenclature.

b. Removal of content which conflicts with changes to the Computerized Patient Record System (CPRS).

c. Additional oversight responsibilities for the Under Secretary for Health and the Deputy Under Secretary for Health for Operations and Management.

d. Delineated responsibilities for the Veterans Integrated Service Network (VISN) Lesbian, Gay, Bisexual, and Transgender (LGBT) Lead and LGBT Veteran Care Coordinator.

e. Updates to the Frequently Asked Questions.

f. Inclusion of sections on Training and Records Management, in accordance with VHA Directive 6330(3), Controlled National Policy/Directives Management System, dated June 24, 2016.

3. RELATED ISSUES: None.

4. REPONSIBLE OFFICE: The LGBT Health Program, Office of Patient Care Services (10P4Y), is responsible for the content of this VHA directive. Questions may be referred to LGBT Health Program at VALGBTProgram@va.gov.

5. RESCISSIONS: VHA Directive 2013-003, Providing Health Care for Transgender and Intersex Veterans, dated February 8, 2013, is rescinded.

6. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of May 2023. This VHA directive will continue to serve as national VHA policy until it is recertified or rescinded.

Carolyn M. Clancy, M.D.

Executive in Charge mailto:VALGBTProgram@va.gov

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NOTE: All references herein to VA and VHA documents incorporate by reference subsequent VA and VHA documents on the same or similar subject matter.

DISTRIBUTION: Emailed to the VHA Publication Distribution List on 6/1/2018.

DATE VHA DIRECTIVE 1341

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CONTENTS

PROVIDING HEALTH CARE FOR TRANSGENDER AND INTERSEX VETERANS

1. PURPOSE

2. BACKGROUND

3. DEFINITIONS

4. POLICY

5. RESPONSIBILITIES

6. TRAINING

7. RECORDS MANAGEMENT

8. REFERENCES

APPENDIX A

FREQUENTLY ASKED QUESTIONS (FAQ) REGARDING THE PROVISION OF

HEALTH CARE FOR TRANSGENDER AND INTERSEX VETERANS........................A-1

PROVIDING HEALTH CARE FOR TRANSGENDER AND INTERSEX VETERANS

1. PURPOSE

This Veterans Health Administration (VHA) directive states policy regarding the respectful delivery of health care to transgender and intersex Veterans who are enrolled in the Department of Veterans Affairs (VA) health care system or are otherwise eligible for VHA care. In accordance with the medical benefits package, VA provides care and treatment to Veterans that is compatible with generally accepted standards of medical practice and determined by appropriate health care professionals to promote, preserve, or restore the health of the individual. AUTHORITY: Title 38 United States Code (U.S.C.) 7301(b); Title 38 Code of Federal Regulations (CFR) 17.38.

2. BACKGROUND

a. VA is committed to addressing health disparities, including disparities among our transgender and intersex Veterans.

b. VHA provides health care for transgender and intersex Veterans, no matter how they present. Not all Veterans who identify as transgender or intersex undergo a transition process. For those who do, they may present to VHA at various points in their gender transition. VHA does not discriminate based on state of gender transition. This applies to all Veterans who are enrolled in VHA’s health care system or are otherwise eligible for VHA care.

c. VHA will provide care to all transgender and intersex Veterans in a manner that is consistent with their self-identified gender identity.

d. VA does not provide gender confirming/affirming surgeries because VA regulation excludes them from the medical benefits package.

e. VA does not provide plastic reconstructive surgery for strictly cosmetic purposes.

3. DEFINITIONS

a. Birth Sex. Birth sex refers to the classification of individuals as female or male, most often on the basis of their external genitalia at birth. In VA records, this information is the sex recorded on the Veteran’s original birth certificate.

b. Gender. Gender refers to the behavioral, cultural, or psychological traits that a society associates with birth sex or gender expression. Common gender categories are man and woman.

(1) Gender Expression. Gender expression is the external display of one’s gender, through a combination of dress, social behavior, and other factors. Gender expression is sometimes (but not always) consistent with gender identity.

(2) Gender Identity. Gender identity refers to how an individual identifies the self as belonging to the male (that is, boy or man), female (that is, girl or woman), or some other gender category (for example, gender non-conforming – see definition below). In VA, administrative staff record this information as self-identified gender identity (SIGI).

c. Gender Confirming/Affirming Surgeries. Gender confirming/affirming surgeries (also referred to as sex reassignment surgeries) include any of a variety of surgical procedures (including but not limited to vaginoplasty and breast augmentation in transgender women and mastectomy and phalloplasty in transgender men) done simultaneously or sequentially with the explicit goal of gender transitioning. Not all transgender or intersex individuals want gender confirming/affirming surgeries.

d. Gender Dysphoria. Gender Dysphoria is the diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) for persons who experience distress related to an incongruence between the gender with which the person identifies and their birth sex. Not all transgender people meet full criteria for this diagnosis.

e. Intersex. Intersex individuals are born with reproductive or sexual anatomy and/or chromosome pattern that does not fit typical definitions of male or female birth sex. People with intersex conditions are often assigned male or female birth sex by others (for example, by parents or doctors). The individual’s gender identity may or may not be consistent with the sex assigned at birth.

f. Self-Identified Gender Identity. Self-Identified Gender Identity (SIGI) is a field in the VA records which refers to how Veterans think about their gender. Veterans may choose from a set of responses which include male, female, transman, transwoman, other, or the individual chooses not to answer. For more information, see http://go.va.gov/SIGI. NOTE: This is a VA internal Web site that is not available to the public.

g. Transgender. A transgender person is someone whose gender identity differs from their birth sex.

(1) Transgender Woman. Transgender women are a subset of transgender individuals who are assigned male sex at birth but self-identify as female and often take steps to socially or medically transition to live as women. This may include feminizing hormone therapy, electrolysis, and surgeries (for example, vaginoplasty, facial feminization, or breast augmentation). Generally, the pronouns these individuals use are “she,” “her,” or “hers,” unless the Veteran requests different pronouns.

(2) Transgender Man. Transgender men are a subset of transgender individuals who are assigned female sex at birth but self-identify as male and often take steps to socially or medically transition to live as men. This may include masculinizing hormone therapy and surgeries (for example, phalloplasty, metoidioplasty, or mastectomy with chest reconstruction). Generally, the pronouns these individuals use are “he,” “him,” or “his,” unless the Veteran requests different pronouns.

http://go.va.gov/SIGI

(3) Gender Non-Conforming (GNC). Gender non-conforming is a term that describes people whose gender does not fit into gender binary definitions of “woman/transgender woman” or “man/transgender man.” This can include people whose identity falls outside of these gender binary categories, people whose identity fluctuates between masculine and feminine, and those who reject conventional gender expectations. Some gender non-conforming people use the terms “non-binary gender identity,” “gender queer,” “gender fluid,” or “gender diverse” to describe themselves.

Sometimes these individuals use gender neutral pronouns such as “they” or “them” instead of “he” or “she.”

4. POLICY

It is VHA policy that staff provide clinically appropriate, comprehensive, Veteran-centered care with respect and dignity to enrolled or otherwise eligible transgender and intersex Veterans, including but not limited to hormonal therapy, mental health care, preoperative evaluation, and medically necessary post-operative and long-term care following gender confirming/affirming surgery. It is VHA policy that Veterans must be addressed based upon their self-identified gender identity; the use of Veteran’s preferred name and pronoun is required. NOTE: VA does not provide or fund gender confirming/affirming surgeries because VA regulation excludes them from the medical benefits package. In addition, VA does not provide plastic reconstructive surgery, in accordance with the medical benefits package and VHA Directive 1091, Plastic Reconstructive Surgery, dated February 21, 2014.

5. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health is responsible for ensuring overall VHA compliance with this directive.

b. Deputy Under Secretary for Health for Operations and Management. The Deputy Under Secretary for Health for Operations and Management is responsible for:

(1) Communicating the contents of this directive to each Veterans Integrated Services Network (VISN).

(2) Ensuring that each VISN Director has sufficient resources to fulfil the terms of this directive in all of the VA medical facilities within that VISN.

(3) Providing oversight of VISNs to assure compliance with this directive, relevant standards, and applicable regulations.

c. Director, National LGBT Health Program. The Director, National LGBT Health Program, is responsible for:

(1) Disseminating this policy to the field and responding to staff questions, concerns, and educational needs regarding implementation of this policy.

(2) Communicating with LGBT VISN Leads about activities in their region to ensure ongoing quality improvement with measurable gains.

d. Veterans Integrated Service Network Director. Each VISN Director is responsible for:

(1) Ensuring that necessary and appropriate health care is provided at all VA medical facilities within the VISN to all enrolled or otherwise eligible Veterans based on the Veteran’s self-identified gender, regardless of birth sex, status of medical/surgical interventions, or appearance.

(2) Identifying the LGBT VISN Lead to oversee and coordinate LGBT Veteran Care Coordinator (VCC) activities in their region.

(3) Supporting the LGBT VISN Lead in their work with the LGBT VCCs in their region.

e. LGBT VISN Lead. Each LGBT VISN Lead is responsible for:

(1) Assisting facilities in their region with identifying and appointing LGBT Veteran Care Coordinators (VCCs), as well as working collaboratively on any remediation needed with LGBT VCC performance or time allocation. The LGBT VISN Lead will also serve as a reliable source of information regarding the appropriate amount of time a VCC may need to perform their duties above the suggested minimum, as well as the need for local resources to support their work.

(2) Assisting the LGBT VCCs with development and coordination of strategic plans and program activities across the VISN and local problem solving, and engagement of facility leadership when necessary.

(3) Communicating, on a minimum quarterly basis, about activities in their region with the national LGBT Health Program in order to ensure ongoing quality improvement with measurable gains.

f. VA Medical Facility Director, Chief of Staff, and Associate Director for Patient Care Services or Nurse Executive. The VA medical facility Director, Chief of Staff, and Associate Director for Patient Care Services or Nurse Executive are responsible for:

(1) Ensuring transgender and intersex individuals are provided all care in VA’s medical benefits package, including but not limited to: hormonal therapy, mental health care, preoperative evaluation, and medically necessary post-operative and long-term care following gender confirming surgeries to the extent that the appropriate health care professional determines that the care is needed to promote, preserve, or restore the health of the individual and is in accord with generally accepted standards of medical practice. NOTE: VA will not provide or fund gender confirming/affirming surgeries because VA regulation excludes them from the medical benefits package. In addition, VA does not provide plastic reconstructive surgery, in accordance with the medical benefits package and VHA Directive 1091, Plastic Reconstructive Surgery, dated February 21, 2014.

(2) Adhering to VA’s values of diversity, inclusion, and commitment to increasing awareness about the health care needs of Veterans by assuring transgender and intersex Veterans receive culturally appropriate, confidential care in a welcoming environment.

(3) Addressing and referring to Veterans (even when they are not present) based on the Veteran’s self-identified gender identity and preferred name, including in conversation and clinical notes, even when this is not their legal name. Pronouns used must be consistent with the Veteran’s preferences.

(4) Offering patients appropriate clinical health screens. Birth sex, gender identity, hormone therapy, surgical status, and current treatments determine which clinical health screens are appropriate. For example, a transgender man should receive breast and cervical cancer screening, if that anatomy is present, and a transgender woman should receive prostate cancer screening.

(5) Modifying administrative data (including name and birth sex) in the Computerized Patient Record System (CPRS), as specified in VHA Directive 2012-036, Identity Authentication for Health Care Services, dated December 26, 2012, and VHA Directive 1906, Data Quality Requirements for Identity Management and Master Patient Index Functions, dated April 29, 2013. Additional guidance is offered in the Identity Management Fact Sheet. For more information see the HC IdM Web site:

http://vaww.vhadataportal.med.va.gov/PolicyAdmin/HealthcareIdentityManagement.asp

x. NOTE: This is an internal VA website that is not available to the public.

(6) Informing Veterans about how birth sex and gender identity will be included in the patient’s health record and the procedure to request a change to the record (VHA Handbook 1907.01, Health Information Management and Health Record, dated March 19, 2015). The Veteran has a right to not be identified as “transgender” or any other label, unless omitting this information would compromise medically necessary care.

(7) Room assignments and access to facilities for which gender is a consideration (for example, restrooms) in a manner which gives preference to self-identified gender, irrespective of appearance and/or surgical status. Where there are questions related to room assignments or other concerns or conflicts about values, an ethics consultation may be requested. NOTE: Federal policy and law supersedes state law on Federal grounds property or in federally leased space.

(8) Providing all health services to transgender and intersex Veterans without discrimination in a manner consistent with care and management of all Veterans.

(9) Requiring all staff, including medical and administrative staff, to treat as confidential any information about a Veteran’s transgender or intersex identity or any treatment related to a Veteran’s gender transition, unless relevant to medical care, consistent with VHA Directive 1605.01, Privacy and Release of Information, dated http://vaww.vhadataportal.med.va.gov/PolicyAdmin/HealthcareIdentityManagement.aspx

August 31, 2016. For example, casual conversation about a Veteran’s identity is inappropriate.

(10) Maintaining an environment free from harassment of any kind. The LGBT Veteran Care Coordinator (VCC) is a resource for the medical facility Director in implementing corrective actions and training. NOTE: For more information, see LGBT VCC section below.

(11) Ensuring the facility LGBT VCC has adequate allocated time to fulfill responsibilities (see LGBT VCC section below). It is suggested that the Medical Facility Director meet at least annually with the LGBT VCC to ensure that responsibilities are being fulfilled and to develop improvement plans as needed. LGBT Veteran needs may vary across settings for multiple reasons. Based on data from currently serving LGBT VCCs, it is recommended to allocate the following minimum number of hours for the LGBT VCC role relative to facility complexity and enrollment:

(a) For facilities with less than 25,000 Veterans enrolled, a minimum of 4 hours per week.

(b) For facilities with 25,000 to 75,000 Veterans enrolled, a minimum of 6 hours per week.

(c) For facilities with over 75,000 Veterans enrolled, a minimum of 8 hours per week.

(12) Determining, based on local needs, whether to assign more than one VCC or to increase the minimum number of hours necessary for this role at the facility. Need for more than one VCC and/or more than the minimum number of hours may be due to:

(a) The size of the facility.

(b) A high number of community-based outpatient clinics and/or multiple campuses.

(c) A high number of anticipated LGBT Veterans.

(d) A great distance between sites.

(e) Minimal existing services for LGBT Veterans.

g. LGBT Veteran Care Coordinator. Every facility must have at least one designated LGBT VCC as a collateral position who dedicates adequate protected time (that is, dedicated administrative time) to fulfill the responsibilities of the role. The LGBT VCC reports directly to the Medical Center Director and coordinates activities with the LGBT VISN Lead. The LGBT VCC plays a critical role in ensuring culturally competent, patient-centered, and effective care for LGBT Veterans because LGBT Veterans are seen at every facility. The LGBT VCC is responsible for:

(1) Supporting the implementation of national and VISN-level policies related to LGBT Veteran health at the VA medical facility to ensure consistent and timely access to culturally competent care for LGBT Veterans.

(2) Investigating and taking corrective action upon awareness of an issue and, as appropriate, offering recommendations to facility leadership for further action to assist the facility in educating staff and creating a welcoming environment (for example, providing education to staff about treatment of Veterans based upon their self-identified gender identity and assuring facilities are inclusive and welcoming).

(3) Communicating with individual facility services (for example, prosthetics, endocrinology, social work, etc.) to provide tailored guidance and education as needed.

This includes working with the clerical staff who may need training in asking about birth sex and self-identified gender identity in a respectful manner, and/or working with local Master Veteran Index coordinators (typically the Privacy Officer) for Veterans making changes to name and/or birth sex fields in the record system.

(4) Serving as a point-person, source of information, Veteran advocate, and problem-solver for LGBT Veteran-related health care issues at the VA medical facility.

The LGBT VCC thus identifies the needs of local LGBT Veterans, assists the facility in developing needed care, serves as liaison with external LGBT community organizations, and develops relationships with internal facility stakeholders.

(5) Communicating to the public via outreach measures, for example, sustainment of a dedicated Internet page for the facility’s LGBT Veteran care resources and participation in community events, and promoting a welcoming environment for LGBT Veterans (e.g., Web site, advisory council, LGBT awareness posters, Pride events) that directly counteracts expectations of discrimination.

6. TRAINING

There are no formal training requirements for this directive. NOTE: Please see Appendix A for recommended training.

7. RECORDS MANAGEMENT

All records regardless of medium (paper, electronic, electronic systems) created by this directive shall be managed per the National Archives and Records Administration (NARA) approved records schedules found in VA Records Control Schedule 10-1. If you have any questions regarding any aspect of records management, you should contact your facility Records Manager or your Records Liaison.

8. REFERENCES

a. 38 USC 7301(b).

b. 38 CFR 17.38.

c. VHA Directive 6330(3), Controlled National Policy/Directives Management System, dated June 24, 2016.

d. VHA Directive 1906, Data Quality Requirements for Identity Management and Master Veteran Index Functions, dated April 29, 2013.

e. VHA Directive 2012-036, Identity Authentication for Health Care Services, dated December 26, 2012.

f. VHA Directive 1605.01, Privacy and Release of Information, dated August 31, 2016.

g. VHA Directive 2009-038, VHA National Dual Care Policy, dated August 25, 2009.

h. VHA Handbook 1907.01, Health Information Management and Health Records, dated March 19, 2015.

i. VHA Handbook 1004.01, Informed Consent for Clinical Treatments and Procedures, dated August 14, 2009.

j. Identity Management Fact Sheet, VHA Office of Informatics and Information Governance Data Quality, Healthcare Identity Management (HC IdM), available at:

http://vaww.vhadataportal.med.va.gov/PolicyAdmin/HealthcareIdentityManagement.asp x.

k. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association (2013).

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APPENDIX A

FREQUENTLY ASKED QUESTIONS (FAQ) REGARDING THE PROVISION OF

HEALTH CARE FOR TRANSGENDER AND INTERSEX VETERANS

1. How can a Department of Veterans Affairs (VA) employee know a Veteran’s gender identity?

VA record systems now have both a “birth sex” field and a “self-identified gender identity” (SIGI) field. Birth sex is used for determining sex-based medical health screenings, and SIGI is used for addressing the Veteran based upon the Veteran’s self-identified gender identity. For information about how to ask about birth sex and SIGI, see: http://go.va.gov/SIGI. NOTE: This is an internal VA website that is not available to the public.

2. Is being transgender the same as being “gay”, “lesbian”, or “bisexual”?

No. Being transgender is not the same as being gay, lesbian, or bisexual. The term “transgender” refers to gender identity or the sense of oneself as a man, woman, or something else (for example, gender non-conforming). Gay, lesbian, and bisexual refer to sexual orientation identities. Sexual orientation identities are the terms one uses to describe sexual and romantic attractions. Transgender people, like all people, can identify with any sexual or romantic identity. A transgender Veteran may identify as heterosexual (“straight”), gay, lesbian, bisexual, queer, pansexual, asexual, etc.

Knowing someone’s gender identity gives you no information about their sexual orientation. The best practice is to ask Veterans how they identify and use those terms.

For more information about sexual orientation terms and uses, see the Glossary on the LGB SharePoint:

http://vaww.infoshare.va.gov/sites/LGBEducation/sitefiles/LGBT%20Veteran%20Health %20glossary.pdf. NOTE: This is an internal VA Web site that is not available to the public.

3. Do all intersex individuals identify as transgender?

No. For example, an individual may be assigned a “female” birth sex and identify as female throughout her lifetime, with or without knowing about her intersex condition.

Some intersex persons with male chromosomes, who have been assigned “female” sex at birth, may experience gender dysphoria even without knowing that they were “reassigned” at, or near, birth. Knowing someone has an intersex condition gives you no information about their gender identity or sexual orientation.

4. I have heard the term transsexual - what does that term mean?

Transsexual is an older term that refers to a subset of transgender individuals who often take steps to socially or medically transition to their preferred gender.

Transgender women are sometimes referred to as male-to-female transsexuals.

Transgender men are sometimes referred to as female-to-male transsexuals. In general, it is best practice to use the term that the Veteran uses to refer to themselves as a way to be respectful.

http://go.va.gov/SIGI http://vaww.infoshare.va.gov/sites/LGBEducation/sitefiles/LGBT%20Veteran%20Health%20glossary.pdf http://vaww.infoshare.va.gov/sites/LGBEducation/sitefiles/LGBT%20Veteran%20Health%20glossary.pdf

APPENDIX A

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5. Where can we refer transgender Veterans?

It is always the preference for Veterans to be treated at their nearest VA facility when they are eligible for care, since that is less expensive and more culturally appropriate. Transgender and intersex Veterans are no different. Since 2011, all VA facilities are required to either provide care or pay for care in the local community for enrolled Veterans who identify as transgender. Treatment plans are individualized and based upon the Veteran’s unique treatment goals and circumstances. The local LGBT Veteran Care Coordinator can assist in identifying training resources for providers to treat transgender or intersex Veterans.

6. What is the correct pronoun to use when speaking with a transgender Veteran or documenting the clinical encounter in a progress note?

You should always address and refer to a transgender Veteran by the Veteran’s preferred name and self-identified gender. This is true in conversation and in documentation in the medical record, irrespective of the Veteran’s appearance. Official documents are not needed (for example, legal name change or changed birth certificate) nor are surgical or medical interventions required for Veterans to be identified by their preferred gender or name. For more information about how to ask about birth sex and self-identified gender identity (SIGI), see: http://go.va.gov/SIGI.

NOTE: This is an internal VA website that is not available to the public.

7. Are transgender Veterans allowed to use public accommodations of their choice?

Yes. VA policies on access to facilities (for example, bathrooms, locker rooms, or room assignments) apply to all VA facilities across the country, regardless of local or state laws or regulations regarding use of facilities based on birth sex. To ensure the safety and respect of Veterans in cities and states with policies restricting access to bathrooms, locker rooms, etc., extra education, signage, and safety precautions could be needed to guarantee the safety of transgender people using the facilities of their choosing.

8. Are transgender Veterans allowed to use the bathroom of their choice?

Yes. Transgender Veterans who self-identify as women are allowed to use bathrooms for women. Likewise, those who self-identify as men are allowed to use bathrooms for men. This is irrespective of the Veteran’s appearance or whether the Veteran has had surgical interventions. Some transgender people may prefer to use single stall bathrooms, typically labeled “unisex,” or something similar. If a transgender person requests a single stall bathroom, they should be directed accordingly, though they remain welcome to use any and all facilities that correspond to their self-identified gender identity.

http://go.va.gov/SIGI

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9. What about room assignments, including shared rooms?

Room assignments are made in accordance with the Veteran’s self-identified gender, irrespective of the Veteran’s appearance or whether the Veteran has had surgical interventions, and in consideration of the needs of other Veterans. Privacy and confidentiality dictate that staff may not share any information about one Veteran with another Veteran without express permission. If a room assignment leads to distress for either Veteran, then efforts need to be made to move the distressed Veteran to a different semi-private room. If both Veterans are distressed, staff should use current policies about resolving roommate disputes to determine if/when and how a room change should happen. NOTE: Ethics consultations are encouraged when concerns arise related to the provision of respectful care for transgender and intersex Veterans and other Veterans.

10. What is sex reassignment surgery?

Sex reassignment surgery is an older term for gender confirming/affirming surgeries or procedures.

11. Will VA provide gender confirming/affirming surgeries or plastic reconstructive surgery if needed?

VA does not provide gender confirming/affirming surgeries in VA facilities or through non-VA care. In addition, VA does not provide plastic reconstructive surgery for strictly cosmetic purposes in VA facilities or through non-VA care. However, transgender Veterans cannot be denied access to surgical interventions that are medically indicated for other medical conditions simply because the procedure is also consistent with transition goals. NOTE: Some transgender Veterans may elect to have one or more medical or surgical procedures over their lifetime to bring their bodies into a closer alignment with their experienced gender. Only a minority of transgender Veterans will undergo gender confirming/affirming surgeries outside VA. Some Veterans receiving care at a VA medical facility may have had gender confirming/affirming surgeries somewhere else. VA does provide health care to pre- and post-operative transgender Veterans, including treatment of surgical complications.

12. How do pre-operative medical and mental health evaluations differ for transgender Veterans?

VA provides pre-operative medical and mental health evaluations for Veterans who receive surgeries outside VA. Medical evaluation prior to any surgery includes pre-operative cardiac risk assessment and careful evaluation of current medications, including hormone dosing. Providers may recommend that Veterans on hormone therapy taper off prior to surgery to reduce risks and reinitiate hormone treatment post-surgery.

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13. Will VA provide feminizing or masculinizing hormone therapy?

Yes, if it is consistent with the Veteran’s wishes, the treatment team’s clinical recommendations, and VA treatment guidance.

14. What guidance is available to clinicians regarding hormone therapy?

VA Pharmacy Benefits Management Services has developed guidance for the use of hormone therapy in transgender and intersex Veterans in VA. This guidance is located at: https://vaww.cmopnational.va.gov/cmop/pbm/default.aspx. NOTE: This is an internal Web site and is not available to the public. Training in prescribing hormone therapy is available at: https://www.tms.va.gov/learning/user/login.jsp, TMS course: VA 22627. NOTE: This is an internal Web site and is not available to the public. This training is also available on an external Web site at: https://www.train.org/vha/welcome, TRAIN course: 1066855.

15. What is the process for informed consent for hormone therapy?

a. For treatment plans that include hormone therapy or surgical interventions, VA clinicians should follow the requirements for informed consent as outlined in VHA Handbook 1004.01, Informed Consent for Clinical Treatments and Procedures, dated August 14, 2009. This includes discussing the indication for the treatment, the risks, benefits, and limitations of the therapy with the Veteran, as well as the risks and benefits of the alternative treatments, including no treatment. Signature consent is not required for hormone therapy; oral informed consent is sufficient. NOTE: Policy regarding informed consent can be found in VHA Handbook 1004.01.

b. Obtaining the patient’s consent for treatments and procedures promotes the Veteran’s involvement in decisions about their care. Shared decision-making combines the provider’s medical knowledge and expertise with the Veteran’s preferences about care. Using shared decision-making for decisions about hormone therapy will help identify a medically appropriate treatment option that promotes the Veteran’s preferences about treatment (for example, desired feminizing or masculinizing outcomes) and incorporate the provider’s knowledge and experience about the risks and benefits of the treatment.

16. What are the goals of hormone therapy? What effects and risks are associated with hormone therapy?

a. Hormone therapy is used to reduce or eliminate gender dysphoria and other symptoms related to the discordance between a transgender or intersex individual’s gender identity and their sex assigned at birth. The treatment produces changes in hormonally-sensitive sex characteristics (that is, reducing characteristics of the birth sex and inducing those of the opposite sex). VA clinicians need to provide transgender and intersex Veterans with a careful evaluation prior to providing prescriptions for hormone therapy. Not all transgender or intersex Veterans will want hormone treatment.

https://vaww.cmopnational.va.gov/cmop/pbm/default.aspx https://www.tms.va.gov/learning/user/login.jsp https://www.train.org/vha/welcome

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b. The goal of feminizing hormone therapy is to suppress testosterone levels and introduce estrogen to achieve a pre-menopausal female hormonal range. The effects are decreased facial and body hair, redistribution of fat, breast development, and prostate and testicular atrophy. Risks include infertility, venous thromboembolism, liver dysfunction, hypertension, and cardiovascular disease. As with any medical therapy, benefits and harms of treatment need individualization using principles of shared decision-making, with an emphasis upon the lowest (safest) dose to achieve benefits.

VA does not encourage the imposition of “menopausal” state in elder transgender women. Hormone treatments should be consistent with the Veteran’s treatment goals and can include feminizing hormone therapy in older transgender women.

c. In cases when anti-androgens and/or doses of estrogens cannot be tolerated by the patient, are ineffective, or if the Veteran would be at increased risk for adverse effects, such as cardiovascular or other thrombotic events, and when an appropriate medical provider has determined that there are no other standard medical options for hormone management, surgical orchiectomy is an acceptable treatment recommendation. In these select Veterans, orchiectomy can be considered medically necessary as part of their hormone management, and not gender confirming/affirming surgery. Decisions about the appropriate use of orchiectomy should be made on a case-by-case basis as determined by the treatment team, and should include a medical provider who has expertise in the management of hormone therapy. NOTE:

Transgender E-consultations and/or ethics consultations are available for case-specific consultation.

d. The goal of masculinizing hormone therapy is to maintain testosterone and estrogen levels in the typical male range, generally through testosterone supplementation and sometimes in combination with a Gonadotropin Releasing Hormone (GnRH) agonist or progestins to suppress menses. The effects are increased facial and body hair and muscle, acne, permanent deepening of the voice, cessation of the menses, redistribution of fat mass, and clitoral enlargement. Risks include hypertension, erythrocytosis, liver dysfunction, lipid changes, weight gain, and sodium retention.

17. Can hormone therapy cause infertility?

Yes. This should be discussed with the prescribing provider as a part of medical decision making. Transgender and intersex Veterans are eligible for the same fertility preservation services as other Veterans about to undergo treatment that can alter fertility. For more information about VA’s coverage of fertility services, please see:

https://vaww.infoshare.va.gov/sites/LGBEducation/Pages/FAQ.aspx. NOTE: This is an internal Web site and is not available to the public.

18. Are there specific diagnostic criteria to consider in prescribing hormone therapy?

A diagnosis is required to prescribe medications. A DSM-5 diagnosis of Gender Dysphoria or other gender dysphoria condition should be the basis for prescription for https://vaww.infoshare.va.gov/sites/LGBEducation/Pages/FAQ.aspx

A-6 hormone therapy for transgender Veterans. There may be clinical exceptions to the diagnosis for prescribing hormone therapy (for example, transgender individuals diagnosed as having “Other Specified Gender Dysphoria” who are post-transition and still require medications). NOTE: Gender Identity Disorder (GID) is an outdated diagnosis from DSM-IV that described a conflict between a person’s birth sex and the gender with which the person identifies. With regard to encounter codes, the term GID may be listed if Gender Dysphoria is not available.

19. Transgender and intersex Veterans are presenting to VA providers with prescriptions for hormones from outside sources, such as from another provider, the Internet, or illicit sources. Should we stop these medications while we do a full evaluation or should a VA provider rewrite the prescriptions so they can be filled in a VA pharmacy and continued?

Under VHA Directive 2009-038, VHA National Dual Care Policy, dated August 25, 2009, VA providers are not permitted to simply rewrite prescriptions from an outside provider, unless the VA provider has first made a professional assessment that the prescribed medication is medically appropriate. NOTE: It may be appropriate for a VA provider to provide temporary prescriptions based on each Veteran's unique situation and a weighing of risks/benefits in order to avoid negative physical and psychiatric consequences while a VA evaluation is in progress.

20. What evaluation is necessary prior to initiation of hormone therapy?

Because the provision of hormone therapy in transgender Veterans is designed to treat the gender incongruence and dysphoria, a diagnosis must be established before hormone therapy can begin. A mental health professional generally establishes a Gender Dysphoria diagnosis prior to provision of hormone therapy. Additionally, the provider who prescribes the hormone therapy must obtain informed consent for that treatment, as described in FAQ #15. The presence of other psychiatric and physical conditions is not necessarily a barrier to initiating treatment. Treatment for comorbid conditions can be recommended in the evaluation, but cannot create a barrier to access for hormone treatment, except where medically contraindicated. For Veterans who enter VA with well documented hormone therapy from outside clinicians, the diagnosis of Gender Dysphoria is still required, and should be confirmed. In such cases, a mental health evaluation may help to both confirm the diagnosis and address other potential mental health needs of the Veteran.

21. How do we handle preventive screening requirements?

In addition to treatments related to their new gender identity, transgender Veterans need appropriate medical screening and/or treatment specific to their birth sex. Clinical reminders are cued to birth sex. Important screening reminders include prostate exams and mammograms for transgender women and vaginal exams and mammograms for transgender men, as indicated. Some transgender Veterans will change the birth sex in their records. For these Veterans, their clinical reminders will not be cued to their natal

A-7 sex but to the sex listed in the birth sex field. Providers and Veterans will need to remember to do preventive screens as needed.

22. Will VA provide or pay for electrolysis for transgender Veterans?

No. VA will not provide electrolysis for gender affirming purposes at this time.

23. Will VA provide medically necessary prosthetics (e.g., wigs, chest binders, dilators, etc.) to eligible transgender and intersex Veterans?

Yes. For more information on prosthetics, see the Prosthetic & Sensory Aids Service Policy SharePoint at https://vaww.infoshare.va.gov/sites/prosthetics/Policy%20Questions/Forms/Answer.asp

x. NOTE: This is a VA internal Web site that is not available to the public.

24. Will VA provide medically necessary vocal coaching to transgender and intersex Veterans?

Yes. VA speech pathologists can offer this care, or if this service is not available at your facility, it can be offered through non-VA community-based care.

25. Can a transgender Veteran request a change of birth sex in Computerized Patient Record System (CPRS) before having gender confirming/affirming surgery?

Yes. Surgery is not a prerequisite for amendment of birth sex in the Veteran’s record. Amending the birth sex of the Veteran in CPRS is based on the Veteran making a written amendment request to the facility’s Master Veteran Index Coordinator (often the Privacy Officer). The request must be accompanied by official documentation as described in the Identity Management Fact Sheet, dated November 2016. However, self-identified gender identity can be changed without documentation by the Veteran or by any VA staff who routinely update demographic data. Changing birth sex will result in loss of information for preventive health screenings, and may complicate medication dosing and medical reports.

26. Do I need to become an expert in treating transgender Veterans?

No, but all clinicians and staff who provide clinical services to transgender Veterans need to be knowledgeable about transgender health issues. Providers are encouraged to consult with specialists on any aspect of care for which they need advice or for ongoing management, as they would for any other Veteran. Everyone needs to be aware that transgender Veterans deserve to receive health care at VA and need to be treated with dignity and respect.

27. What education is available to VA staff?

Cultural awareness and sensitivity education, as well as clinical trainings, are available and can be found on the Transgender SharePoint:

A-8 http://go.va.gov/Transgender. NOTE: This is an internal VA website that is not available to the public. For local trainings, the LGBT Veteran Care Coordinator will have access to the most current information.

28. What do I do if I become aware of possible discrimination or harassment of a transgender Veteran?

VA is founded on respect of Veterans and does not tolerate discrimination or harassment. To report concerns, you may work with the LGBT Veteran Care Coordinator, your supervisor, and/or the patient advocates. The VA Medical Facility Director is responsible for implementing corrective actions and training.

29. As a VA staff member, where can I find good resources on transgender care?

There are VA and non-VA resources that can be helpful. A good repository for this information is http://go.va.gov/Transgender. You may also wish to consult with your local LGBT Veteran Care Coordinator about training. NOTE: This is an internal VA website that is not available to the public.

http://go.va.gov/Transgender http://go.va.gov/Transgender