Dr. Kauth: I’ve been in VA all my career, it’s 26 years now. I started as a trainee as a psychology intern at the New Orleans VA, and was at New Orleans for about 15 years before I transferred over to Houston.
I have two main jobs, at least two. One is as co-director of mental health research center called the MIRECC, Mental Illness Research Education and Clinical Center. It’s one of 10 competitively funded centers that focus on particular aspects of mental health care for veterans, Our focus is on providing evidence based treatments and the delivery of those treatments to vulnerable populations, particularly rural veterans. We’re in a very rural area of the country, In East Texas, Arkansas, Mississippi and Louisiana.
The other half of my job is the central office job. I’m one of two people who serve as the director for the LGBT health program. I’m currently under office of patient care services now. That office has been up and running since 2012. It actually started about a year after the VA released their first health care policy, their first national health care policy on transgender care. I was involved in the communication rollout on that healthcare policy because of my education background and training background and my colleague Jillian Shipherd who it the other half of the director role, was also involved in that communication workgroup. This was also the time of “Don’t Ask, Don’t Tell” was being repealed and VA was getting flooded with lots of questions about what they’re doing to address the needs not just transgender veterans, but lesbian gay and bisexual veterans as well. This was all in the news. It was people from outside the VA who wanted to know more, people inside the VA who wanted to know more and weirdly enough for us, myself and Jillian, we’re the two people who answered those questions because it was our area of expertise and we were involved in the transgender directive rollout. So we leveraged that position to an office because we said these issues are going to continue to be important, we’re going to continue to get lots of questions from the field. We need to be doing more in this area and Central Office agreed.
DAV: It’s clearly an important topic. It’s an area that is only going to become more important as we go along. What is your interest in this particular vein of study was or how you ended up in this field?
Dr. Kauth: Sexuality, sexual attraction, sexual health has always been an interest of mine, since I’ve been a graduate student. In the early days of my career in the VA, I worked in HIV mainly and all of those interests kind of intersected in the work in HIV clinics so I was able to do things that were very interesting to me. When the concept of the MIRECC came along, it was actually my background, training, and education with HIV patients that got me noticed by the center director who invited me to be the director of education for that center
DAV: What is VA’s official policy on LGBT veterans and what is the goal for VA in serving this population?
Dr. Kauth: Good question. The VA’s policy is—all veterans deserve respect and dignity. VA has a nondiscrimination patient care policy that includs sexual orientation and gender identity and expression among the characteristics that we will not discriminate against. We have two healthcare policies that address the unique needs of this diverse population. There is a directive for transgender veteran and a directive for veterans who identify as lesbian gay or bisexual. The overall goal I think is to serve all who served, do that in an affirming way, and have VA be the provider of choice for all veterans including veterans who identify as LGBT or have related identities.
DAV: How does VA support LGBT veterans across the whole spectrum of care?
Dr. Kauth: LGBT veterans, like our veterans general, have similar kinds of health conditions that involve them in primary care, and in mental health sometimes and in specialty care. They also have some unique needs as a result of historically being stigmatized and discriminated against. Minority stress can be viewed as a chronic stressor that can contribute to depression, increased anxiety, and suicide ideation. Over time it can result in maladaptive ways of coping; drinking too much, using substances to cope, not engaging in healthy positive behaviors and not seeking healthcare when you need it. At a societal level, minority stress also contributes to, frankly, not training healthcare provided to treat people like them, because it has been historically not been viewed as very important. All of those things together contribute to LGBT people, not just veterans, having higher rates of some health conditions, both mental and physical health conditions compared to non-LGBT people. So, to address those higher rates of health conditions within the VA, we ask that our clinical providers do an assessment of patients sexual orientation as well as their gender identity and take a brief history of sexual health and do appropriate follow-up based on the responses they get to identify risks of mental and physical health conditions that need to be treated. In addition, because of that history of stigmatization, LGBT veterans may benefit from support groups to come out, to feel better about themselves to meet others who are going through similar situations and increase their level of social support. Transgender veterans in particular who are dealing with gender dysphoria will benefit from gender counseling, through medical transitioning with help of hormone therapy, and we can provide support letters for changing identity documents or getting gender affirming surgeries outside the VA.
DAV: We know with women veteran issues, VA has done some mini residency programs to try to help clinical providers get up to speed with certain unique gender specific issues. What kind of training do you incorporate to help make the patient experience better for LGBT veterans?
Dr. Kauth: Yeah, There are different levels of training. We have at least six or seven online trainings available 24/7 on demand in the VAs educational platform. Most of those are also available outside the VA to community providers as well through a public health platform called VHATRAIN where community providers can get that same training for free, and get free continuing medical education. Those six or seven trainings are largely focused on clinical providers to raise their awareness on health disparities and how to treat the mental and physical health needs of LGBT veterans. A couple of them are broad and more general and geared to non-clinical staff so they have a greater sense of the diverse group of folks who come through our doors and how to treat them with respect, such as the clinic clerks the housekeepers in the hallway the people parking the cars in the parking lot.
We also have LGBT veteran care coordinators at every facility whose job is, in part, to help educate staff where there are gaps in knowledge or training needed, but also to generally to raise awareness about LGBT veterans coming through our door and working to create a more welcoming environment for them so they can recognize that they are expected and welcome there. You mentioned the fellowships. For five years, I believe we have had nine post-doctoral psychology fellowship across VA. There are intra-professional fellowships where psychologists in training can work across disciplines to treat LGBT veterans.
Sometimes LGBT veterans have a number of conditions that require working with primary care providers or specialty care providers. It’s not just a mental health issue. Although these trainees are for psychologists, the psychologists work across disciplines to provide more continuity of care for LGBT veterans and really specialize in working with LGBT veterans. The goal of training physicians in the VA is really to be a pipeline so that our highly trained, skilled trainees can take jobs within VA and stay in VA and we benefit from their training. At least half of our LGBT fellows remain in VA, which is great; that increases our capacity to work with LGBT veterans.
DAV: You mentioned in talking about the care and services provided, transition care or support. I wanted to touch base a little bit more broadly on that. Can you explain that to me as to what transition care or support would be available to LGBT—or specifically transgender—veterans?
DK: Let me start by saying every transgender individuals transition journey is individualized; there is no one way of transitioning that everybody goes through. And so, the start, really, is having a conversation with that individual about their particular transitioning goals and how we can work with them to better meet their transitioning goals.
That transition pathway could involve being part of a social support group in the VA or outside the VA. It could involve socially transitioning; it could involve starting on hormone therapy to change their physical body to look how they feel about themselves. It could mean help in providing support documents so the veteran can change their identity documents, not an easy thing to do. We don’t currently provide gender affirming surgery in the VA; we’re prohibited by regulation from providing those surgeries or paying for them in the community. But, we do provide support letters for veterans who seek those surgeries outside the VA. We will work with the surgeons to provide letters that help make that individual qualified to get those surgeries.
DAV: It’s great to hear you say all of this and it seems like VA is really making an effort to ensure that it’s policies and programs and services are in place to support this population and it seems like the goal is really breakdown this stigma that may be associated with LGBT veterans so that they can, in fact, access the care and benefits that they earned through their service. I’m curious, what course of action might a veteran pursue if they feel that they have not been treated with fairness and respect within VA?
Dr. Kauth: Let me preface that to say that can happen. People who are lesbian gay bisexual and transgender are socially stigmatized in this culture and they served in the military if they’re a veterans at a time when they could not be open about their identities, and while some things have changed in recent years, it hasn’t changed for everyone. LGBT veterans, according to the research we see, come to the VA anticipating that they might experience discrimination. Many veterans view the VA and the Department of Defense as one and the same organizational and believe the polices that were in effect in the military are in effect in the VA, which is not true. That creates a higher hurdle for us to demonstrate to LGBT veterans that they are welcome here and we can provide them high quality care here. Way we can do that, as I mentioned earlier are: ensuring that healthcare providers ask about sexual orientation and gender identity, and sexual health and social experiences which may involve exposure to violence at home or on the street. Assessing for the higher rates of health conditions that LGBT veterans might experiences, including military sexual trauma; and then providing care to them within an affirming framework that recognizes that part of the contribution of these health conditions is living within an environment that stigmatizes who they are.
DAV: Where can someone go to learn more about VAs policies and programs related to LGBT veterans?
Dr. Kauth: A great place to start is on our internet page on the VA website and the easiest way to find it is to Google LGBT veteran patient care and it’s usually the first link that pops up. There is a host of information on that site, including a locator service where veterans can find information about their LGBT veteran care coordinator at the facility that they go to. There are also some downloadable resources on that site like health fact sheets for gay and bisexual male veterans, for lesbian and bisexual female veterans for trans men and trans women veterans as well and those are great resources to have. Another way that people can get more information is to email us at firstname.lastname@example.org.
DAV: Is there anything else you’d like to mention?
Dr. Kauth: I guess I would add, I’m very proud of the work we’re doing at the VA and the fact we have about 176 LGBT veteran care coordinators out on the field, on the front lines, working to change the culture in VA and make it a more welcoming place for LGBT veterans who come to our door. I would add that generic environments are not welcoming to people who are sexual and gender minorities; that is not their space, it the space for the majority culture. Sexual and gender minorities like LGBT people, look to see visible signs and signals in the environment that they are expected and welcome there. So part of the job of the LGBT veteran care coordinator is to change the environment, like displaying information in the facilities like the We serve all who served poster and other media materials and hold events at the local facilities to let those veterans know they’re welcome here but also raise awareness among other veterans and among staff. We serve a diverse patient population and everyone is welcome at the VA.