The Incidental Economist

Izabela Sadej, MSW, is a policy analyst at Boston University School of Public Health. She tweets at @IzzySadej. 

There is a long history of discrimination against Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) individuals serving in the U.S. military. Until September 2011, the “Don’t Ask Don’t Tell” policy prohibited active-duty personnel from being asked about or discussing their sexual orientation for fear of retaliation and possible discharge. After former President Donald Trump banned transgender individuals from serving in the military, the U.S. Department of Defense updated their guidance to prohibit discrimination based on gender identity, particularly transgender identity, in March 2021.

The Veterans Health Administration (VHA) does not routinely collect or document sexual orientation and gender identity (SOGI) information from Veterans, despite known physical and mental health disparities among both sexual and gender minority individuals and the Veteran population. The intersection of these two identities, especially considering the military’s treatment of this group, has resulted in questions about reluctancy among sexual and gender minority Veterans discussing SOGI information in VHA settings.

New Research

A recent study explored Veteran’s comfort in disclosing and responding to questions about SOGI information, particularly when asked 1) on VHA surveys and 2) in clinical discussions with VHA providers.

(Affiliations of the authors for this study include Mollie A. Ruben at the University of Maine Department of Psychology and the Center for Healthcare Organization and Implementation Research at VA Boston Healthcare System; Michael R. Kauth at VHA LGBT Health Program, South Central Mental Illness Research, Education, and Clinical Center, Baylor College of Medicine Menninger Department of Psychiatry and Behavioral Sciences, and VA Houston HRS&D Center for Innovations in Quality, Effectiveness and Safety; Mark Meterko at VHA RAPID SHEP Patient Experience Survey Program and Boston University School of Health Law, Policy and Management; Andrea M Norton at the Aleda E. Lutz Veteran Affairs Medical Center; Alexis R. Matza at VHA LGBT Health Program and Boston VA Research Institute Inc; and Jillian C. Shipherd at VHA LGBT Health Program, VA Boston Healthcare System National Center for PTSD, and Boston University School of Medicine.)

An online survey was administered to the Veteran Insights Panel (VIP), a group of Veterans who have voluntarily agreed to provide feedback to VHA for improvement purposes. VIP participants are of various ages, gender identities, sexual orientations, races, and ethnicities. The researchers contacted 3255 Veterans and received 806 responses. The study’s sample population is said to be representative of the general Veteran population, with slightly more representation of older age groups.

The survey included multiple-choice style questions to identify four sociodemographic characteristics (race/ethnicity, gender, sex assigned at birth, and sexual orientation) of participants, followed by questions concerning their comfort level in responding to SOGI- and race/ethnicity-related questions on VHA confidential surveys and in discussion with VHA providers. Participants rated their comfort in reporting their identity characteristics on a 5-point scale from 1 (Strongly Disagree) to 5 (Strongly Agree).

Descriptive statistics were used to quantify patient perceptions of answering SOGI and race/ethnicity questions. Stratified analyses (independent samples t-tests and analysis of variance) examined differences in comfort answering SOGI and racial/ethnic identifying questions across sociodemographic groups. Paired samples t-tests examined differences in comfort between a confidential VHA survey and clinical interactions with VHA providers.

Findings

With average scores ranging from 4.20–4.35 on the 1-5 scale, participants generally reported favorable perceptions answering SOGI questions on both confidential VHA surveys and in discussion with their VHA providers. There was a slight preference for in-person discussion versus a survey. Some additional findings are below.

• Reporting on a VHA Confidential Survey:
  • By gender expression: In comparison to gender-diverse participants, cisgender men and women reported feeling more comfortable sharing their identity across all characteristics, except race/ethnicity.
  • By sex at birth: Female-born participants were significantly more comfortable reporting their sexual orientation and race/ethnicity than male-born participants.
  • By sexual orientation: Compared to sexual and gender minority participants, heterosexual participants were significantly more comfortable reporting their sexual orientation, gender identity, and birth sex, and marginally more comfortable reporting their race/ethnicity.
• In Discussion with a VHA Provider:
  • By gender expression: Cisgender men and women were more likely to feel comfortable discussing their identities with VHA providers compared to gender-diverse Veterans.
  • By sex at birth: Male- and female-born participants did not differ significantly in their comfort levels.
  • By sexual orientation: Heterosexual participants, when compared with sexual and gender minority participants, were significantly more comfortable discussing their sexual orientation, gender identity, and birth sex, and marginally more comfortable discussing their race/ethnicity.

An unexpected finding showed that disclosing race/ethnicity on a confidential VHA survey had the lowest comfort rating among participants (lower than disclosing SOGI information). Participants who identified as multiracial or “other” reported significantly less favorable perceptions reporting race/ethnicity on a survey or with providers compared with all other racial identities. Black participants reported less favorable perceptions of reporting race/ethnicity on a survey compared with White participants, while Native American participants reported significantly less favorable perceptions reporting race/ethnicity in discussion with providers compared with White participants.

Limitations to this study include a small number of sexual and gender minority participants, particularly those that are gender-diverse, which hindered the ability to examine the intersection of SOGI identities and race/ethnicity. Additionally, there is a possibility of selection bias and/or response bias among both VIP participants in general and study participants, with the possibility that participation in either favors those who are more comfortable discussing their identities. A more qualitative and/or observational approach would allow for gaining a better understanding of other factors that could impact Veterans’ comfort in discussing identity characteristics.

Conclusions

While participants were generally comfortable discussing their SOGI identities on VHA surveys and with VHA providers, cisgender and heterosexual participants were significantly more comfortable compared with sexual and gender minority participants. The unexpected observation that participants were less comfortable reporting their race/ethnicity on a VHA survey indicates that there is more work to be done to better identify and understand how Veterans’ identities intersect.

Understanding Veterans’ comfort in disclosing all types of sociodemographic information in VHA settings is essential to improving providers’ abilities to deliver appropriate care. Practices such as electronic health record modernization can aid in the collection of SOGI information and identifying health disparities among sexual and gender minority patients. This is well needed, as the trickle-down effects of discriminatory practices during military service can still be felt by the Veteran community.

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