VA system issues memo on treating trans vets

"The thing is there are other facilities that are doing what is in this policy," said Monica Helms, president of the Transgender American Veterans Association (TAVA). "The difference is these other places don't have a written policy, so it's almost like the doctors that are there who treat transgender individuals, they decided this is how they're going to do it, and the only difference is Boston decided to put it down on paper."

She said she knows of about a dozen other VA hospitals and healthcare systems that provide inclusive healthcare for transgender patients, but TAVA has been pushing for them to put that policy in writing, and the Boston VA system is the first they know of to do so.

Diego Sanchez, former co-chair of the Massachusetts Transgender Political Coalition (MTPC), praised the memo's author, VA clinical psychologist Dr. Jillian Shipherd, for her commitment to ensuring that transgender patients receive adequate healthcare throughout the entire VA Boston Healthcare System. About 10 years ago when he was serving as director of JRI Health's TransHealth Education and Development Program, Sanchez said Shipherd contacted him and asked him to do staff trainings at the Jamaica Plain VA hospital. Sanchez and Holly Ryan, now co-chair of MTPC, did a series of trainings for the staff focused on three areas: General trans healthcare and barriers to care, HIV prevention for trans patients and mental health and substance abuse issues in the trans community. By about 2000 Sanchez said he began receiving positive feedback from trans patients about the treatment they received at the VA, particularly after the VA added an option for patients to identify as transgender on medical forms and began the practice of referring to patients according to their chosen name and gender pronoun.

Sanchez said by putting basic standards of care for transgender patients in writing, Shipherd has ensured that all providers in the Boston VA system understand their obligation to transgender patients.

"I'm absolutely delighted that she is able to do that at this time, and the reason is because policies require that everyone is competent," said Sanchez.

The memo mandates that veterans will be addressed and referred to by VA staff according to their self-identified gender both in verbal exchanges and in patient records. Patients will also be given rooming assignments and access to facilities such as restrooms based on their self-identified gender. The memo explains that while federal law prevents the VA from providing patients with sex reassignment surgery, the VA will provide hormone therapy and mental health services to transgender patients according to the accepted standards of care.

"Transgender patients will be cared for in an environment of openness, respect and honesty," reads the memo, in part. "A veteran's physical status, surgical history, hormonal status, and medications are private, but should be available to providers directly involved in the veteran's care. In this way the veteran is assured quality care, minimized risk of adverse pharmacological events (e.g., in the case of hormonal medication prescriptions), and provided with a supportive environment free of discrimination."

Shipherd said she began working on the memo about six months ago when she served as chair of the VA Boston Healthcare System's diversity committee because she wanted to ensure that all providers with the system were on the same page when it comes to trans health.

"I would say it's codifying the existing practice of those who had received some training, and it helps for those who haven't received training to know what to do," said Shipherd.

She said the memo is also meant to give transgender veterans the assurance that they will receive appropriate treatment at the VA. In the past, she said, many veterans assumed that providers who were providing certain treatments to trans patients like hormone therapy and mental health services were doing so under the radar of higher-ups in the VA system, and they felt that they had to be discreet in seeking out those services. Shipherd said the memo sends the message that transgender patients are just as entitled to healthcare through the VA as other patients.

"It's not about making sure you find someone who is sensitive to your needs. It's the policy of the VA Boston system. And I think providers welcome it as much as patients do because it makes things very straightforward," said Shipherd.

After she drafted the memo she sent it to all of the Boston VA's service chiefs to solicit their comments, and after the comment period Boston VA chief of staff Michael Charness signed the memo, making it official policy. Shipherd said she worried that the memo would meet opposition from within the VA, but none materialized.

"I have to tell you I have received nothing but positive and helpful comments. There have been no attempts to block this policy at all," said Shipherd.

Janice Josephine Carney, transgender liaison for New England GLBT Veterans and a Vietnam veteran herself, said she has been receiving services from the Boston VA system for the past 10 years, and she said Shipherd's memo is a welcome acknowledgement of the high standard of services already offered to transgender patients at the VA. She praised Shipherd and the Boston VA system for taking the step of writing their commitment to transgender health into official policy.

VA clinical psychologist Dr. Jillian Shipherd said the memo sends the message that transgender patients are just as entitled to healthcare through the VA as other patients."It's reaffirming that all the Boston facilities, how they treat transgender veterans. There's a big risk for her and the powers that be to make this statement," said Carney.

Carney added that the Boston VA's stance on trans health, including its willingness to provide hormones and therapy, could potentially put it at odds with the U.S. Department of Veteran Affairs. The only federal guideline around the treatment of transgender patients is a provision of the Code of Federal Regulations that says that the medical benefits package available to veterans "does not include the following: ... Gender alterations." Shipherd's memo interprets that provision as banning only sex reassignment surgery, but both Carney and Helms said other VAs have offered widely different interpretations of the language, with some banning hormone treatments and mental health services related to gender identity issues and, in a few cases, some VA facilities denying all treatment to trans patients.

"In rare occasions some will even say, 'No, we don't have to treat you at all.' That's become less and less of a problem, but in the rural areas that could be an issue, especially in the South," said Helms.

Carney said some within the trans community worry that by putting the policy in writing Boston could become a target of the federal government, which could order them to stop providing some forms of treatment to transgender patients. She said she believes there is little of danger of that as long as the Boston VA makes clear that it does not allow surgery.

"As long as they're not coming out and supporting the surgery in any way, shape or form I don't think the federal government will say [that they cannot provide treatment]. ... I think they're at that point now at the national level that they'd tolerate hormone treatment and psychological treatment," said Carney.

Helms said she worries about a backlash, but she also sees the Boston memo as an advocacy tool to improve transgender health coverage in VA facilities across the country. She said TAVA has been lobbying members of Congress on the Veterans Affairs committee to push for regulations around transgender healthcare at VA facilities, and they can use the Boston memo to show Congress that some facilities have already taken that step.

"We had a positive response [from committee members], but this is something new, and we hope we'll be able to approach them with this document, now that we have something written down, and say, how difficult would it be to do something like this on the national level? So that's in the infancy stage," said Helms.

Shipherd said she hopes the U.S. Department of Veterans Affairs will not oppose Boston's policy.

"The intent is to improve access for a group of veterans who traditionally, historically have trouble accessing appropriate healthcare. ... I would imagine people in Washington want all veterans to access appropriate care, so while I understand the fear I'm hoping that won't happen," said Shipherd.

While the Boston VA memo has been met with widespread praise among the trans veterans community, some have voiced concerns that the memo is weighted too heavily towards MTFs and gives very little information about healthcare for FTMs. While the memo defines transgender as an umbrella term including people who are FTM or MTF transsexuals, as well as cross-dressers, intersex people and others who fall outside the gender binary, all of the examples provided in the memo relate to MTFs. Additionally, the memo gives definitions of MTF, intersex, and cross-dresser, but it does not define FTM. Michael West, an FTM veteran who has been receiving healthcare through the Boston VA for about seven years, said that he contacted Shipherd after reading the memo and that she explained that the lack of information on FTMs was an unintentional omission and that more inclusive language and examples will be used whenever the policy is revised.

West said that medical providers at the VA often have comparatively little experience treating FTMs, and each time he sees a new provider at the VA he has to explain to them what it means to be FTM. He said a written definition of FTM and some examples about special health issues they might face would make it easier for FTM patients.

"Even in the community itself there's so many transwomen and cross-dressers that are veterans also, and there's very few of us that are transmen, but we are out there. ... I think it's a great start. The document has a lot of potential to do so much good in our community. And even on an educational trans 101 perspective it has the potential of goodness all around. It's just that we would like to see it be more inclusive of representing the entire community," said West.

Shipherd confirmed that the lack of information on transmen was an error and said when she wrote the policy she drew largely from her own experiences treating transgender patients, who have mostly been MTF.

"The criticism is absolutely correct. The policy is written the way it was written based on my experiences and the population I work with, and it was not meant to be a slight," said Shipherd. She said when the memo comes up for review in 2010 the language will be changed to make it more inclusive.

Sanchez said the policy very explicitly includes the entire transgender community in its protections, and he said that focusing on the lack of examples involving FTMs risks missing the bigger picture.

"FTMs are welcome today. This policy makes that clear. And having extended conversation about this particular case is off the topic of the fact that the VA has codified its commitment to serving trans people with competence and care. ... It's one of the few places that someone can go in and receive a mammogram and a prostate check in one visit without a single raised eyebrow, and that's an achievement," said Sanchez.