Veterans Health Care

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Transgender Policy at the Veterans Administration in Boston

Veterans who would like to access the VA and would like a trans-friendly contact at the Jamaica Plain Hospital can contact Jillian Shipherd, PhD at 617-232-9500 ext 45821


DEPARTMENT OF VETERANS AFFAIRS

VA BOSTON HEALTHCARE SYSTEM

PATIENT CARE MEMORANDUM; SEPTEMBER 2007

MANAGEMENT OF TRANSGENDER VETERAN PATIENTS

1. PURPOSE:

To establish guidelines for the safe, ethical, and appropriate management of transgender individuals within VA Boston Healthcare System. This policy applies to any individual who self-identifies as transgender (an umbrella term, see definitions below) seeking care at any VA Boston Healthcare System facility. This policy applies irrespective of the veteran's status with regard to gender revision surgery and therefore includes those who have had gender revision surgery outside of VHA, those who might be considering such surgical intervention, and those who do not wish to undergo gender revision surgery but self-identify as transgender.

2. BACKGROUND:

Nationwide, there is a VA prohibition against providing gender revision surgery or sex reassignment surgery (SRS). However, VA Boston Healthcare System has a number of transgender patients seeking 'usual and customary' treatment. Some transsexual patients have completed or are en-route to full transition from one gender to another. This transition often takes years for a patient to fully complete; some never fully complete the transition. Moreover, other transgender individuals prefer to live outside the traditional boundaries of gender which may not necessitate surgical interventions or other elements of transition. Overall, research suggests that the proportion of individuals with veteran status is higher in the transgender population than in the general population of the United States. Thus, VA Boston Healthcare System cares for transgender patients who present at multiple points on this transition continuum, including individuals who are not seeking SRS. Thus, transition status cannot a prerequisite for providing appropriate healthcare.

3. POLICY:

a. When a transgender veteran presents for health care at any VA Boston Healthcare System facility, including specific male or female health issues, the veteran will be provided health care, consistent with VHA policies for all patients. Health care will be delivered to that veteran, based upon that veteran's self-identified gender, recognizing that unique health issues are associated with some transgender patients.

As an example, a male-to-female transsexual will be referred to as "she" in all contacts and documents irrespective of appearance and/or surgical history. It is appropriate for such treatment to occur in women's health clinics and in women's housing for residential and inpatient programs. If the veteran is taking hormone therapy, there are increased medical risks for breast cancer, pituitary and liver problems, as well as cardiovascular disease. Moreover, there may be screenings that are appropriate to conduct ( e.g., prostate exams) or not to conduct (e.g., pap smear) that are not typical procedure for staff in women's clinics. However, appropriate screenings to address these issues will occur and are the responsibility of the provider to monitor.

b. Veterans will be addressed, and referred to, on the basis of their self-identified gender (e.g. "she" for a male-to-female transgender individual), regardless of the veteran's appearance and/or surgical history. Computerized documentation of gender should also be consistent with the veteran's self-identified gender, including salutations on computer-generated letters to patients. Transgender veterans are encouraged to request this documentation change.

c. Room assignments and access to any facilities for which gender is normally a consideration ( e.g., restrooms) will proceed on the basis of self-identified gender, irrespective of appearance and/or surgical history.

d. As per Code of Federal Regulations Title 38, Chapter 17, Section 38.c, VA Boston Healthcare System does not provide surgery or funding of gender revision surgery (commonly referred to as sex reassignment surgery or SRS).

e. Hormonal therapy will be provided for a transgender patient in a manner consistent with the prevailing standard of care. Health care providers unfamiliar with this aspect of care will consult with providers who have this expertise. Referral to community providers and agencies for this care may be made as appropriate using Fee-for-Services payment as consistent with overall VHA guidelines.

f. Mental health services, including treatment for diagnoses recognized by the American Psychiatric Association will be provided as appropriate to the veteran's overall VHA plan of care. Referral to community providers and agencies for this care may be made as appropriate. Using Fee-for-Services payment will be consistent with overall VHA guidelines.

g. Providing care to transgender patients may present unique situations and clinical questions. These should be managed on a case-by-case basis, but always with adherence to the basic principles set forth in VA policy including M-2, Part XIV, Chapter 11 (November 17, 1993). As an example, it may be medically indicated that a male-to-female transsexual undergo an orchiectomy (removal of testes) to reduce exposure to testosterone agonists (known to have adverse side effects). This type of situation would be considered acceptable procedure. Referral to community providers and agencies for this care may be made as appropriate, using Fee-for-Services payment as consistent with overall VHA guidelines.

h. Transgender patients will be cared for in an environment of openness, respect and honesty. 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. Patient privacy and confidentiality will be protected in concordance with HIPAA guidelines.

i. VA Boston Healthcare System staff are responsible for the safety of all patients and are encouraged to manage negative reactions of patients/staff toward transgender patients as they would other instances of discriminatory behavior.

4. DEFINITIONS:

a. Sex: Biologically-based genital assignment at birth.

b. Gender: Self-determined identification reflecting internal experience, usually concordant with sex. This policy addresses cases where there is discordance between sex and gender.

c. Transgender: Transgender is an umbrella term used to capture a variety of gender expressions. It includes individuals that self-identify as transsexuals (male-to-female or female-to-male), cross-dressers, intersexed individuals, and those who do not fit into the binary gender categories of male and female. "Transgender" individuals challenge traditional notions of complete correspondence between sex and gender.

d. Cross-dresser: A man who dresses in typically female clothing either part-time (usually in private) or full-time but retains his male gender identity. In keeping with this policy, cross-dressing men should be addressed as "he" in all contacts and documents irrespective of appearance. Housing for residential and inpatient programs should be consistent with self-identified gender as male. Female cross-dressers are rare, due to societal acceptance of more varied appearances for women, but should also be treated in accordance with self-identified gender (female).

e. Intersexed: Intersexed (previously known as hermaphrodites) individuals are born with ambiguous genitalia (for genetic and/or hormonal reasons) but are often assigned male or female gender by others at birth ( e.g., parents), even though the individual may or may not later identify with the assigned gender.

f. Male-to-Female Transsexual: These individuals are assigned to male sex at birth but self-identify as female and often take steps to "transition" to female, including feminizing hormone therapy, electrolysis, and surgeries.

g. Gender revision surgery or sexual reassignment surgery (SRS): Any of a potential series of surgical procedures that can be done simultaneously or sequentially. "Full" or "Complete" SRS indicates that a patient has completed SRS and may or may not be receiving ongoing hormonal treatment. Surgical intervention is not a pre-requisite for any services including appropriate housing consistent with self-identified gender at residential and inpatient programs.

5. RESPONSIBILITIES:

a. Medial Center Director/ Chief of Staff will ensure a uniform, integrated system of care to meet the needs of transgender patients, excluding the provision of surgical gender revision. Further, the Director and Chief of Staff are responsible for assuring that health services to transgender veterans are provided in a manner consistent with care and management of all veteran patients. As such, care will be delivered in a manner that is equitable, consistent, accessible, respectful, and ensures continuity and quality.

b. Chief of Staff will ensure access to care, including gender specific care, consistent with overall VHA guidelines, and addressing any concerns related to discrimination based on gender.

c. Patient Advocate is responsible for the recording of any complaints related to care received by transgender individuals. These complaints will be brought to the attention of the Chief of Staff and Medical Center Director in addition to the supervisors and other appropriate persons within the organization.

d. Providers: All providers will deliver services and utilize techniques that are consistent with the patient's health care goals. Providers will deliver care in a manner that is equitable, consistent, accessible, respectful, and ensures continuity and quality. It is the responsibility of each provider to seek consultation when issues arise that are outside his/her scope of practice with regard to clinical management of transgender veterans (see Appendix A).

e. Transgender Liaison (if available) : Will consult with transgender veterans about accessing appropriate care and provide information about transgender care resources available outside of VHA.

f. Employees: All VA employees are responsible for the creation of a discrimination-free environment for transgender veterans to seek health care. Discrimination against veterans on the basis of gender-identity will not be tolerated.

6. PROCEDURES:

a. Guidelines for the medical management of transgender veterans should be consistent with those for veterans born with sex and gender concordance.

b. When requested, veterans will be given information about gender revision health care services available outside of VHA, as well as basic patient education and "Fact Sheets" about transgender-specific issues. See Attachment A for resources.

c. When transgender patients are hospitalized or in residential programs, private rooms and private showers may facilitate patient confidentiality and safety. In cases where private facilities are not available, transgender veterans will be housed with residents of the veteran's self-identified gender.

7. REFERENCES:

a. Code of Federal Regulations Title 38, Chapter 17, Section 38.c:

b. M-2, Part XIV, Chapter 11 (November 17, 1993): Department of Veterans Affairs, Veterans Health Administration Manual M-2, "Clinical Programs," Part XIV, "Surgical Service," Chapter 11, "Gender Reorientation (Sex Change)," and Chapter 12, "Plastic Reconstructive Surgery."

8. RESCISSION:

None

9. REVIEW DATE AND RESPONSIBILITY:

This policy will be reviewed annually by the Chairperson of the Diversity Committee (or designee) and be reissued no later that September 2010.

MICHAEL E. CHARNESS, MD

Chief of Staff