Mental Health of Transgender Veterans: Patients' Perspective on the Psychiatric Care Provided at the Local Department of Veterans Affairs Medical Center

Medical care quality and availability relate closely to an individual's geographic location, race or ethnicity, and other sociodemographic factors, including gender, education, and age. Due to difficulties with employment, lack of family support, and a high incidence of homelessness, the members of the transgender population appear to be at greater risk of exposure to healthcare-related disparities and discrimination. In addition, to healthcare access challenges, members of this population often encounter providers who lack adequate knowledge of transgender care and treatment resources. Although the World Professional Association for Transgender Health and the Veteran's Health Administration (VHA) have attempted to standardize the treatment options available to transgender individuals, little data exists regarding the benefits of the currently accessible treatment modalities. The issue is highly relevant to the veteran population because gender dysphoria (GD) is 5 times more prevalent among veterans than in the general public. In previous studies, scientists have revealed a need for additional publications that focus on evaluating the available interventions. These researchers indicate that transgender clients are more susceptible to mental health concerns and frequently use psychiatric emergency services. This scholarly project aimed to obtain objective information and elicit perceptual data from the transgender veterans receiving care at a local Veterans Affairs Medical Center (VAMC). The objectives of this project included (a) collecting demographic and mental health data to help estimate the prevalence of GD within the local VA mental health system and to identify the spectrum of services provided to transgender veterans in the specified setting; (b) gathering perceptual data from transgender veteran patients regarding their mental health needs; and (c) presenting the results of the data collection to stakeholders and the mental health nurse practitioners at the local VA facility. The data collected from the chart reviews and questionnaires supported the notion that individuals with GD/GID often have comorbid psychiatric conditions and are high utilizers of emergency psychiatric services. The information retrieved from the chart reviews helped to illustrate gaps in service utilization. Alongside, the perceptual data gained from the questionnaires provided clinicians with information regarding perceived effectiveness of currently offered interventions. In addition, this project gave veterans an opportunity to suggest actions that could enhance their treatment and to voice concerns about how they feel while receiving services at the identified location. The project findings supported the need for additional interventions. Although VHA initiatives on transgender care have helped to improve access to VA health benefits and standardized treatment options, more effort is necessary to change the environment at the facilities, improve providers' knowledge, and eliminate bias towards transgender individuals and their care.

Running head: MENTAL HEALTH OF TRANSGENDER VETERANS 1 Mental Health of Transgender Veterans: Patients' Perspective on the Psychiatric Care Provided at the Local Department of Veterans Affairs Medical Center Anna Kasabyan, RN, BSN University of Utah In partial fulfillment of the requirements for the Doctor of Nursing Practice MENTAL HEALTH OF TRANSGENDER VETERANS 2 Executive Summary Medical care quality and availability relate closely to an individual's geographic location, race or ethnicity, and other sociodemographic factors, including gender, education, and age. Due to difficulties with employment, lack of family support, and a high incidence of homelessness, the members of the transgender population appear to be at greater risk of exposure to healthcarerelated disparities and discrimination. In addition, to healthcare access challenges, members of this population often encounter providers who lack adequate knowledge of transgender care and treatment resources. Although the World Professional Association for Transgender Health and the Veteran's Health Administration (VHA) have attempted to standardize the treatment options available to transgender individuals, little data exists regarding the benefits of the currently accessible treatment modalities. The issue is highly relevant to the veteran population because gender dysphoria (GD) is 5 times more prevalent among veterans than in the general public. In previous studies, scientists have revealed a need for additional publications that focus on evaluating the available interventions. These researchers indicate that transgender clients are more susceptible to mental health concerns and frequently use psychiatric emergency services. This scholarly project aimed to obtain objective information and elicit perceptual data from the transgender veterans receiving care at a local Veterans Affairs Medical Center (VAMC). The objectives of this project included (a) collecting demographic and mental health data to help estimate the prevalence of GD within the local VA mental health system and to identify the spectrum of services provided to transgender veterans in the specified setting; (b) gathering perceptual data from transgender veteran patients regarding their mental health needs; and (c) presenting the results of the data collection to stakeholders and the mental health nurse practitioners at the local VA facility. The data collected from the chart reviews and questionnaires supported the notion that individuals with GD/GID often have comorbid psychiatric conditions and are high utilizers of emergency psychiatric services. The information retrieved from the chart reviews helped to illustrate gaps in service utilization. Alongside, the perceptual data gained from the questionnaires provided clinicians with information regarding perceived effectiveness of currently offered interventions. In addition, this project gave veterans an opportunity to suggest actions that could enhance their treatment and to voice concerns about how they feel while receiving services at the identified location. The project findings supported the need for additional interventions. Although VHA initiatives on transgender care have helped to improve access to VA health benefits and standardized treatment options, more effort is necessary to change the environment at the facilities, improve providers' knowledge, and eliminate bias towards transgender individuals and their care. Committee: DNP Project Chair: Michael Johnson, PhD, APRN Specialty Track Director: ElLois W. Bailey, DNP, PMHNP-BC Assistant Dean for MS & DNP programs: Pamela Hardin, PhD, RN Content experts: LGBT Veterans Care Coordinator, Breeze Hannaford, LCSW Salt Lake County Health Department Supervisor Therapist Heather Kunz, MSW, CS MENTAL HEALTH OF TRANSGENDER VETERANS 3 Table of Contents EXECUTIVE SUMMARY .............................................................................................................2 PROBLEM STATEMENT ..............................................................................................................4 CLINICAL SIGNIFICANCE & POLICY IMPLICATIONS .........................................................5 PURPOSE ........................................................................................................................................6 OBJECTIVES ..................................................................................................................................6 LITERATURE REVIEW ................................................................................................................6 Literature Search Strategy........................................................................................6 Gender Dysphoria ....................................................................................................7 Treatment Options and Standards of Care ..............................................................8 Disparities Faced by Transgender Individuals .........................................................9 Comorbidities and Services Utilization .................................................................12 THEORETICAL FRAMEWORK .................................................................................................13 IMPLEMENTATION ....................................................................................................................14 EVALUATION..............................................................................................................................15 RESULTS ......................................................................................................................................17 Objective Data .......................................................................................................17 Perceptual Data ......................................................................................................19 Limitations .............................................................................................................21 RECOMMENDATIONS ...............................................................................................................21 DNP ESSENTIALS .......................................................................................................................23 CONCLUSIONS............................................................................................................................24 REFERENCES ..............................................................................................................................26 APPENDIX A: RESULTS ............................................................................................................31 APPENDIX B: PROPOSAL DEFENSE POWERPOINT ............................................................35 APPENDIX C: IRB APPROVAL CONFIRMATIONS ...............................................................40 APPENDIX D: QUESTIONNAIRE..............................................................................................43 APPENDIX E: POSTER PRESENTATION.................................................................................46 APPENDIX F: POWERPOINT PRESENTATION ......................................................................47 MENTAL HEALTH OF TRANSGENDER VETERANS 4 Mental Health of Transgender Veterans: Patients' Perspective on the Psychiatric Care Provided at the Local Department of Veterans Affairs Medical Center Problem Statement The quality and availability of medical care coincide with an individual's geographic location, race or ethnicity and other sociodemographic factors, including gender, education, and age (U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality [AHRQ], 2015). Members of the transgender population appear to be at a higher risk of exposure to healthcare-related disparities and discrimination. Based on data from the National Transgender Discrimination Survey, 90% of surveyed transgender individuals reported harassment or discrimination, 19% experienced homelessness at some point, and 57% reported some degree of family rejection (Grant et al., 2011). Homelessness, difficulties with employment, and a lack of family support have a significant impact on an individual's quality of life, as well as their physical and emotional wellbeing. Aside from encountering challenges with health care access, members of this community often face refusal of care and lack of clinical competency among health care professionals in treating transgender patients. Nearly 50% of a sample reported an insufficient knowledge level among providers regarding transgender care (Grant et al., 2011). The findings of the National Transgender Discrimination Survey helped to facilitate changes in treatment guidelines of individuals with gender identity disorder (GID) and gender dysphoria (GD). In 2011, the VHA issued a national directive to standardize the treatment of transgender veterans, and this had a great impact on their care. It is important to mention that gender dysphoria is five times more prevalent among the veteran population, compared to the general public MENTAL HEALTH OF TRANSGENDER VETERANS 5 (Blosnich et al., 2013). In the two years following release of the VHA directive, the number of transgender individuals receiving mental health services and hormone therapy at the VA facilities had increased by 40% (Kauth et al., 2014). The number of transgender veterans seeking help continues to grow; however, limited information is available regarding the helpfulness of current interventions. An inadequate amount of research exists examining the impact of the resources on the overall mental health of transgender veterans. The VAMC is the only local medical facility recognized as a leader in LGBT healthcare equality. Information provided by the veterans could help mental health providers understand the needs of transgender veterans. Clinical Significance and Policy Implications The transgender veteran client panel at a VAMC serving the Intermountain West consists of predominantly middle-aged to older individuals transitioning from male-to-female, with fewer cases for female-to-male transitions (The Endocrine Society, 2016) and the vast majority of these veterans served in military forces. In their responses to the National Transgender Discrimination Survey (Grant et al., 2011), many transgender individuals indicated that they experienced harassment, physical violence and sexual violence throughout their lives. The combination of those factors drastically increases the risk for suicide attempts among transgender veterans. Information provided by the program coordinator (B. Hannaford, personal communication, November 10, 2016) indicated that members of their client-panel often utilize emergency room services for psychiatric crisis evaluations and frequently require inpatient psychiatric admission. The Substance Abuse and Mental Health Services Administration (2012) reported that members of the LGBT community are at significantly higher risk of abusing mind-altering substances and require treatment programs tailored to their needs. MENTAL HEALTH OF TRANSGENDER VETERANS 6 A better understanding of transgender veterans' perspectives on the psychiatric care and interventions provided through the Intermountain West VAMC LGBT program will directly benefit members of the treatment team, facility, and veterans. Therefore, the stakeholders of this project would be members of the gender dysphoria team, the LGBT program coordinator, and transgender veterans. The findings of the project may help to evaluate adequacy and benefits of currently provided mental health services. Purpose The overarching goal of this scholarly project is to improve patients' healthcare outcomes through the providers' enhanced understanding of the mental health needs of transgender veterans treated in the outpatient psychiatric setting. Objectives 1. Collect demographic and mental health data to estimate the prevalence of gender dysphoria within the local VA mental health system and to identify the spectrum of services provided to the transgender veterans at the specified setting. 2. Gather perception data from transgender veteran patients regarding their mental health needs. 3. Present results of the data collection to the stakeholders and mental health providers at the local VA facility. Literature Review Literature Search Strategy The following literature review summarizes information extracted from 10 peer-reviewed articles and 2 diagnostic manuals. Due to the limited number of evidence-based publications in the area of interest, the synthesis of the review includes sources with level 2 and 3 evidence from PubMed, Medline Plus, and CINAHL databases. The search terms "transgender AND mental MENTAL HEALTH OF TRANSGENDER VETERANS 7 health," "transgender veterans AND care," and "transgender AND veterans" helped to identify a large number of publications. Specifications for publication date, article type, and language filters narrowed the results of the search. Gender Dysphoria Diagnostic criteria. In Diagnostic and Statistical Manual of Mental Disorders [DSM]-V, the American Psychiatric Association [APA] defines gender dysphoria (GD) as differences between the individual's biological phenotype and primary and/or secondary sex characteristics (as opposed to expressed or experienced gender), which have been persistent for longer than 6 months. The person with gender dysphoria must identify and verbalize a desire to function as an individual of the opposite gender in order to meet diagnostic criteria. The condition is associated with significant distress or impairments in important areas of functioning (APA, 2013). Prevalence. Many challenges affect data accuracy on the number of individuals diagnosed with gender dysphoria. Public stigma towards transgender individuals, fear of mistreatment in a healthcare setting, limited access to care, and numerous other socioeconomic factors influence the number of individuals who seek psychiatric help and receive proper diagnoses. The prevalence of the condition varies between genders, at 0.005% to 0.014% among natal males and 0.002% to 0.003% for natal females (APA, 2013). Based on the data presented in the Report of the National Transgender Discrimination Survey, 60% of surveyed individuals were males at birth; 83% of responding transgender individuals identified as white Caucasian. Of the 6,377 individuals who completed the survey, 1,261 stated that they had served in military forces (Grant et al., 2011). Current literature supports the notion that gender dysphoria is more prevalent among individuals with a military background than in the general public (Blosnich et al., 2013). The hypermasculinity theory has MENTAL HEALTH OF TRANSGENDER VETERANS 8 been the most prevalent explanation for this phenomenon. The desire to become "a real man" by engaging in masculine activities appears to be the driving force of these behaviors (Blosnich et al., 2013). Course of illness. Gender dysphoria differs in its presentation among children, adolescents, and adults. The variations in DSM-V criteria reflect that differentiation. Incongruences between experienced gender and somatic sex cause a higher level of functional impairment and emotional distress among adult and adolescent transgender individuals. Children experience and react to gender identity issues in a more concrete and behavioral manner (APA, 2013). The transgender patient panel at the local VA mental health facility consists primarily of individuals ages 40 to 70. A majority of the members have comorbid psychiatric conditions (The Endocrine Society, 2016). Treatment Options and Standards of Care Treatment of gender dysphoria and associated conditions requires a multidisciplinary approach (Coleman et al., 2011). A team of providers commonly includes reproductive specialists, surgeons, endocrinologists, mental health providers, speech therapists, and primary care providers. Since the second half of the 20th century, treatment approaches maintain the same primary focus, which centers on facilitation of physical transformations. Hormone replacement therapy and gender reassignment surgery are often necessary to alleviate distress and promote functioning among individuals suffering from gender dysphoria (Coleman et al., 2011). More recent data suggests that some individuals achieve satisfaction and comfort through hormonal therapy combined with gender expression coaching and psychotherapy (Coleman et al., 2011). For an extended period, psychiatric providers were gatekeepers determining the seriousness of those attempting to undergo the transition, but the scope of their practice has MENTAL HEALTH OF TRANSGENDER VETERANS 9 broadened over time. Currently, they help to treat the comorbid psychiatric conditions that often include substance use and chronic suicidality. In addition, mental health professionals assist clients with gender dysphoria through affirmation and promotion of resilience and positive selfimage (Coleman et al., 2011). Triggered by reported health care disparities among transgender veterans, in 2011 the Department of Veterans Affairs published the first directive identifying health care standards for transgender and intersex veterans. The VHA mandated standardized transgender care across all VA facilities with zero tolerance of harassment and maltreatment. The most recent benefit package modification of the directive includes hormonal therapy, mental health, and supportive services as well as perioperative and postoperative care (National Center for Transgender Equality, 2011). However, the directive excludes gender reassignment surgical procedures. This exclusion creates controversy among health care providers and dissatisfaction in the veterans, but meets flexible international standards of care (Coleman et al., 2011). Disparities Faced by Transgender Individuals Sociodemographic factors. Sociodemographic factors strongly influence health access and the quality of long-term care. Family support positively correlates with stable housing and a lesser likelihood of suicide attempts and engagement in destructive behaviors (Grant et al., 2011). Blosnich et al. (2013) describe an association between adequate state employment, discrimination/hate crime protection and a reduction in self-directed violence among transgender individuals. Exogenous factors can either protect against or aggravate the dysphoria associated with gender identity disorder. The results of a nationwide, comprehensive assessment of discrimination against transgender and gender non-conforming individuals helped gather MENTAL HEALTH OF TRANSGENDER VETERANS 10 information related to prejudice against people with gender dysphoria in education, employment, health, family life, housing, public accommodations, identification documents, and police interaction (Grant et al., 2011). More than 60% of surveyed transgender individuals experienced serious acts of harassment or discrimination, 19% reported homelessness, and 57% stated that they had experienced rejection and estrangement from their families. Transgender individuals are at significantly higher risk of harassment and bullying at school and are more likely to be victims of physical (61%) and sexual (64%) assaults (Grant et al., 2011). Reisner et al. (2015) suggested that youth with GID bear an increased health burden when compared to their cisgender peers. They present with two to three times higher rates of depression, anxiety, and suicidal ideation and have a 50% higher rate of utilizing inpatient health services. Healthcare disparities. The percentage of uninsured is disproportionally high among individuals with GD compared to the general public. Services needed for gender transformation are expensive and frequently not covered by insurance companies, which greatly limit transgender individuals' access to care (Johnson, Mimiaga, & Bradford, 2008). Aside from an inability to afford healthcare services, clients with GD often avoid medical settings in anticipation of anti-transgender bias and discrimination. Of the 6,450 transgender and gender nonconforming people who responded to the national survey, 28% indicated that they had postponed medical care when sick or injured due to fear of discrimination, and 48% stated that they did not access services due to a lack of financial resources (Grant et al., 2011). Healthcare providers had refused medical care to nineteen percent of the respondents at some point in their lives (Grant et al., 2011). MENTAL HEALTH OF TRANSGENDER VETERANS 11 Based on the findings of the Lambda Legal Health Care Fairness Survey (2010), which captured data from 4,916 LGBT individuals, approximately 27% of transgender and gendernonconforming respondents had experienced denial of medical care, 20.9% had been victims of harsh and abusive language, and 7.8% had been physically mistreated by healthcare professionals. Among individuals with GD or GID who sought treatment in medical facilities, many questioned their care providers' competency. In a study by Lutwak et al. (2014), 89% of transgender care recipients stated that their providers were unacquainted with their unique needs. Transgender individuals are less likely to receive preventative care or non-acute medical treatment. When these factors combine with a high incidence of risky behaviors, comorbid substance use, frequent cardiovascular complications, and heightened HIV rates, the consequences are worsened health outcomes and declines in life expectancy. Lack of LGBT-focused training and education. Although the vast majority of providers feel comfortable working with members of the LGBT community, they often have an inadequate level of knowledge related to the treatment of those individuals' multifaceted conditions and require guidance in providing culturally competent care (Mattocks et al., 2014). When asked to rate their LGBT-related curricula, medical students from 170 schools expressed uncertainty about their level of competency and preparedness to address the specific needs of this subgroup of the population and rated their curricula as "fair" or worse (White et al., 2015). A longstanding history of anti-transgender bias in healthcare has shaped our current disparities in GD care. Researchers suggest that a culturally sensitive and patient-focused communication style can help providers to establish a working alliance with LGBT patients and promote health-related behavioral changes (Utamsingh, Richman, Martin, Lattanner, & Chaikind, 2015). The Veterans Health Administration recognizes the importance of ongoing staff MENTAL HEALTH OF TRANSGENDER VETERANS 12 education concerning GD/GID-related care (Kauth et al., 2014) and created seven 1-year postdoctoral psychology fellowships from 2013 to 2014 to help prepare champions of sexual and gender minority (SGM) care. Comorbidities and Services Utilization As indicated by Healthy People 2020 (n.d.), transgender individuals are at significantly higher risk of contracting HIV/STDs. They are more prone to substance use and suicidality, and three times more likely to suffer from major depressive disorder and generalized anxiety disorder (National Alliance on Mental Illness, n.d.). Experts link some of the medical and psychiatric comorbidities to gender-transforming interventions including hormone-related cardiovascular events, infertility and malignancies, exacerbation of affective disorders, and suicidal ideation (Feldman et al., 2016). Members of the LGBT community have a higher incidence of alcohol and tobacco use disorders and often exhibit treatment resistance to conventional interventions (Substance Abuse and Mental Health Services Administration, 2012). Transgender veterans appear to be the most vulnerable members of the LGBT community. GID-diagnosed veterans are 20 times more likely to endorse suicidality or engage in self-directed violence than the general VHA population (Blosnich et al., 2013). Nearly 50 percent of transgender veterans experienced hospitalization due to suicide-related events, and 90 percent have comorbid psychiatric diagnoses other than GID; the most frequent is posttraumatic stress disorder (PTSD). Based on the findings of locally conducted research, PTSD affected 46% of the sample, 41% had comorbid major depressive disorder (MDD), and one-third of the participants suffered from substance use disorders (SUD) (The Endocrine Society, 2016). Clearly, the data support the need to emphasize improvements in transgender care quality. Members of the LGBT community present with a unique set of triggers, values, and MENTAL HEALTH OF TRANSGENDER VETERANS 13 stresses, which providers should understand and address in order to promote successful treatment outcomes. Theoretical Framework The model for change, a theoretical framework used to guide implementation of the evidence-based changes into clinical practice, was the guide for this project. Rosswurm and Larrabee (1999) created this model to support health professionals through the transformation process into evidence-driven medicine. A drastic increase in research studies during the past few decades has triggered a paradigm shift in health care. The ability to explore, examine, and integrate research findings into clinical practice has become a new standard of care. The model for change facilitates the synthesis of theoretical knowledge, research findings, and empirical evidence. Rosswurm and Larrabee (1999) used change theory as the foundation for the model. The theory consists of six essential steps: assessment, linking, synthesis, design, implementation, integration, and maintenance (Rosswurm & Larrabee, 1999). The initial step, assessment of internal data, allows the practitioner to examine current practices and gather evaluative information. The foundation of this project is the collection of internal data provided by the recipients of mental health care services at the local VA facility. The model of change provides theoretical foundations for the standardization and synthesis of information gathered through questionnaires and the literature review (Rosswurm & Larrabee, 1999). As outlined in the model's processes, a comparison between internal data and external standards of care will serve to justify the need for a change. The second step of the model classifies the information and identification of potential interventions (Rosswurm & Larrabee, 1999). This step correlates with the project implementation plan, which includes the synthesis of statistical findings and discussion of MENTAL HEALTH OF TRANSGENDER VETERANS 14 proposed interventions. The framework may help to assess the feasibility of the evidence and critique selected outcomes. The purpose of this project is to enhance providers' understanding of transgender veterans' mental health needs and recommend interventions for change. The objectives closely correspond with three initial steps of the model, which pertain to internal data assessment, evaluation, and synthesis of collected evidence. Implementation Demographic data collection involved the gathering of objective information from electronic medical record reviews at the local VA facility. This process revealed thirty charts of individuals with ICD-9 and ICD-10 codes for gender identity disorder and gender dysphoria through which it was possible to detect and classify the mental health services those transgender veterans received. In addition, the findings from research conducted at the local VAMC by endocrinologist, Dr. Marissa Grotzke, which measured the prevalence of gender identity disorder and comorbidities among veterans, supplemented the statistical data collected for this subgroup of patients. The project entailed development of a questionnaire with the assistance of content experts, to obtain data on how transgender veteran patients perceived the mental health care they have received. Following the project defense in October 2016, the University of Utah Institutional Review Board (IRB) and VA Central IRB granted approvals. The transgender support and empowerment group meets twice a month, and participants were enrolled during two meetings where they received information pertaining to the questionnaires. Synthesis of the data collected from the chart review and the questionnaires formed the basis of the project results. Attendees at a bimonthly multidisciplinary gender dysphoria team meeting heard and discussed the findings and proposed interventions. Members of the group, the project chair, and MENTAL HEALTH OF TRANSGENDER VETERANS 15 the content expert provided feedback for a later educational presentation to the mental health providers at a local VA facility. Evaluation To evaluate Objective 1, which included the IRB application process and collection of demographic data, both the University of Utah IRB and, subsequently, the VA Central IRB granted approvals. The University of Utah and the VA IRB categorized this scholarly project as a low-risk research study, as opposed to a quality improvement project. Based on this determination, the VA research coordinator decided to deny access to the Computerized Patient Record System data pull, which impeded the possibility of obtaining more inclusive data. A request for the demographic and prevalence information through alternative routes, such as the VA Informatics and Computing Infrastructure database, would have violated the IRB-approved protocols. An inadequate amount of time was available to make alterations to the IRB application, therefore the project continued with chart reviews, following the original, IRBapproved protocols. With exclusion of prevalence data, this satisfied Objective 1. Successful completion of perceptual data collection and presentation of the detailed findings to the stakeholders and metal health providers fulfilled Objectives 2 and 3. The content expert and project chair approved the questionnaire designed to collect perception data among transgender veterans at the local VA facility. The process involved statistical data analyses conducted by using the Excel program. A PowerPoint presentation included graphic and narrative summaries of the project's findings and a discussion of proposed future interventions. The project chair and content expert provided feedback for incorporation into the final presentation, which mental health advance practice-nursing providers (APRNs) received during a monthly APRN meeting. MENTAL HEALTH OF TRANSGENDER VETERANS 16 Implementation and Evaluation Plan Objectives 1. Collect demographic and mental health data to estimate the prevalence of gender dysphoria within the local VA mental health system and identify the spectrum of services provided to transgender veterans. 2. Gather perception data from transgender veteran patients regarding their mental health needs. 3. Present results of the data collection to the mental providers at the local VA facility. Implementation Evaluation Obtain demographic data from the electronic medical records chart review. Demographics and mental health service utilizations data obtained. Identify mental health services used by the veterans with GD. Information from the literature review summarized. Systemize data gathered from the literature review related to transgender veteran care. UU and VA IRB approvals obtained. Request UU and VA IRB approval. Develop a questionnaire with the help of the content expert to assess transgender veterans' perceptions of the received mental health services. Questionnaire approved by the content expert and project chair. Recruit participants during bimonthly transgender support group meetings. 12 transgender veterans completed the questionnaire. Analyzed collected statistical data. Synthesize and organize statistical findings. Incorporated the feedback provided by the project chair, content expert, and members of multidisciplinary gender dysphoria team into final presentation. Develop PowerPoint presentations detailing findings. Discuss findings and proposed interventions during Educated VA PMH bimonthly multidisciplinary APRNs about current gender dysphoria team standards of care for meetings. transgender veterans, perception data, and proposed plans of action. MENTAL HEALTH OF TRANSGENDER VETERANS 17 Results Objective data The review of records included thirty charts of individuals with a GD or GID diagnosis. Based on the information retrieved from the local research conducted by Dr. Marissa Grotzke in 2015, 39 clients at the identified VA medical center had a diagnosis of GD or GID (The Endocrine Society, 2016). Taking into consideration the rapidly increasing number of transgender individuals seeking assistance through local VA facilities, the endocrinologist working with the multidisciplinary gender dysphoria team estimates the current number of transgender patients on the panel at 73 (M. Grotzke, personal communication, March 24, 2017.) In light of this information, the 30-chart segment appears to be an adequate sample size, as it approximates the number of previously identified GD or GID clients. Overall, there were 22 (73%) male-to-female and 8 (27%) female-to-male transgender veterans. The individuals' ages ranged from 28 to 74, with a median age of 49. The majority (n = 29 or 97%) had comorbid psychiatric conditions. The most prevalent conditions identified during chart reviews included MDD, SUD, PTSD, and anxiety disorders. More than a half (n = 17 or 57%) of the veterans suffered from depressive disorders, 43% (n = 14) had comorbid substance use disorder, 30% (n = 9) had received a PTSD diagnosis, and 20% (n = 6) struggled with anxiety conditions. Five veterans (17%) suffered from serious mental illness including bipolar disorder and schizophrenia, 3 veterans (10%) had eating disorders, and 2 (7%) had personality disorders. The main goal of the chart reviews was to identify service utilization among transgender individuals within the past 2 years, including emergency and maintenance care. The emergency department (ED) providers and the crisis teams had evaluated 13 of the veterans (43%) from MENTAL HEALTH OF TRANSGENDER VETERANS 18 January 2015 to February 2017 due to psychiatric emergencies, 16% (n = 5) visited the ED once, 23% (n = 7) had two mental health-related emergency visits, and 3% (n = 1) had three visits. The vast majority of the emergency room evaluations were related to voiced suicidal/homicidal ideations (SI/HI) and self-harm behaviors (n = 20 or 91%). Eleven veterans (36%) had entered inpatient psychiatric units. Among the 13 admissions, SI/HI precipitated 10, and suicide attempts, self-harm behaviors, and alcohol detoxification triggered the rest. Table 1 (see Appendix A) presents the frequencies of mental health related ED visits and hospitalizations. Of the 11 veterans who entered inpatient psychiatric units, 64% (n = 7) suffered from comorbid tobacco use disorder, 64% (n = 7) had depressive disorder diagnoses, 36% (n = 4) had PTSD, and 27% (n =3) suffered from eating disorders and military sexual trauma, and two individuals (18%) had bipolar disorder diagnoses. In regard to non-emergency services provided through the local VAMC, 90% (n = 27) of the 30 veterans in the reviewed charts received individual psychotherapy, 70% (n = 21) saw an endocrinologist, and 63% (n = 19) received hormonal therapy. Primary care and psychiatric providers within the local VA healthcare system have seen 67% (n = 20) of the identified individuals. Twenty individuals (67%) participated in group therapy treatments, 13 (43%) saw a peer support specialist in the past two years, 33% (n = 10) enrolled in PTSD related treatments, 23% (n = 7) were in contact with the homelessness program, 27% (n = 8) of veterans were using vocal coaching, and 20% (n = 6) were participants in a vocational rehabilitation program. Six veterans (20%) attended Dialectical Behavioral Therapy groups, but only 16% (n = 5) of the individuals used recreational services and 10% (n = 3) had substance-related treatments or nutrition consults. Table 2 (see Appendix A) presents the frequencies and percentages of program utilization. MENTAL HEALTH OF TRANSGENDER VETERANS 19 Perceptual data The analysis of questionnaires distributed and collected during two transgender support groups provided veteran perceptual data. The participants of this project identified services they utilized at the local VA facility and rated their effectiveness on a 1 to 10 scale, with a 10 indicating highest effectiveness. All the participants were at least 21 years old. They completed and returned 12 questionnaires by the end of the second transgender support group meeting. Of these 12 questionnaires, participants only fully completed 8. This project's data analysis includes all questionnaires. Table 3 (see Appendix A) presents average ratings of the services and percentages of service utilization. Based on the results of the questionnaire, VA providers referred 42% (n = 5) of the respondents to the GID or GD-related treatments and 58% (n = 7) of the respondents referred themselves. The majority of the participants (n = 11 or 92%) received individual psychotherapy treatments. Participants rated these treatments, on average, at 8.2 out of 10. Most participants (n = 11 or 92%) also saw endocrinologists and primary care providers (n = 10 or 83%) at the VA facility. On average, participants rated the endocrinology treatments at 7.6 out of 10, and rated primary care services as 7.9 out of 10. More than half (n = 7 or 58%) of the participants saw peer support specialists (PSS), and rated the efficacy of PSS services as 8.3. Less than half of the participants (n =5 or 42%) underwent PTSD-related treatments, participated in the homelessness program, attended recreational activities, or saw speech therapists. Participants rated the PTSD treatments on average, as 7.0 out of 10 and recreational therapy as 7.6. They awarded the vocal coaching services and the homelessness program an average score of 8.6. Four participants (33%) utilized the case management services and 3 veterans (25%) were involved in vocational rehabilitation program. Participants rated those services at a 7.3 for vocational rehabilitation and 8 out of 10 for case management. MENTAL HEALTH OF TRANSGENDER VETERANS 20 The overall satisfaction rate for the services received at the facility related to GID/GD was 8.1, indicating high satisfaction. The overall effectiveness rating of the services received was 8.3, indicating high effectiveness. During this project, participants also reflected on the qualities of their mental health (MH) providers and expressed their concerns related to the services in identified setting. Table 4 (see Appendix A) presents the patient perceptions of mental health clinicians and concerns related to MH services. All participants agreed or strongly agreed that their MH providers were gender sensitive, competent, and receptive to patients' ideas. Two participants (17%) indicated that they neither agreed nor disagreed that their MH providers were fully aware of their unique needs, stressors, and triggers. More than half of the participants (n = 8 or 66%), indicated that they had privacy and confidentiality concerns while receiving mental health services. Three participants (25%) expressed worries about safety and the potential for discrimination by MH providers. Twenty-five percent of the participants (n = 3) expressed concerns about forced treatment, and six participants (50%) were worried about discrimination from other patients. In the last portion of the questionnaire, participants answered open-ended questions that allowed them to express their perceptions and identify needs. Three participants (25%) stated that support groups are the most important aspect of their care. The same number of participants (n = 3 or 25%) perceived individual psychotherapy interventions as the most valued and important service. They also listed primary care service, overall health, and hormone therapy as valued and important treatment modalities. In response to questions about potential changes in services that to better meet their psychiatric and medical needs, the participants suggested the following: (a) gender reassignment surgery coverage; (b) access to cosmetic surgeries; (c) improved accessibility of psychiatric and mental health providers; (d) injectable estrogen instead MENTAL HEALTH OF TRANSGENDER VETERANS 21 of estrogen pills; (e) information about available resources; and (f) information about alternative treatment options, including herbal supplements. Limitations Due to the lack of access to system-wide data from the electronic health record utilized at the VAMC, this project lacks information about the prevalence of GID and GD. Based upon previous research by Dr. M. Grotzke, this information would help illustrate changes in the number of transgender veterans seeking services at the local VA facility. The estimated number of veterans receiving services at the facility is more than double the number of charts evaluated in this study. This may affect the generalizability of the results. Therefore, one must interpret this project's results with caution and should not generalize them to the wider population. The data analysis includes only services received within a 2-year period, therefore a wider time frame for service utilization review could provide a more comprehensive picture. A limited number of participants completed and returned questionnaires. In addition, participants had limited time to complete the questionnaire. Since the project's guidelines restricted recruitment of participants to those in the transgender support group, veterans who did not attend were unable to share their perceptions. Recruitment that is more inclusive and a larger time frame could produce a higher number of participants and completed data. Recommendations The data collected from the chart reviews and questionnaires supports the notion that individuals with GD or GID often have comorbid psychiatric conditions and are high utilizers of emergency psychiatric services. This is congruent with research findings published in recent literature (Mizock, 2017). Information from electronic charts supports the conclusion that MENTAL HEALTH OF TRANSGENDER VETERANS 22 individual psychotherapy and endocrinology services seem to be the most highly utilized treatment modalities at this clinical site. Conversely, in the past 2 years, a limited number of transgender veterans either participated in recreational therapy and homeless and vocational rehabilitation programs, or received substance use treatment and family therapy. The limited use of those services was unexpected since a large number of transgender individuals experience homelessness, difficulties with employment, and rejection by family members, and have a history of exposure to violence and trauma (Grant et al., 2011). This subgroup of the population often demonstrates co-occurrence of depressive disorder, anxiety, substance use, and PTSD. This phenomenon correlates with worsened patient outcomes. Lack of concurrent treatment of gender dysphoria and comorbid psychiatric conditions may cause significant distress and interfere with the recovery process (Coleman et al., 2011). To better understand the problem's underlying etiology, further evaluation is necessary. The assessment of the barriers preventing transgender veterans from utilizing the full spectrum of available services is a necessary precursor for the development of an effective intervention plan. Four out of the 14 services rated by veterans received a score of 5 or less, with 10 as the highest or the most effective. Multiple factors could influence those ratings, including specificity of the clinical setting in which medical professionals offered treatments as well as staff awareness and knowledge related to transgender veteran care. Further exploration of these issues could help to customize future interventions in order to improve average effectiveness ratings for those services. The U.S. government repealed the military "Don't Ask, Don't Tell" policy in 2011 as an attempt to terminate discriminatory treatment based on sexual orientation (Harrison-Quintana & Herman, 2012). However, the change did not affect the status of transgender individuals in the MENTAL HEALTH OF TRANSGENDER VETERANS 23 military, who cannot join the U.S. armed forces if their transgender status is disclosed (Gates & Herman, 2014). Half of the participants expressed concerns related to harassment by other patients, and 66% of the sample expressed worry about their confidentiality and privacy. It is likely that societal and internalized transphobia are intensifying veterans' levels of discomfort and fear. Promotion of educational opportunities related to gender dysphoria among clinicians and the general patient population may lessen the stigma surrounding gender dysphoria. In addition, the congregation of all services related to GID/GD in one clinical setting could help to alleviate worries associated with harassment and promote a safe and comfortable environment for this group of veterans. More extensive research studies are needed to produce statistically significant results. Scientifically supported evidence is a powerful tool that could drastically change the standards of treatment for transgender veterans. DNP Essentials The concept of the strong interconnection between body and mind is not new in healthcare. Nevertheless, medical specialists often segregate their practices in the silos of their own fields, with minimal interaction among providers. The American Association of Colleges of Nursing [AACN] (2006), in the Essentials of Doctoral Education for Advanced Nursing Practice, emphasized the importance of "Interprofessional collaboration for improving patient and population health outcomes" (AANC, 2006, p. 14). This project supports initiatives for interdisciplinary alliance and patient-centered care. Gender dysphoria is a unique psychiatric condition, which requires a collaborative treatment approach among psychiatric and medical professionals. Worldwide standards of care for transgender individuals indicate the need for MENTAL HEALTH OF TRANSGENDER VETERANS 24 hormonal therapy and possible surgical interventions to alleviate symptoms associated with the condition (Coleman et al., 2011). The collaborative work of psychiatric providers, endocrinologists, primary care providers, and speech therapists produces positive treatment outcomes. The ultimate goal of the project is to improve the treatment outcomes among transgender veterans at the local VA mental health clinic. Comprehensive evaluation of the currently provided treatment requires veterans' reflection on the psychiatric care they receive, as well as evaluation of the team's efforts. Interprofessional collaboration is critical in this setting. Although each team member has a unique set of skills, diagnostic and prescriptive abilities, all share the responsibility to maintain patients' safety and well-being. Conclusion More than 15,000 transgender individuals are currently serving in the military forces (National Center for Transgender Equality, n.d.) and nearly 5,000 transgender veterans are receiving services nationwide at local VA facilities (Cramer, 2017). Transgender veterans are at a significantly higher risk of experiencing psychiatric and medical health disparities (Brown & Jones, 2016). Although VHA initiatives on transgender care have helped to improve access to VA health benefits and standardized treatment options, more effort is necessary to change the environment at the facilities, improve providers' knowledge, and eliminate bias about transgender individuals and their care. This project aimed to enhance providers' knowledge about the transgender patient population they serve at the local VA facility. The information retrieved from the chart reviews helped to illustrate gaps in service utilization. Alongside this information, the perceptual data gained from the questionnaire provided clinicians with information regarding perceived effectiveness of currently offered interventions. In addition, this project gave veterans an MENTAL HEALTH OF TRANSGENDER VETERANS opportunity to suggest interventions that could enhance their treatment and to voice concerns about how they feel while receiving services at the identified location. The project findings support the need for additional efforts and interventions. Increased knowledge regarding this patient population's needs and concerns is a first step in addressing issues identified by veterans. Enhanced awareness of their needs could facilitate actions necessary to reduce or eliminate concerns related to discrimination and confidentiality and to develop a plan integrating interventions suggested by veterans into clinical practice. 25 MENTAL HEALTH OF TRANSGENDER VETERANS 26 References American Association of Colleges of Nursing. (2006). 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Health care issues among lesbian, gay , bisexual, trasgender and intersex (LGBTI) populations in the United States: Introduction. Journal of Homosexuality, (54)3, 213-224. Retrieved from http://www.tandfonline.com/doi/abs/10.1080/00918360801982025#aHR0cDovL3d3dy50 YW5kZm9ubGluZS5jb20vZG9pL3BkZi8xMC4xMDgwLzAwOTE4MzYwODAxOTgy MDI1P25lZWRBY2Nlc3M9dHJ1ZUBAQDA= MENTAL HEALTH OF TRANSGENDER VETERANS 28 Kauth, M. R., Shipherd, J. C., Lindsay, J., Blosnich, J. R., Brown, G. R., & Jones, K. T. (2014). Access to care for transgender veterans in the Veterans Health Administration: 2006- 2013. American Journal of Public Health, 104(S4), S532 534. doi:10.2105/AJPH.2014.302086 Lambda Legal. (2010). When health care isn't caring: Lambda Legal's survey on discrimination against LGBT people and people living with HIV. 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Teaching & Learning in Medicine, 27(3), 254-263. doi: 10.1080/10401334.2015.1044656 30 MENTAL HEALTH OF TRANSGENDER VETERANS 31 Appendix A Results Table 1 Frequencies of Mental Health Related Emergency Room Visits and Psychiatric Hospitalizations Type Number of Patients Number Reasons for Visits/Admissions of Visits/Admissions Mental Health-Related Emergency Room Visits 13 22 Passive Suicidal Ideations, Self- Harm Behaviors, Suicidal/Homicidal Ideations, Alcohol Detoxification, and Access to Mental Health Services Psychiatric Hospitalizations 11 13 Suicidal/Homicidal Ideations, SelfHarm Behaviors, Suicide Attempts and Alcohol Detoxification MENTAL HEALTH OF TRANSGENDER VETERANS 32 Table 2 Frequencies and Percentages of Service Utilization Service Received n % Participants Utilized Individual Psychotherapy 27 90 Endocrinology Services 21 70 Group Therapy 20 67 MH Provider 20 67 Primary Care 20 67 Peer-Support Services 13 43 PTSD Treatment 10 33 Vocal Coaching/Mannerism 8 27 Homeless Program 7 23 Vocational Rehabilitation 6 20 Dialectical Behavioral Therapy 6 20 Recreational Therapy 5 16 Dietitian 3 10 Substance Use Treatment 3 10 MENTAL HEALTH OF TRANSGENDER VETERANS 33 Table 3 Average Ratings of the Services and Percentages of Service Utilization Services Average Rating % Participants Utilized Individual Psychotherapy 8.2 92 Endocrinology Services 7.6 92 Primary Care 7.9 83 Peer-Support Services 8.3 58 7 42 Recreational Therapy 7.6 42 Vocal Coaching/Mannerism 8.6 42 Family/Couples Psychotherapy 3.5 33 Homeless Program 8.6 33 8 33 7.3 25 5 25 4.7 25 3 17 PTSD Treatment Case-Management Services Vocational Rehabilitation Dietitian Pharmacist Consult Substance Use Treatment MENTAL HEALTH OF TRANSGENDER VETERANS 34 Table 4 Patient Perceptions of Mental Health Clinicians and Concerns Related to Mental Health Services Statement n I feel like my Psychiatric Mental Health Providers/Clinicians are: Variables Strongly Strongly Agree Neutral Disagree Agree Disagree Gender Sensitive 12 75% 25% Competent /Knowledgeable 12 83% 17% Receptive to my Ideas 11 73% 27% Aware of my Needs, Stressors, and Triggers 12 58% 25% 17% Effective in Helping Me to Learn about my Condition 11 55% 36% 9% Privacy and Confidentiality 12 41% 25% 8% 17% 8% Safety 11 18% 9% 37% 27% 9% Forced Treatment 12 8% 17% 33% 17% 25% Discrimination by Mental Health Providers 12 8% 17% 25% 8% 42% Discrimination by Other Patients 12 25% 25% 25% 8% 17% While Receiving Mental Health Services at the Current Location I have been Concerned about: MENTAL HEALTH OF TRANSGENDER VETERANS Appendix B Proposal Defense 35 MENTAL HEALTH OF TRANSGENDER VETERANS 36 MENTAL HEALTH OF TRANSGENDER VETERANS 37 MENTAL HEALTH OF TRANSGENDER VETERANS 38 MENTAL HEALTH OF TRANSGENDER VETERANS 39 MENTAL HEALTH OF TRANSGENDER VETERANS 40 Appendix C University of Utah and Department of Veterans Affairs Institutional Review Board Approval Confirmations University of Utah Institutional Review Board Approval: IRB: IRB_00097738 PI: Anna Kasabyan Title: Mental Health of Transgender Veterans: Patients' Perspective on the Psychiatric Care Provided at the Local Department of Veterans Affairs Medical Center Date: 2/9/2017 Effective 2/9/2017, the above-referenced protocol is approved to begin the research procedures outlined in the University of Utah IRB-approved application and documents. For VA studies, final approval from the R&D Committee is required before initiating study procedures at the VA location. APPROVAL DOCUMENTATION Review Type: Expedited Review, as described in 45 CFR 46.110 and/or 21 CFR 56.110 Expedited Category(ies): Category 5, Category 7 Risk Level: Minimal Approval Date: 2/8/2017 Expiration Date: 2/7/2018 11:59 PM DETERMINATIONS • Waiver/Alteration Determination: The IRB has determined that the request for waiver of documentation of informed consent as described in this application is approved for this research under 45 CFR 46.117(c). • Waiver/Alteration Determination: The IRB has determined that the request for the waiver of consent and authorization as described in this application is approved for this research under 45 CFR 46.116(d) and 45 CFR 164.512(i)(2)(ii). APPROVED DOCUMENTS VA Consent Forms Cover Letter new Surveys, etc. Questionnaire w/ changes Literature Cited/References References Other Documents HIPAA waiver of authorization.pdf ONGOING SUBMISSIONS FOR APPROVED PROJECTS MENTAL HEALTH OF TRANSGENDER VETERANS • • • • 41 Continuing Review: The research protocol must be re-reviewed and re-approved prior to the expiration date via the continuing review application: http://irb.utah.edu/submitapplication/reviews/index.php Amendment Applications: All changes to the research application, protocol, or approved documents must be submitted and approved prior to initiation: http://irb.utah.edu/submitapplication/amendments.php Report Forms: The research must adhere to the University of Utah IRB reporting requirements for unanticipated problems and deviations: http://irb.utah.edu/submitapplication/forms/index.php Final Project Reports for Study Closure: The research application must be closed with the IRB once the research activities are complete: http://irb.utah.edu/submit-application/finalproject-reports.php Click IRB_00097738 to view the application and access the approved documents. Please take a moment to complete our customer service survey. We appreciate your opinions and feedback. MENTAL HEALTH OF TRANSGENDER VETERANS Department of Veterans Affairs Research and Development Committee Approval: 42 MENTAL HEALTH OF TRANSGENDER VETERANS 43 Appendix D Questionnaire Are you 18 years old or older? YES__ /NO__ Are you currently receiving services related to diagnosed Gender Identity Disorder or Gender Dysphoria at local VA facility? YES__/ NO__ Identify referral source to VA LGBT program: Self ____/ VA provider____/ non-VA provider____ Instructions: Please rate the efficacy of received services Are you currently enrolled/connected to: ______ Individual Psychotherapy poor 1 2 3 4 5 6 7 8 9 10 great ______Family/Couples Psychotherapy poor 1 2 3 4 5 6 7 8 9 10 great ______Substance Use Treatment poor 1 2 3 4 5 6 7 8 9 10 great ______PTSD Treatment poor 1 2 3 4 5 6 7 8 9 10 great ______ Homeless Program poor 1 2 3 4 5 6 7 8 9 10 great ______Recreational Therapy poor 1 2 3 4 5 6 7 8 9 10 great ______Vocal Coaching/Mannerism poor 1 2 3 4 5 6 7 8 9 10 great ______Vocational Rehabilitation poor 1 2 3 4 5 6 7 8 9 10 great ______Peer-Support Services poor 1 2 3 4 5 6 7 8 9 10 great ______Hormone Replacement Therapy poor 1 2 3 4 5 6 7 8 9 10 great ______Primary Care poor 1 2 3 4 5 6 7 8 9 10 great ______ Dietitian/ Nutritional Services poor 1 2 3 4 5 6 7 8 9 10 great ______Pharmacist Consult poor 1 2 3 4 5 6 7 8 9 10 great ______Case-Management Services poor 1 2 3 4 5 6 7 8 9 10 great MENTAL HEALTH OF TRANSGENDER VETERANS 44 Overall how satisfied you are with the received care related to your condition (Gender Identity Disorder or Gender Dysphoria)? Not satisfied 1 Somewhat satisfied 2 3 4 5 6 Very satisfied 7 8 9 10 How effective are the interventions received at the local VA facility for treating symptoms of your condition (Gender Dysphoria/Gender Identity Disorder)? Not effective 1 Somewhat effective 2 3 4 I feel like my psychiatric health providers/clinicians are: 5 6 Strongly Agree Very effective 7 Agree 8 9 Neither Agree, nor Disagree 1 Gender Sensitive 2 Competent /Knowledgeable 3 Receptive to my ideas 4 Aware of my needs, stressor and triggers 5 Effective in helping me to learn about my condition While receiving mental health services at the current location I have been concerned about: 1 Privacy and confidentiality 2 Safety 3 Forced treatment 4 Discrimination by mental health providers 5 Discrimination by other patients 10 Disagree Strongly Disagree MENTAL HEALTH OF TRANSGENDER VETERANS What do you perceive to be the most important aspects of your treatment? ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ What can be done differently to better meet your psychiatric/medical needs? ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 45 MENTAL HEALTH OF TRANSGENDER VETERANS Appendix E Poster Presentation 46 MENTAL HEALTH OF TRANSGENDER VETERANS Appendix F PowerPoint Presentation 47 MENTAL HEALTH OF TRANSGENDER VETERANS 48 MENTAL HEALTH OF TRANSGENDER VETERANS 49 MENTAL HEALTH OF TRANSGENDER VETERANS 50 MENTAL HEALTH OF TRANSGENDER VETERANS 51 MENTAL HEALTH OF TRANSGENDER VETERANS 52 MENTAL HEALTH OF TRANSGENDER VETERANS 53 MENTAL HEALTH OF TRANSGENDER VETERANS 54 MENTAL HEALTH OF TRANSGENDER VETERANS 55 MENTAL HEALTH OF TRANSGENDER VETERANS 56 MENTAL HEALTH OF TRANSGENDER VETERANS 57