V A Directive

[Guest Donna Jean]

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I think that this needs to be here for us vets....

Department of Veterans Affairs VHA DIRECTIVE 2011-024

Veterans Health Administration

Washington, DC 20420 June 9, 2011

PROVIDING HEALTH CARE FOR TRANSGENDER AND INTERSEX VETERANS

1. PURPOSE: This Veterans Health Administration (VHA) Directive establishes policy regarding the respectful delivery of health care to transgender and intersex Veterans who are enrolled in the Department of Veterans Affairs (VA) health care system or are otherwise eligible for VA care.

2. BACKGROUND: In accordance with the medical benefits package (title 38 Code of Federal Regulations (CFR) Section 17.38), VA provides care and treatment to Veterans that is compatible with generally accepted standards of medical practice and determined by appropriate health care professionals to promote, preserve, or restore the health of the individual.

a. VA provides health care for transgender patients, including those who present at various points on their transition from one gender to the next. This applies to all Veterans who are enrolled in VA’s health care system or who are otherwise eligible for VA care, including: those who have had sex reassignment surgery outside of VHA, those who might be considering such surgical intervention, and those who do not wish to undergo sex reassignment surgery, but self-identify as transgender. Intersex individuals may or may not have interest in changing gender or in acting in ways that are discordant with their assigned gender.

b. VA does not provide sex reassignment surgery or plastic reconstructive surgery for strictly cosmetic purposes.

c. Definitions

(1) Sex. Sex refers to the classification of individuals as female or male on the basis of their reproductive organs and functions.

(2) Gender. Gender refers to the behavioral, cultural, or psychological traits that a society associates with male and female sex.

(3) Transgender. Transgender is a term used to describe people whose gender identity (sense of themselves as male or female) or gender expression differs from that usually associated with their sex assigned at birth.

(a) Transsexual (Male-to-Female). Male-to-female (MTF) transsexuals are individuals who are male sex at birth, but self-identify as female and often take steps to socially or medically transition to female, including feminizing hormone therapy, electrolysis, and surgeries (e.g., vaginoplasty, breast augmentation).

THIS VHA DIRECTIVE EXPIRES NOVEMBER 30, 2012

VHA DIRECTIVE 2011-024

June 9, 2011

2

(B Transsexual (Female-to-Male). Female-to-male (FTM) transsexuals are individuals who are female sex at birth, but self-identify as male and often take steps socially or medically transition to male, including masculinizing hormone therapy and surgeries (e.g., phalloplasty, mastectomy).

(4) Sex Reassignment Surgery. Sex reassignment surgery includes any of a variety of surgical procedures (including vaginoplasty and breast augmentation in MTF transsexuals and mastectomy and phalloplasty in FTM transsexuals) done simultaneously or sequentially with the explicit goal of transitioning from one gender to another. This term includes surgical revision of a previous sex reassignment surgery for cosmetic purposes. NOTE: This term does not apply to non-surgical therapy (e.g., hormone therapy, mental health care, etc.) or Intersex Veterans in need of surgery to correct inborn conditions related to reproductive or sexual anatomy or to correct a functional defect.

(5) Gender Identity Disorder (GID). GID is a conflict between a person’s physical sex and the gender with which the person identifies.

(6) Intersex. Intersex individuals are born with reproductive or sexual anatomy and/or chromosome pattern that doesn’t seem to fit typical definitions of male or female. People with intersex conditions are often assigned male or female gender by others at birth (e.g., parents), although the individual may or may not later identify with the assigned gender.

3. POLICY: It is VHA policy that medically necessary care is provided to enrolled or otherwise eligible intersex and transgender Veterans, including hormonal therapy, mental health care, preoperative evaluation, and medically necessary post-operative and long-term care following sex reassignment surgery. Sex reassignment surgery cannot be performed or funded by VHA or VA.

4. ACTION

a. Veterans Integrated Service Network (VISN) Director. Each VISN Director must ensure that necessary and appropriate health care is provided to all enrolled or otherwise eligible Veterans based on the Veteran’s self-identified gender, regardless of sex or sex reassignment status.

b. Medical Center Director and Chief of Staff. The Medical Center Director and Chief of Staff are responsible for ensuring that:

(1) Transgender patients and intersex individuals are provided all care included in VA’s medical benefits package, including, but not limited to: hormonal therapy, mental health care, preoperative evaluation, and medically necessary post-operative and long-term care following sex reassignment surgery to the extent that the appropriate health care professional determines that the care is needed to promote, preserve, or restore the health of the individual and is in accord with generally-accepted standards of medical practice:

VHA DIRECTIVE 2011-024

June 9, 2011

3

(a) Patients will be addressed and referred to based on their self-identified gender. Room assignments and access to any facilities for which gender is normally a consideration (e.g., restrooms) will give preference to the self-identified gender, irrespective of appearance and/or surgical history, in a manner that respects the privacy needs of transgender and non-transgender patients alike. Where there are questions or concerns related to room assignments, an ethics consultation may be requested.

(B The documented sex in the Computerized Patient Record System (CPRS) should be consistent with the patient’s self-identified gender. In order to modify administrative data (e.g., name and sex) in CPRS, patients must provide official documentation as per current VHA policies on Identity Authentication for Health Care Services and Data Quality Requirements for Identity Management and Master Patient Index Functions.

© Sex reassignment surgery, as defined in subparagraph 2b(4), will not be provided or funded.

(d) Non-surgical, supportive care for complications of sex-reassignment surgery will be provided.

(e) While care is delivered to the Veteran based upon that Veteran’s self-identified gender, there may be health issues associated with some transgender patients that necessitate appropriate sex specific screenings and/or treatments. For example, a MTF transsexual patient over the age of 50 may require breast cancer and prostate cancer screening. A FTM transsexual patient may require screening for breast and cervical cancer.

(f) A diagnosis of GID, or other gender dysphoria diagnoses, is not a pre-condition for receiving care consistent with the Veteran’s self-identified gender.

(2) All other health services are provided to transgender Veterans without discrimination in a manner consistent with care and management of all Veteran patients.

(3) All staff, including medical and administrative staff, are required to treat as confidential any information about a patient’s transgender status or any treatment related to a patient’s gender transition, unless the patient has given permission to share this information.

(4) Mandated diversity awareness is maintained and a zero-tolerance standard for harassment of any kind.

5. REFERENCES

a. Title 38 CFR § 17.38 ©.

b. VHA Directive 2009-051, Plastic Reconstructive Surgery.

c. VHA Directive 2007-037, Identity Authentication for Health Care Services.

VHA DIRECTIVE 2011-024

June 9, 2011

4

6. FOLLOW-UP RESPONSIBILITY. The Office of Patient Care Services (10P4) is responsible for the contents of this Directive. Questions related to medical care may be referred to Specialty Care Services (10P4E) at (202) 461-7120. Questions related to mental health care may be referred to the Office of Mental Health Services (10P4M) at (202) 461-7310.

7. RESCISSIONS. None. This VHA Directive expires November 30, 2012.

Robert A. Petzel, M.D.

Under Secretary for Health

DISTRIBUTION:

E-mailed to the VHA Publications Distribution List 6/9/2011

Donna Jean

USAF

Loadmaster

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Edited July 15, 2011 by Donna Jean
I thought this needed to be pinned

[Guest Isabella_Anne]

I would encourage all vet to make a copy of this directive and take it with them for every visit to the VA. If your Dr. or anyone tells you something different, show them this directive. That will stop any unnecessary delays in transgender and intersex healthcare. Hopefully. Make sure you tell them "they have been directed to provide you transgender healthcare and its not an option". Be firm but respectful. If you still have problems I would contact the Medical Chief of Staff for your VA facility and let him or her know whats going on. Do not take no for an answer. I know its hard for some of us, but you will be doing yourself and the next vet that comes behind you a favor. People have worked hard to get us these benefits and if we don't use them, it was a lot of work for nothing.

Hugs,

Isabella

[Guest Donna Jean]

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Absolutely!

Donna Jean

[MackenzieB]

"Veterans who are enrolled in the Department of Veterans Affairs (VA) health care system or are otherwise eligible for VA care."

This pretty much means you were in Vietnam (or earlier), or one of the Gulf Operations. Perhaps you have a service related injury or condition? And don't make more than $44,000 household income.

In my case, I was in after Vietnam but out prior to the first Gulf War. No service related injuries except for a mild hearing loss. And my pay alone is over the $44k limit, much less the household income. So I'm Category 8. Which means "Thanks for stopping by but you're not eligible for VHA services".

Directive or no directive, you still have to be able to access the VA's services in the first place.

[Guest Donna Jean]

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Caitlin.....

This directive covers a LOT of veterans......not all....

If you don't fit the parameters, I'm so sorry....

We're making progress a little at a time....

Yes, I was in Vietnam and I make way less than $44,000 a year...(unemployed...0% income...)

Although I was in combat...I got out with my butt intact....

I don't know what to say to you.....

I'm sorry...

Donna Jean

[MackenzieB]

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Caitlin.....

This directive covers a LOT of veterans......not all....

If you don't fit the parameters, I'm so sorry....

We're making progress a little at a time....

Yes, I was in Vietnam and I make way less than $44,000 a year...(unemployed...0% income...)

Although I was in combat...I got out with my butt intact....

I don't know what to say to you.....

I'm sorry...

Donna Jean

Nah, nah, nah...

There's no reason to feel sorry at all. I have never used the VA for services. I've never even thought about it prior to the directive coming out. There's a couple of reasons for that...

I work there. Granted, privacy is assured via HIPAA and the VA is extremely stringent about patient confidentiality. But people are people. It's just too easy for some gabby person to let something slip about a co worker or somebody that they see running around the facility all of the time.

If I could get into the VA for services I'd still be paying out of pocket. The Fed Employee's insurance doesn't cover anything dealing with transitioning. So it wouldn't be saving me that much anyway.

My original plan was to see a LGBT friendly Doc in Seattle and do hrt via that clinic or facility. I'm all set for a physical next Friday at Capitol Hill Medical (a LGBT owned and friendly clinic). This is covered under my insurance. And since my BP isn't the greatest, I can get Spiro, follow up appointments and lab tests covered under insurance. Which is way better than if I had gone to the VA anyway.

But yes, going someplace else is a little more inconvenient. At the VA the clinic and pharmacy are down an elevator and then down a hallway. But I think that I'd rather have at some of it paid for under insurance and drive 3 miles.

So, don't feel sorry for me, it's probably for the better in the long run.

But in light of transitioning and the VA, I have to say that it's probably one of the better employers out there to be working for while in transition. The EEOC department in this facility has dealt with several Trans people who've transitioned on the job. They already have a real good set of policies and procedures in place for when I get to the RLE at work point. So no, I'm not feeling sorry. I actually have it pretty good.

But Thanks for Caring!

Caitlin

[Guest Isabella_Anne]

"Veterans who are enrolled in the Department of Veterans Affairs (VA) health care system or are otherwise eligible for VA care."

This pretty much means you were in Vietnam (or earlier), or one of the Gulf Operations. Perhaps you have a service related injury or condition? And don't make more than $44,000 household income.

In my case, I was in after Vietnam but out prior to the first Gulf War. No service related injuries except for a mild hearing loss. And my pay alone is over the $44k limit, much less the household income. So I'm Category 8. Which means "Thanks for stopping by but you're not eligible for VHA services".

Directive or no directive, you still have to be able to access the VA's services in the first place.

I would try to get a percentage for your hearing loss. It will get your foot in the door for later in life. Just a suggestion.

Isabella

[Drea]

But in light of transitioning and the VA, I have to say that it's probably one of the better employers out there to be working for while in transition.

Generally speaking, US goverment employees are well protected. Number one rule I hear is don't lie to them.

[Guest roxannemariska]

Have a TG frend was treated exactly according to this directive in a VA hospital in Los Angeles. Does anyone know how much, if any, TRICARE Prime will cover along these lines. Haven't looked into it.

[Guest Pammy]

I have Tricare Prime and so far it has paid for all my medications, including HRT. It also has covered my medical doctor visits (less the usual copay).

I would like to point out to those of us who use Tricare that the pharmacy copay has changed from $3 to $5 for formulary meds. However, if you use the Express Scripts home delivery service, the copay has dropped to $0! I suspect they are trying to get as many people as possible to use that service rather than their local pharmacy.

Peace

Pam

[Guest cassie51]

Thank you so much for posting this Donna Jean, you have just given me at least a little ray of hope. The last I knew the VA didn't even want to acknowledge TG or GID issues. I use the VA because I can't afford my own insurance since the economy tanked. Just knowing now that I could get some help if I decide to take the plunge is a big morale booster. You really made my night!

[Guest Guest_SL]

"Veterans who are enrolled in the Department of Veterans Affairs (VA) health care system or are otherwise eligible for VA care."

This pretty much means you were in Vietnam (or earlier), or one of the Gulf Operations. Perhaps you have a service related injury or condition? And don't make more than $44,000 household income.

In my case, I was in after Vietnam but out prior to the first Gulf War. No service related injuries except for a mild hearing loss. And my pay alone is over the $44k limit, much less the household income. So I'm Category 8. Which means "Thanks for stopping by but you're not eligible for VHA services".

Directive or no directive, you still have to be able to access the VA's services in the first place.

I would try to get a percentage for your hearing loss. It will get your foot in the door for later in life. Just a suggestion.

Isabella

I agree. Hearing loss due to live fire exercises or job related hearing damage may allow you to be eligible for 10% disability. I have 70% and of that 10% is for hearing damage. If you get in the system, that's a big plus. My local VA facilities and the staff are great. First rate. Though I have yet and in all probability never will discuss my gender identification with my psychologist, but I'm sure she'd be very supportive and offer the best care she could provide.

I get tired of hearing Vets trash the VA for minor things when the system is struggling to cope with the flood of Vets from OIF and OEF and I make a point of personally leaving positive feedback with the patient advocate each visit. It's something they rarely hear. Funny, the WWII Vets never complain. Never. They're the group I try to hang out with. My service covered three active conflicts and though never in combat, I had quite a few service related injuries and illnesses and I could have never afforded the level of care I enjoy through the VA. My last job was very low paying (Economically depressed) and my last employer wasn't required and did not provide his work force with any medical coverage whatsoever. So in my cast the VA has been a god send. Apply. It can't hurt. Get an advocacy group, American Legion helped me, to work with you and the VA. Give it a try and good luck.

SL

[Guest Guest_SL]

This doesn't directly apply to this topic and it can be moved if needed, but I have to ask, has anyone in the VA system on this site actually dealt with their issues with their mental health providers?

I kind of tested the waters with my psychologist by mentioning having read a well know transgender biography and she mentioned our facility had a number of transgender patients who were in our system and how the directive was strictly applied. She's too sharp to have missed the signal but my other issues are more front burner. But at some point, I'd like to discuss things with her but I'm afraid she'll shunt me off to a provider who's not on her level of ability.

Sorry if this is out of place and mods, feel free to move it or delete it.

SL

[Guest Pammy]

Sara_Lee, you seem to have a great attitude toward the VA system. My experiences are somewhat less than positive but, like you, one rarely hears a complaint out of me. I will complain vociferously about the heat and humidity, lack of quality food and annoying dogs, but I don't tear down the hand that feeds me. My disability rating is less than yours but, through Tricare Prime, I have been getting top-notch care for a low copay and an annual bill that would barely cover a comparable plan for one month.

You are a breath of fresh air!

Love

Pamela

[Guest Emily Ray]

SL

I think that most VA's are getting their care up to what the directive requires. My VA in Minneapolis even has a support group where about 10 members get together and talk about our transitions. I started my transition with the VA and I know about 7 other veterans who did the same. My case became complex and their level of experience wasn't great enough to help me and so I found an alternate group of providers from the comunity that had either decades of treat trans experience or were themselves trans.

But, though I generally am pleased with my care at the VA they did misdiagnose me and caused me a great deal of mental anguish that has had long lasting consequences. They effectively destroyed my blossoming self-confidence. Under the huge strain they put on me with their misdiagnosis I returned to not feeling my feelings and that as we all know can be very unhealthy.

Huggs

Emily

[Guest Guest_SL]

First,

I'm always bothered by the VA patients who do receive less than top quality and I'm lucky to live in a state that is rated highly in their VA facilities and they are expanding like crazy! My mental health providers are superior to any I've dealt with in the civilian sector. One relocated to an put-patient and I followed her for her care. The VA tried to prevent it but mental health is different and they had to allow me to continue under her care.

Emily,

I felt that you were kind of a good example of transition with the least amount of impact on your health and personal life, at least you were doing so well when I dropped off and it pains me greatly to know the VA caused what seems to be nothing less than traumatic. If that's disheartening to me, it must have been and may well still be, a huge set back for you and I'm so very sorry to learn of this. I hope you're getting back on track.

I was extremely fortunate to get in the VA system as quickly as I did and that was only with the help of a wonderful lady who works the VA admin center.

My local VA rep is......ummmm? But this gal saw what I was up against and contacted the AE on my behalf (Not her job.) and I was in the system in under two years.

Back to my off topic thought. Should I open up to my psychologist and risk her moving me to another provider or do I sit on this and look for input and support here at Laura's? Considering how I left here twice and basically went back on my goal of helping others, I'm in a moral dilemma with what appears to be very few morals. You gotta wonder.......

Thanks ladies!

Sara Lee

[MackenzieB]

"Veterans who are enrolled in the Department of Veterans Affairs (VA) health care system or are otherwise eligible for VA care."

This pretty much means you were in Vietnam (or earlier), or one of the Gulf Operations. Perhaps you have a service related injury or condition? And don't make more than $44,000 household income.

In my case, I was in after Vietnam but out prior to the first Gulf War. No service related injuries except for a mild hearing loss. And my pay alone is over the $44k limit, much less the household income. So I'm Category 8. Which means "Thanks for stopping by but you're not eligible for VHA services".

Directive or no directive, you still have to be able to access the VA's services in the first place.

I would try to get a percentage for your hearing loss. It will get your foot in the door for later in life. Just a suggestion.

Isabella

I agree. Hearing loss due to live fire exercises or job related hearing damage may allow you to be eligible for 10% disability. I have 70% and of that 10% is for hearing damage. If you get in the system, that's a big plus. My local VA facilities and the staff are great. First rate. Though I have yet and in all probability never will discuss my gender identification with my psychologist, but I'm sure she'd be very supportive and offer the best care she could provide.

I get tired of hearing Vets trash the VA for minor things when the system is struggling to cope with the flood of Vets from OIF and OEF and I make a point of personally leaving positive feedback with the patient advocate each visit. It's something they rarely hear. Funny, the WWII Vets never complain. Never. They're the group I try to hang out with. My service covered three active conflicts and though never in combat, I had quite a few service related injuries and illnesses and I could have never afforded the level of care I enjoy through the VA. My last job was very low paying (Economically depressed) and my last employer wasn't required and did not provide his work force with any medical coverage whatsoever. So in my cast the VA has been a god send. Apply. It can't hurt. Get an advocacy group, American Legion helped me, to work with you and the VA. Give it a try and good luck.

SL

I have a few reasons why I'm not going to pursue that course (I was the OP from the quote, changed my name). Most of my medical care is covered under the fed employee health insurance with the exception of hrt and that's cheap enough that I don't really care.

I'm not currently seeing a GT and if I were, I wouldn't be comfortable going to the VA. I work at the VA. I'm the person who is assigned to take care of all of the medical equipment in mental health. So they see me a lot in a work capacity. I wouldn't feel comfortable seeing a therapist there as a patient.

I'm not saying that people shouldn't come to the Seattle VA. I'm just saying that as an employee of the Seattle VA, I'd prefer to be seen off campus then by somebody I might see in the hallways half a dozen times per week. Please don't confuse this, I'm NOT implying anything either negative or questionable about the quality of care there.

Regardless of what medical facility it may be, if I work there, I'm not going to go there as a patient.

[Guest KarenLyn]

I have Tricare and they stopped paying for my hrt when I saw a fill-in instead of my regular doctor. The fill-in made a point of coding everything as treatment for transsexualism and Tricare balked at that.

I have a new doc now that I haven't even met. My insurance through my current employer covers everything so I probably won't use Tricare anytime in the near future.

As for the VA, I make to much to qualify. I might sign up when I finally get to retire. If I get to retire...

Karen

[Carolyn Marie]

Please don't confuse this, I'm NOT implying anything either negative or questionable about the quality of care there.

Regardless of what medical facility it may be, if I work there, I'm not going to go there as a patient.

Understood, hon, and I totally agree. Half a lifetime ago I worked at a VA clinic in L.A., and I wouldn't have gone there for care, either, for the same reasons.

HUGS

Carolyn Marie

[Guest Donna Jean]

Please don't confuse this, I'm NOT implying anything either negative or questionable about the quality of care there.

Regardless of what medical facility it may be, if I work there, I'm not going to go there as a patient.

Understood, hon, and I totally agree. Half a lifetime ago I worked at a VA clinic in L.A., and I wouldn't have gone there for care, either, for the same reasons.

HUGS

Carolyn Marie

Right....that's why the people that work at McDonalds go to Burger King for lunch......

You know, we can argue the downsides and virtues of VA's across the country, but, as we all know, they don't offer standardized care....

So.....we get what we get...

I have to say that my personal experiences with the two VA's that I've been with have given me outstanding care! One in central Ohio and here in New Orleans....

The only thing that I could possibly ask for, on top of what I'm already getting, ...would be SRS!

And, next time there.....I'm gonna hugg the patient advocate!

Dee Jay

[Guest jcovillion23]

So according to there directives they cover surgeries as well as care, If they do I never knew that and it would be helpful as I am service connected

[MackenzieB]

Sorry, but the VA does NOT cover surgeries, at least not srs, orchies (well, yes they do) or FFS. That is presently restricted by Federal law.

[Guest Guest_SL]

Last time I visited the advocate and told her how great everyone was, etc. her mouth hung open like I had told her she won the lottery. She then made a document and with my permission, sent it around to all the departments. One two separate occasions at two different clinics, I've seen patients have to be escorted out by local police and security for disruptions and threatening behavior to VA personnel. At one clinic there are three gals who man the front desk and don't let any Vet leave without a polite thank you for service and do they need any help? Then there the WWII guys who man the coffee and doughnut station. Great bunch of Vets. One doughnut place would donate the day old doughnuts which was really nice and the health department made them stop so the Vets bought their own out of pocket and the health department made them stop that as well.

SL

[Guest Donna Jean]

_{So according to there directives they cover surgeries as well as care, If they do I never knew that and it would be helpful as I am service connected}

Sorry, but the VA does NOT cover surgeries, at least not srs, orchies (well, yes they do) or FFS. That is presently restricted by Federal law.

The Veterans Administration will NOT cover SRS but will cover some complications connected to your SRS at a later time....

It may do Orchies and does all the time in cases of testicle cancer. But as far as an MTF issue, I've only heard of a couple of instances and the doctor covered it under other guidelines than SRS ....

Dee Jay

[Guest Crim]

Printed this out for sure, some good info here.