VA Health Care: Better Data Needed to Assess the Health Outcomes of Lesbian, Gay, Bisexual, and Transgender Veterans
Fast Facts
Veterans Affairs researchers have found that LGBT veterans may experience higher rates of depression and more frequent thoughts of suicide. Yet the VA can't systematically analyze the health of these veterans because it doesn't consistently collect data on sexual orientation or self-identified gender identity. For example, according to the VA, 89% of veterans' records lack gender identity data. Without this data, the VA may miss opportunities to provide appropriate health screenings and identify disparities.
We recommended the VA improve its data collection and analysis to improve health equity and better understand the needs of LGBT veterans.
Highlights
What GAO Found
The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) analyzes national-level data by birth sex to assess health outcomes for women veterans. For example, it analyzes frequency data to identify their most common health conditions. However, VHA is limited in its assessment of health outcomes for the lesbian, gay, bisexual, and transgender (LGBT) veteran population because it does not consistently collect sexual orientation or self-identified gender identity (SIGI) data.
VHA officials stated that providers may record veterans' sexual orientation—which can be used to identify lesbian, gay, and bisexual veterans—in non-standardized clinical notes in electronic health records. However, without a standardized field, providers may not be consistently collecting these data, and VHA does not know the total number of these veterans in its system. VHA officials recognize the importance of consistently collecting these data, but have yet to develop and implement a field for doing so.
VHA collects SIGI data—which can be used in part to identify transgender veterans—in enrollment, administrative, and electronic health record systems. Although VHA has worked to improve the collection of these data, GAO found inconsistencies in how VHA records SIGI and, according to VA, 89 percent of veterans' records lack SIGI information. VHA added a field to collect this information in the administrative system; however, these data are not linked to electronic health records. As such, VHA providers cannot see the data during clinical visits when determining the appropriate services for transgender veterans, such as screening certain transgender men for breast and cervical cancers, as required by VHA policy. VHA's plan to link SIGI data across both systems has been postponed several times, and the data remain unlinked.
VHA Sexual Orientation and Self-Identified Gender Identity (SIGI) Data Collection Limitations, Fiscal Year 2020
Until VHA can more consistently collect and analyze sexual orientation and SIGI data for the veteran population served, it will have a limited understanding of the health care needs of LGBT veterans, including any disparities they may face.
Why GAO Did This Study
VHA provides care to a diverse population of veterans, including women and LGBT veterans. These veterans may experience differences in health outcomes that are closely linked with social or economic disadvantage, and VA considers it important to analyze the services they receive as well as their health outcomes to improve health equity.
House Report 115-188 included a provision for GAO to review VA's data collection and reporting procedures for information on veterans' gender and sexual orientation. This report describes how VHA assesses health outcomes for women veterans and examines the extent to which VHA assesses health outcomes for LGBT veterans.
GAO reviewed VHA directives and VHA's Health Equity Action Plan. GAO interviewed officials from VHA's Women's Health Services and LGBT Health Program, VHA researchers who focus on women and LGBT veterans, and representatives from other health care systems with experience collecting gender and sexual orientation information.
Recommendations
GAO is making four recommendations to VA to consistently collect sexual orientation and SIGI data, and analyze these data to assess health outcomes for LGBT veterans. VA concurred with GAO's recommendations and identified actions it is taking to address them.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Veterans Affairs | The Undersecretary for Health should consistently collect sexual orientation data in VHA's health record system, which could include adding a field for providers to input veterans' sexual orientation. (Recommendation 1) |
In September 2022, VHA implemented a sexual orientation field and clinical reminder in its Computerized Patient Record System (CPRS) and Veterans Health Information Systems and Technology Architecture (VistA). Although early in its implementation, the Cerner Millennium has a live sexual orientation field as well.
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| Department of Veterans Affairs | The Undersecretary for Health should analyze veterans' sexual orientation data in order to assess health care outcomes for lesbian, gay, and bisexual veterans. (Recommendation 2) |
As of fall 2022, VHA implemented sexual orientation fields in CPRS/VistA/Cerner and began data collection. In March 2023, VHA produced a report including initial analyses of demographic, physical health, and mental health and substance use variables by sexual orientation. The report provides a baseline understanding of the health outcomes of lesbian, gay, and bisexual veterans.
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| Department of Veterans Affairs | The Undersecretary for Health should consistently collect veterans' self-identified gender identity data within and across record systems. (Recommendation 3) |
VHA concurred with this recommendation and has taken several steps to consistently collect self-identified gender identity (SIGI) data across enrollment, administrative, and health records systems. This includes ensuring consistent response options across these systems and that data can be viewed across systems. In January 2022, VHA provided evidence that enrollment forms have been updated to include standard SIGI responses and a patch has been implemented displaying SIGI data from VistA in CPRS.
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| Department of Veterans Affairs | The Undersecretary for Health should analyze veterans' self-identified gender identity data in order to assess health care outcomes for transgender veterans. (Recommendation 4) |
In September 2022, VHA completed initial analyses of SIGI data and combined the data with other data elements, such as birth sex, to assess health outcomes for transgender and gender diverse veterans. Initial analyses were documented in a preliminary report.
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