Medical, nursing, and other allied health professions students have the unique opportunity to gain clinical experience in the Veterans Affairs (VA) health care system, which is operated under the Veterans Health Administration (VHA) (eg, the Washington VA Medical Center in Washington, DC). In such settings, health professions students will likely encounter patients who identify as LGBTQ+, specifically transgender and gender-expansive patients. This article serves as a primer to improve understanding of transgender health care within the VHA, the evolving policy and legal landscape regarding this topic, and the unmet need for surgical services for this population. We conclude with a call to action for VHA policy changes to improve access to surgical services for transgender and gender-expansive veterans.
Transgender Health Care at the VA: The Basics
A transgender person is someone whose gender identity, the deep-rooted sense of one’s own gender, does not align with the sex assigned to them at birth. In 2021, the VHA noted that official data on LGBT veterans, which included transgender and gender-expansive veterans, were limited and that collection of sexual orientation and gender identity data was not routinely done.1 Since then, the VA has begun to collect these data. Transgender and gender-expansive people are twice as likely as all adults to volunteer to serve in the US military.2 There are at least 134 000 transgender veterans who have served in the US military and are eligible for health care benefits through the VHA.2 The VHA expected this population to increase pending discharge upgrades and as younger generations identify more as LGBTQ+.1 At least 9000 transgender and gender-expansive veterans have received some care through the VHA.3
The current discussion is focused on transgender and gender-expansive veterans and their health care at the VHA, which operates a health system that is separate and distinct from the military health system operated by the US Department of Defense. While the 2 departments (ie, the VA and Department of Defense) have agreements to share clinical and nonclinical resources, VHA and Department of Defense health care policies are distinctly separate and should not be confused. Thus, the scope of this discussion is limited to VHA policies regarding gender-affirming surgery, which is currently prohibited within the VHA.
A significant health challenge faced by transgender and gender-expansive veterans is dealing with partisan political attacks on their health care as well as societal stigma, discrimination, and prejudice targeted at transgender and gender-expansive people generally. In 2023, more than 650 anti-LGBTQ+ bills were considered at the state and federal levels, of which more than 70 became law.4–7 Partisan attempts to deny access to evidence-based, medically necessary care for transgender and gender-expansive military personnel and veterans were introduced in Congress in 2023.8,9 Republican lawmakers included a ban on all gender-affirming care, including hormone therapy, for transgender and gender-expansive veterans in the House Veterans Affairs fiscal year 2025 funding bill.10 The societal stigma, discrimination, and prejudice that exist in the US contributes to minority stress, which is additive, chronic, and socially based stress leading to increased risks for mental health issues or psychological distress such as anxiety and depression.11
The global health community recognizes that being transgender is not a pathology or a mental disorder. Gender incongruence or gender dysphoria may be diagnosed, but being transgender is not a legitimate diagnosis and individuals are not diagnosed as being transgender. While the International Classification of Diseases, 11th Revision (ICD-11) recognizes gender incongruence as a matter of sexual health, the US has not yet adopted the ICD-11. The US continues to rely on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, which maintains a diagnosis of gender dysphoria. Gender dysphoria is “from the distress caused by the body and mind not aligning and/or societal marginalization of gender-variant people.”12 Elevated levels of psychological distress (increased risks for anxiety, depression, substance use disorder, and suicidality) is a known health concern faced by transgender and gender-expansive people.13 The health concerns of transgender and gender-expansive veterans are no different. These stressors may be more acute among veterans due to dealing with stigma and discrimination during and after their service in the military, particularly those who served under previous discriminatory policies. Past studies have reported that almost one-third of transgender and gender-expansive veterans have attempted suicide and that transgender veterans who have accessed VA care die by suicide at twice the rate of similarly situated cisgender veterans.13 It is important to note that being a transgender and gender-expansive person does not inherently make someone suicidal; being mistreated by society can lead to suicidality. However, studies have also shown that having access to evidence-based, medically necessary, gender-affirming care improves the mental health of transgender people.14
Clinical guidelines highlight not only the safety and effectiveness of gender-affirming care, but also the significant benefits of such care for the patient with gender dysphoria/incongruence. World Professional Association for Transgender Health (WPATH) guidelines provide “safe and effective pathways to achieving lasting personal comfort…in order to maximize their overall health, psychological well-being, and self-fulfillment.”11 These standards of care enable transgender and gender-expansive people to receive medically necessary, evidence-based, high-quality health care with dignity and respect. The guidelines include recommendations on the provision of primary care, gynecologic and urologic care, mental health services, hormonal and surgical treatments, and many other types of clinical care. Surgical care, in the form of gender-affirming surgery, is often provided by plastic reconstructive surgeons. The WPATH guidelines also apply to the care provided by the VHA. A summary overview of resources for transgender health and standards of care are provided in the Table.
In 2012, the VHA created the LGBTQ+ Health Program. VHA directives 1341 (Providing Health Care for Transgender and Intersex Veterans) and 1340 (Provision of Health Care for Veterans Who Identify as Lesbian, Gay, Bisexual, and Queer) provide policy and guidance on LGBTQ+ affirming care for veterans. Policy implementation challenges are described in detail by Singh et al15 but are otherwise beyond the scope of this discussion. While the VHA provides many aspects of LGBTQ+ affirming care, we discuss how the VHA continues to fall short of providing guideline-concordant care due to its ongoing prohibition on gender-affirming surgery.
Gender-Affirming Surgery and the VHA
The VHA’s mission is to “honor America’s Veterans by providing exceptional health care that improves their health and well-being.”16 In 2013, the VHA issued its first directive (directive 1341) calling for dignified and respectful treatment of transgender veterans.17 This spirit of dignity and respect is one shared by the WPATH guidelines. Despite the VHA mission, discrimination against transgender and gender-expansive veterans endures in health care settings. While transgender and gender-expansive veterans currently have access to hormone therapies and mental health care, they are currently prohibited by VHA directive 1341 from accessing gender-affirming surgery through their VHA medical benefits.17 As much as 54% of transgender people seek out gender-affirming surgery as part of their gender-affirming care; the exact rates differ by gender identity and can range from 28% of transwomen to 54% of transmen.18
Gender-affirming surgery is a medically necessary treatment for significant gender dysphoria. The WPATH and its US affiliate, USPATH, along with all major medical associations, support the provision of gender-affirming care, including gender-affirming surgery, for eligible transgender people.19 Gender-affirming surgery can lead to many benefits, notably a 44% decrease in suicidal ideation and 42% decrease in psychological distress.20 Despite the body of clinical evidence, VHA prohibition of medically necessary gender-affirming surgery is reflected in the Code of Federal Regulations as a single line stating that “the ‘medical benefits package’ does not include the following:…(4) Gender alterations.”21 As such, the VHA cannot currently provide gender-affirming surgery for the approximately 4000 transgender veterans22 who would be interested in such surgery. The prohibition of gender-affirming surgery for transgender veterans is contrary to the goal of providing dignified and respectful treatment. VHA directive 1341, as currently written, perpetuates health inequity and places transgender veterans at increased risk of negative clinical outcomes.
A systematic review of the literature on mental health outcomes of transgender veterans provides some compelling context regarding the health of transgender veterans and the importance of medically necessary gender-affirming surgery.23 The authors found that most studies on transgender veterans reported statistically significantly worse mental health outcomes and greater suicidality when compared with cisgender veterans and that this effect is related to stigma and gender discrimination. One study found that transgender veterans die by suicide at a younger age than cisgender veterans.24 These prohibitive policies against gender-affirming surgery place these veterans at risk of serious health consequences. As previously alluded to, avoiding these negative consequences is one of the significant and many benefits that gender-affirming surgery can provide to transgender veterans. Receiving both hormone treatment and surgery, such as chest or genital gender-affirming surgery, results in fewer short- and long-term experiences with suicidality and depression symptoms.25 Hormone treatment and gender-affirming surgery can both be part of a complementary treatment approach for transgender patients, and there are limitations to hormone therapy that gender-affirming surgery can address such as mastectomy or continued dysphoria despite taking hormone therapy.26 Given the medical necessity and benefits of gender-affirming surgery, it is not surprising that medical ethicists have argued that the VHA’s prohibitive policy on gender-affirming surgery violates the basic ethical tenants of beneficence, nonmaleficence, and justice.27 In other words, the prohibitive policy of directive 1341 is also indefensible from an ethical standpoint.
In 2016, the VHA began reconsidering the prohibition via a notice of proposed rulemaking as a result of petitions for rulemaking from the public. However, less than 6 months later, at the end of 2016, the VHA indicated its intention to withdraw from the rulemaking process and in 2018 reversed its decision after lawsuits (Figure).28 At the time in 2016, the VHA wrote to members of Congress that the rationale for withdrawing from rulemaking was that the VHA was waiting for “appropriated funding” before making a change to the medical benefits package.28 Since then, there was little further movement by VHA on removing the prohibition.
The Biden administration’s promise to permit gender-affirming surgery as a VHA medical benefit for transgender veterans brought hope for a final conclusion to the back-and-forth. In 2021, the VHA began rulemaking and cost-benefit analysis with the intention to issue new rules providing for gender-affirming surgery. This built on years of public advocacy and evidence, including a 2016 RAND study for the Department of Defense and a 2018 to 2020 economic analysis by the VA that both found the financial impact of gender-affirming surgery on their departments to be very low and “almost immaterial.”28,29 By providing gender-affirming surgery for transgender veterans, the VHA will likely find it to be cost-effective, allowing for cost offsets by reducing or eliminating costs associated with alleviating gender dysphoria, depression, and suicidality associated with not being able to live fully aligned with one’s gender identity. Delayed care is a serious potential consequence of not including gender-affirming surgery as a medical benefit at the VHA; the 2022 US Transgender Survey reported that 28% of transgender individuals delayed seeking care due to cost.30 Transgender veterans have a strikingly high rate of poverty, with 1 out of 3 experiencing homelessness (3 times more likely than nontransgender veterans).31,32 It is unlikely that transgender veterans in poverty will be able to afford medically necessary gender-affirming surgery without the assistance of the VHA.
Three years later, the rulemaking process has been excruciatingly slow, with no draft proposal in sight. In 2022, the VHA held 2 meetings with proponents and opponents of providing for gender-affirming surgery.33 Delay in rulemaking has an impact not only on transgender veterans’ health and well-being, but may also impact strategic planning and outreach of surgical centers specializing in gender-affirming surgery. As of spring 2023, there appeared to be some movement in that the regulatory dashboard of the Office of Information and Regulatory Affairs within the Executive Office of the President showed a potential proposed rule with anticipated release in October 2023. A new argument was also put forth on the dashboard, that revising the VHA policies to include gender-affirming surgery would be “in accordance with the President’s priorities that advance equity and support underserved, vulnerable, and marginalized communities.”34
Despite President Biden’s priorities, in June 2023, Military.com reported that VA Secretary Denis McDonough shared that he is “not yet ready” to put forth the proposed rule for public comment and admitted that he is now the roadblock on advancing this matter of equitable care for transgender veterans.35 Shortly thereafter, in July 2023, House Republicans passed, in a purely partisan vote, HR 4366—Military Construction, Veterans Affairs, and Related Agencies Appropriations Act, 2024, which included a prohibition against VA funding for “surgical procedures or hormone therapies for the purposes of gender-affirming care.”36 The White House has voiced strong opposition to the inclusion of provisions jeopardizing gender-affirming and reproductive health care and stated that President Biden would veto the bill should it reach his desk for signature.37
Stymied by politics, the transgender and gender-expansive community is left with little recourse. In January 2024, the Transgender American Veterans Association and Yale Law School’s Veterans Legal Services Clinic filed a lawsuit against the VA to ask the federal Court of Appeals to compel the VA to provide an answer to the transgender and gender-expansive community by responding to petitions made by the public in 2016, which asked for rulemaking to allow coverage for gender-affirming surgery.38,39 In February 2024, the VA denied the petition, and rulemaking was deferred indefinitely pending a review of the impact the VA’s recent expansion of the Honoring our Promise to Address Comprehensive Toxics Act of 2021 (PACT Act) might have on the number of veterans eligible for gender-affirming surgery.40–42 The Transgender American Veterans Association filed a second lawsuit against the VA in April 2024, seeking judicial review of the VA’s denial given clear medical consensus regarding the benefits of gender-affirming surgery.43
Considering the expansion of the PACT Act has resulted in an increase of 400 000 new enrollees for VA care in the last year44 and 9 million veterans already receive care (an increase of 4%), a similar increase in transgender and gender-expansive veterans who would be new enrollees and seeking gender-affirming surgery equates to an increase of, at most, an additional 175 patients seeking surgical services. Given the previous discussion regarding the Department of Defense and VA economic analyses, we anticipate the likely financial impact of the PACT Act expansion to be very small. No publicly available economic analysis has been conducted, and it is unknown whether the VA’s review will result in an economic analysis for the public to review. It is reasonable to speculate that this purported need for additional analysis in light of the PACT Act is merely a political pretext to delay providing care to transgender and gender-expansive during a presidential election year in which access to transgender and gender-expansive care may be a topic unjustly used by parties to attack one another, rather than as a medically necessary and worthwhile investment in the VA health care system.
Conclusions
Health profession students must understand that transgender health care is often used as a pawn in partisan politics. In preparation for clinical experiences at the VA, students can use our discussion to develop an understanding of transgender health care and the limitations thereof at the VHA. Present day, transgender veterans’ access to gender-affirming surgery through the VHA is stalled through various barriers put forth by forces such as policy, politics, and lack of willpower to change the system. As we enter a period of conservatism in government, the barriers may be accentuated.
However, because of the medical necessity of gender-affirming surgery and clear clinical benefit, the VHA has an obligation to provide gender-affirming surgery. Directive 1341 itself defines allowable plastic reconstructive surgery as care to “promote, preserve, or restore the health of the individual.”17 Stalling on the gender-affirming surgery provision perpetuates a discriminatory barrier to care and ignores the overwhelming evidence regarding the efficacy of gender-affirming surgery. Providing gender-affirming surgery in a timely manner will help veterans access the medically necessary care they have rightfully earned through their service to, and sacrifices for, the country.
Conflicts of Interests Disclosures
Paula M. Neira previously received nominal remuneration as a member of the Department of Veterans Affairs Veteran Engagement Group for the Gender-Affirming Care Evaluation (GRACE) Survey. There are no other financial disclosures.