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According to recent census reports, nearly a million veterans have a same-sex partner, yet little is known about them or their use of Veterans Health Care Administration (VHA) services. Gay, lesbian, and bisexual (GLB) veterans recruited from the community (N = 356) completed an on-line survey to assess their rates of VHA utilization and whether they experience specific barriers to accessing VHA services. Andersen's model of health care utilization was adapted to provide an analytic and conceptual framework. Overall, 45.5% reported lifetime VHA utilization and 28.7% reported past-year VHA utilization. Lifetime VHA health care utilization was predicted by positive service connection, positive screen for both posttraumatic stress disorder (PTSD) and depression, and history of at least one interpersonal trauma during military service related to respondent's GLB status. Past-year VHA health care utilization was predicted by female gender, positive service connection, positive screen for both PTSD and depression, lower physical functioning, a history of military interpersonal trauma related to GLB status, and no history of stressful experiences initiated by the military to investigate or punish GLB status. Rates of VHA utilization by GLB veterans in this sample are comparable to those reported by VHA Central Office for all veterans. Of those who utilized VHA services, 33% reported open communication about their sexual orientation with VHA providers. Twenty-five percent of all participants reported avoiding at least one VHA service because of concerns about stigma. Stigma and lack of communication between GLB veterans and their providers about sexual orientation are areas of concern for VHA. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
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Veterans Administration Health Care Utilization Among Sexual
Minority Veterans
Tracy L. Simpson
Veterans Affairs Puget Sound Health Care System, Seattle,
Washington, and University of Washington
Kimberly F. Balsam
University of Washington
Bryan N. Cochran
University of Montana
Keren Lehavot and Sari D. Gold
Veterans Affairs Puget Sound Health Care System, Seattle,
Washington, and University of Washington
According to recent census reports, nearly a million veterans have a same-sex partner, yet little is
known about them or their use of Veterans Health Care Administration (VHA) services. Gay,
lesbian, and bisexual (GLB) veterans recruited from the community (N356) completed an on-line
survey to assess their rates of VHA utilization and whether they experience specific barriers to
accessing VHA services. Andersen’s model of health care utilization was adapted to provide an
analytic and conceptual framework. Overall, 45.5% reported lifetime VHA utilization and 28.7%
reported past-year VHA utilization. Lifetime VHA health care utilization was predicted by positive
service connection, positive screen for both posttraumatic stress disorder (PTSD) and depression,
and history of at least one interpersonal trauma during military service related to respondent’s GLB
status. Past-year VHA health care utilization was predicted by female gender, positive service
connection, positive screen for both PTSD and depression, lower physical functioning, a history of
military interpersonal trauma related to GLB status, and no history of stressful experiences initiated
by the military to investigate or punish GLB status. Rates of VHA utilization by GLB veterans in
this sample are comparable to those reported by VHA Central Office for all veterans. Of those who
utilized VHA services, 33% reported open communication about their sexual orientation with VHA
providers. Twenty-five percent of all participants reported avoiding at least one VHA service
because of concerns about stigma. Stigma and lack of communication between GLB veterans and
their providers about sexual orientation are areas of concern for VHA.
Keywords: veterans, health care utilization, lesbian, gay, bisexual
Data from the 2000 census indicate that more than 50,000
active-duty military personnel and nearly one million veterans
had a same-sex partner (Gates, 2004). Because the 2000 census
identified only individuals who reported a current same-sex
relationship, it is likely that the actual number of same-sex-
oriented active-duty service members and veterans was higher.
Gay, lesbian, and bisexual (GLB) individuals comprise a sig-
nificant proportion of our military forces, yet until very re-
cently, “Don’t ask, Don’t tell” (DADT) and other exclusionary
policies rendered them a largely invisible component of the
active-duty and veteran communities (Burks, 2011;Shilts,
1993). Research on the specific needs of this group has only
recently begun (Moradi, 2009).
Like all veterans, GLB veterans who met length-of-service
requirements and were discharged honorably or under general
honorable conditions are eligible to receive Veterans Health Care
Administration (VHA) services. It is unknown whether GLB vet-
erans utilize VHA services at rates similar to the veteran popula-
tion as a whole, and it is unclear whether there are unique barriers
to VHA care for GLB veterans. Data on GLB health care utiliza-
tion from civilian samples are mixed, with studies finding compa-
rable or greater rates of mental health care utilization (Grella,
Tracy L. Simpson, Veterans Affairs Puget Sound Health Care System,
Seattle, Washington, and Department of Psychiatry and Behavioral Sciences,
University of Washington; Kimberly F. Balsam, Department of Social Work,
University of Washington; Bryan N. Cochran, Department of Psychology,
University of Montana; Keren Lehavot and Sari D. Gold, Veterans Affairs
Puget Sound Health Care System, Seattle, Washington, and Department of
Psychiatry and Behavioral Sciences, University of Washington.
Kimberly F. Balsam is now at Palo Alto University.
A small grant from the Palm Center was used to pay for advertising
for the study. The preparation of these materials was supported by
resources from the Center of Excellence in Substance Abuse Treatment
and Education at the Veterans Affairs Puget Sound Health Care System,
Seattle, Washington. We thank Andrew David for his expert editorial
assistance, Carol Malte for her statistical consultation, and Mike Wells
for assistance with the National Center for Veterans Analysis and
Statistics databases.
Correspondence concerning this article should be addressed to Tracy
L. Simpson, Veterans Affairs Puget Sound Health Care System, 1660 S.
Columbian Way, Seattle, WA 98108. E-mail: tracy.simpson@va.gov
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Psychological Services © 2013 American Psychological Association
2013, Vol. 10, No. 2, 223–232 1541-1559/13/$12.00 DOI: 10.1037/a0031281
223
Greenwell, Mays, & Cochran, 2009), but lower rates of general
health care among GLB groups than heterosexuals (Austin &
Irwin, 2010;Buchmueller & Carpenter, 2010;Kerker, Mostashari,
& Thorpe, 2006). Concerns about stigmatization and past experi-
ences of discrimination are associated with lower non-mental
health care utilization rates among civilian GLB individuals (Bur-
gess, Tran, Lee, & van Ryn, 2007;Clark, Bonacore, Wright,
Armstrong, & Rakowski, 2003;Kinsler, Wong, Sayles, Davis, &
Cunningham, 2007;Malebranche, Peterson, Fullilove, & Stack-
house, 2004;Mayer et al., 2008), although research has also found
that reporting a major incident of discrimination is associated with
increased mental health care utilization for this group (Burgess et
al., 2007).
To provide a context for understanding GLB veterans’ VHA
utilization, it is helpful to first consider the rate at which all
veterans seek health care from VHA. Information from VHA
Central Office indicates that in fiscal year 2005 (FY05), which
corresponds to the data collection time frame of the current study,
5.5 million of the approximately 24.5 million U.S. veterans uti-
lized VHA care during that year (22.4%; National Center for
Veterans Analysis & Statistics, 2011). Research based on the
Centers for Disease Control and Prevention U.S. 2000 Behavioral
Risk Factor Surveillance System (BRFSS) dataset found that
13.1% of veterans utilized VHA services in the past year (Nelson,
Starkebaum, & Reiber, 2007). In the BRFSS study, correlates of
VHA utilization included low income, low educational attainment,
and racial/ethnic minority status.
In order to evaluate the rates and correlates of VHA utilization
among GLB veterans, the present study analyzed cross-sectional
self-report data collected over 9 months during 2004 and 2005
from a national sample of GLB veterans. Andersen’s Emerging
Behavioral Model of Health Services Use (Andersen, 1995,2008),
which has been widely used to identify factors related to health
care utilization among civilian (Bowen & Gonzalez, 2008;Dh-
ingra, Zack, Strine, Pearson, & Balluz, 2010), GLB (Datti &
Conyers, 2010;Grella et al., 2009), and veteran populations (Elhai,
Grubaugh, Richardson, Egede, & Creamer, 2008;Fasoli, Glick-
man, & Eisen, 2010;Maguen et al., 2007) was used as the
framework for identifying factors associated with lifetime and
past-year VHA utilization among GLB veterans (see Figure 1).
Andersen’s model postulates that health care utilization is influ-
enced by a variety of environment and person-specific character-
istics including (1) predisposing individual characteristics affect-
ing one’s likelihood of accessing care (e.g., age, gender) as well as
beliefs or attitudes, knowledge, and values about health or health
services that may influence utilization; (2) the presence or absence
of enabling resources that make it easier to utilize care, and (3)
clinical need for care.
The health beliefs portion of the Andersen model for the present
study included whether respondents had concerns about GLB-
related stigmatization (Clark et al., 2003;Kinsler et al., 2007;
Malebranche et al., 2004) on the part of VHA providers or other
VHA patients. In addition, after accounting for the other aspects of
the Andersen model, we evaluated whether three different types of
GLB-related stressors experienced during military service were
associated with likelihood of VHA utilization: (1) degree of anx-
iety regarding the need to conceal one’s sexual orientation; (2) a
history of one or more interpersonal traumas experienced during
military service that respondents perceived to be related to their
sexual orientation (e.g., physical or sexual assault that was due to
GLB status), and (3) a history of one or more stressful experiences
initiated by the military to investigate or punish GLB status (e.g.,
isolated from unit, interrogated about one’s own or other’s sexual
orientation, etc.; see Bowling, Firestone, & Harris, 2005;Burks,
2011;Shilts, 1993). Based on previous work evaluating the cor-
relates of VHA utilization, we hypothesized that older age, female
gender, lower income, lower educational attainment (Haskell et al.,
2011;Nelson et al., 2007;Ouimette, Wolfe, Daley, & Gima,
2003), and greater psychiatric and physical health problems (Fasoli
et al., 2010;Maguen et al., 2007) would all be associated with
greater likelihood of lifetime and past-year VHA utilization. In
order to evaluate whether GLB-related factors have a bearing on
VHA utilization, we also tested whether concerns about experi-
encing stigmatization by VHA providers or other veterans, having
a greater degree of anxiety regarding concealing GLB status dur-
ing military service, and having had either one or more GLB-
related military interpersonal traumas or one or more stressful
experiences initiated by the military to investigate or punish GLB
status were associated with lower probability of lifetime and
past-year VHA utilization For this initial evaluation, we did not
separate VHA mental health care from other types of care.
Andersen’s Behavioral Model of Health Care Utilization (1995) Adapted
to Account for GLB-related Factors Among GLB Veterans
Predisposing Characteristics
Demographics: age, gender
Sociocultural: bisexual vs.
gay/lesbian, ethnicity
Health Beliefs: avoidance of VA
services due to concerns about
stigma
Enabling Resources
Personal/Family: education,
income, employment, Medicare
eligibility (by age), partner status,
military discharge status, years
since left military, service
connection
Community: rural/urban
Need
Perceived: screening status for
PTSD, alcohol problems, physical
component score from SF-8
Evaluated: not available
GLB-related Military
Experiences
Anxiety about concealing sexual
orientation; negative military-
initiated experiences related to
sexual orientation; military trauma
related to sexual orientation
VHA Utilization
Lifetime: yes or no
Past-Year: yes or no
Figure 1. Andersen’s Health Beliefs Model of health care utilization
(1995) adapted to account for GLB-related factors among GLB veterans.
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224 SIMPSON, BALSAM, COCHRAN, LEHAVOT, AND GOLD
Methods
Participants
A convenience sample of gay, lesbian, bisexual, and transgender
(GLBT) individuals (n416) participated in a survey regarding
veterans’ military experiences, mental and physical health, health
care utilization, and their relationships. Because this study focused
on GLB veterans, individuals who identified their sexual orienta-
tion as heterosexual (n5) or other (n12) were excluded. In
addition, those who identified their gender as transgender (n28)
or other (n5) were excluded from the present analysis because
of insufficient representation; our aim was to focus on GLB
veterans, and although some aspects of their experiences of stig-
matization and prejudice are undoubtedly similar to those of GLB
veterans, many aspects are likely unique and are best investigated
separately (Dean et al., 2000). Current active-duty military per-
sonnel were also excluded (n23) as they have not transitioned
to veteran status and therefore would be unlikely to have accessed
VHA services. Some participants met multiple exclusionary crite-
ria. The final sample was composed of 356 GLB veterans.
Procedure
From May 2004 to January 2005, participants were recruited via
national on-line sources and print periodicals that specifically
serve the GLBT veterans community and the GLBT community at
large using electronic mail lists, websites, and newspapers. No
participants were recruited from within VHA. The advertisement
directed interested individuals to an Internet address with a link to
the study information form. Those interested provided consent to
participate and did not disclose any personal identifying informa-
tion, thus allowing them to remain anonymous so as to provide a
safe context for disclosure. Once participants gave consent to
participate by clicking that they agreed to the study conditions, a
link to the survey was provided. There was no financial remuner-
ation for study participation.
The protocol was approved by the Institutional Review Board
under the University of Washington.
Materials
VHA utilization (dependent variables), reasons for not using
VHA, and communication with VHA providers about sexual
orientation (descriptive variables). Lifetime and past-year
VHA utilization status were queried by asking participants
whether they had ever used each of 16 specific types of services
and whether they had used them in the past year (see Table 1).
Lifetime VHA utilization was determined to be positive if a
participant indicated having used at least one of the 16 services,
and the same procedure was used to determine past-year VHA
utilization status. Participants who had never utilized VHA ser-
vices were asked to indicate which of eight reasons were relevant
in their decision to not utilize VHA care, including “I have other
insurance coverage” and “I am concerned that the VA staff would
not accept my sexual orientation.” Participants who had utilized
VHA were asked whether their VA providers knew about their
sexual orientation and how often it was discussed with them.
Individual characteristics (independent variables).
Demographic and sociocultural factors. Gender (male vs.
female), age (continuously scaled), sexual orientation (gay/lesbian
vs. bisexual), and ethnicity (non-Hispanic white vs. minority group
membership) were assessed.
GLB adapted health belief factor. All participants were asked
to indicate whether they would like to access any of 16 VHA
services but do not because of concerns about GLB stigmatization
(at least one such service; yes/no).
Enabling resource factors. The following enabling factors
were assessed: highest level of education (less than bachelor
degree vs. bachelor degree or higher), Medicare eligibility (less
than 65 years vs. 65 and older), annual family income (less than
Table 1
Rates of Specific VHA Services Used Lifetime and Past Year for the Overall Sample (N356)
Lifetime Past year
Avoided due to
stigma
VHA service n%n%n%
General outpatient medical care 99 27.8 71 19.9 35 9.8
Specialty outpatient medical care 76 21.3 38 10.7 20 5.6
Emergency room 45 12.6 9 2.5 17 4.8
Inpatient medical care 35 9.8 3 0.8 18 5.1
Vision care 39 11.0 30 8.4 30 8.4
Dental care 35 9.8 14 3.9 35 9.8
Individual counseling 39 11.0 21 5.9 38 10.7
Group counseling 11 3.1 3 0.8 23 6.5
Individual substance abuse treatment 2 0.6 1 0.1 7 2.0
Group substance abuse treatment 2 0.6 0 6 1.7
Inpatient psychiatric care 13 3.6 0 4 1.1
Vocational rehabilitation 36 10.1 4 1.1 14 3.9
Special services/evaluations 13 3.6 2 0.6 4 1.1
Social work 9 2.5 1 0.1 7 2.0
Clergy/chaplain services 3 0.8 1 0.1 6 1.7
Other 40 11.2 26 7.3 21 5.9
Note. VHA Veterans Health Care Administration.
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225
VHA UTILIZATION AMONG GLB VETERANS
$25,000 vs. $25,000 or higher (U.S. Department of Health and
Human Services, 2010), employment status (not employed vs.
employed at least part-time), relationship status (partnered vs. not
partnered), military discharge status (honorable or general vs.
other), years since leaving military (continuously scaled), service
connection status (i.e., veterans who are service connected receive
a monthly monetary payment to compensate for a condition or
injury related to military service; yes/no), and size of the city/town
the respondents reside in (population less than 50,000 vs. popula-
tion 50,000 or greater (Wikipedia contributors, 2011).
Need factors. Posttraumatic stress disorder (PTSD) symptoms
were assessed using the PTSD Checklist Civilian Version (PCL-C;
(Blanchard, Jones-Alexander, Buckley, & Forneris, 1996), a 17-
item self-report measure that corresponds directly to the DSM–
IV–R criteria for PTSD (American Psychiatric Association, 2000).
PCL-C values of 38 for women (Dobie et al., 2002) and 44 for men
(Blanchard et al., 1996) were used as cutoff scores for identifying
respondents who screened positive for a likely diagnosis of PTSD.
Cronbach’s alpha for the PCL-C was .95 for this sample.
Depression for the 2-week period preceding survey completion
was assessed using the Patient Health Questionnaire-9 (PHQ-9;
Kroenke, Spitzer, & Williams, 2001). All but one veteran who
screened positive for major depressive disorder (MDD) also
screened positive for PTSD, so PTSD and MDD status were
combined to make the following categories for the logistic regres-
sion models: neither, PTSD only, PTSD and MDD. Cronbach’s
alpha for the PHQ-9 was .94 in the present sample.
Past-year alcohol consumption and alcohol-related conse-
quences were assessed using the Alcohol Use Disorders Identifi-
cation Test (AUDIT; Saunders, Aasland, Babor, de la Fuente, &
Grant, 1993). A standard cut score of 8 was used to indicate likely
problem-drinking status (problem drinker, yes/no). The Cron-
bach’s alpha for the AUDIT was .80 in the present study.
The health status and health-related quality-of-life of respon-
dents were assessed using the Short Form-8 (SF-8; Ware, Kosin-
ski, Dewey, & Gandek, 2001). Physical functioning, role limita-
tions due to physical problems, bodily pain, general health, and
vitality were assessed using Physical Component Summary (PCS)
scores, which range from 0 to 100. Higher PCS scores reflect a
greater quality of life (continuous PCS scores were used in the
model) and the Crohnbach’s alpha for the PCS was .89 in the
present sample.
GLB military experiences. Based on information provided by
Shilts (1993) regarding the types of challenges GLB military
members may have faced when they were banned from military
service, we created two original scales to evaluate whether the
GLB veteran’ in our sample experienced such situations during
their military service (Cochran, Balsam, Flentje, Malte, & Simp-
son, in press). The first scale was comprised of 26 items and was
subjected to a principal components analysis using varimax rota-
tion. The four components identified accounted for 41.99% of the
total variance (anxiety around concealment, transition to civilian
life, reflections on military career, and degree of support experi-
enced during military). Only the first subscale had adequate inter-
nal reliability (Crohnbach’s ␣⫽.73) and was used in the present
study. It is comprised of eight items, and the factor loadings ranged
from .371 to .781. Sample items from this subscale include “If I
had let people in the service know of my sexual orientation, I
probably would have been harmed physically” and “In the service,
I was constantly trying to conceal my sexual orientation.” Partic-
ipants responded to each item on a scale from 1 to 5, where 1
strongly agree and 5 strongly disagree; lower scores indicate
greater anxiety about concealing one’s sexual orientation. We used
a continuous score for this assessment because virtually all partic-
ipants reported concealment anxiety to some degree.
The second scale consists of eight items that assess whether any
stressful experiences initiated by the military to investigate or
punish GLB status occurred during military service, including
incarceration, forced psychiatric evaluation, dismissal from the
military, or isolation from their unit due to sexual orientation.
Because these experiences are individually relatively rare and
multiple instances are fairly unlikely to have happened to the same
person, we dichotomized this subscale for use in the analyses (any
such experience: yes/no).
The Life Events Questionnaire from the Clinician-Administered
PTSD Scale (Blake et al., 1995) assesses 16 potentially traumatic
events (e.g., natural disasters, accidents, physical assault, sexual
assault, etc.). It was adapted to assess whether each trauma type
occurred before, during, or after military service. In addition,
individuals who endorsed interpersonal traumas, such as physical
or sexual assault, during the military were asked whether they
perceived that it was due to their sexual orientation (any such
experience: yes/no).
Data Analysis
Univariate analyses were conducted on all the predictor vari-
ables (chi-square for categorical variables and independent sample
ttests for ratio and interval scale variables) to identify which
variables differed across veterans who did and did not report
lifetime VHA utilization and across those who did and did not
report past-year VHA utilization. This was done to reduce the
number of variables for the logistic regressions for the following
Andersen model categories: demographic and sociocultural char-
acteristics, enabling resources, and clinical need. An alpha level of
p.10 was used to retain variables with marginally significant
differences in the models in order to be more conservative and so
as to be sure to take into account things that are typically included
in studies of health care use, such as age. Differences between
VHA users and nonusers on the GLB variables were also analyzed,
but in light of our specific interest in these variables, they were all
entered into the multivariate equations. Variables that showed
differentiation on either lifetime or past-year VHA utilization
status, or both, were used in both the lifetime and past-year
regression models to maintain a consistent set of independent
variables.
Hierarchical logistic regressions were conducted to determine
whether self-reported VHA utilization and nonutilization (both
lifetime and past year) could be reliably predicted and if so, by
which independent variables; the Wald statistic was used to deter-
mine significance (p.05). Hierarchical logistic regression was
used so that the contributions of the specific aspects of the adapted
Andersen model could be examined separately and controlled for
sequentially as is typically done when using this model for eval-
uating factors associated with health care utilization (see Elhai et
al., 2008;Fasoli et al., 2010). The blocks of variables were entered
in accordance with Andersen’s model as follows: demographic and
sociocultural factors (i.e., age, gender with female as the reference
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226 SIMPSON, BALSAM, COCHRAN, LEHAVOT, AND GOLD
group), GLB-adapted health belief factor (concern about GLB-
related stigma at VHA), enabling factors (i.e., family income,
service connection, employment status, years since left military),
clinical need factors (i.e., PTSD diagnostic screen status, SF-8
physical component scale score), and GLB-related negative mili-
tary experiences (i.e., severity of anxiety about concealing GLB
identity, history of GLB investigation or punishment, history of
GLB-related interpersonal trauma). Cases with missing data rele-
vant to the models were excluded (n33).
Results
Sample characteristics are presented in Table 2. Participants’
ages ranged from 19 to 83. Nearly one third of the participants was
female, and nearly all (94.4%) identified themselves as gay or
lesbian, as opposed to bisexual (5.6%).
Rates of VHA Utilization, Reasons for Not Utilizing
VHA, and Disclosure of GLB Status to VHA
Providers
The rates of utilization for the 16 VHA services queried for both
lifetime and during the past year may be found in Table 1. The
lifetime rate of self-reported VHA utilization for all participants
was 45.8% (n163), and past-year VHA utilization for all
participants was 28.7% (n102; see Table 2 for details). The
proportion of respondents reporting that they do not access specific
services they would like to access due to concerns about GLB-
related stigmatization are also included in Table 1. Approximately
one quarter (n91; 25.6%) of respondents said that they avoid
using at least one VHA service they would like to access because
of concerns about stigmatization, with 55 (15.4%) indicating that
they avoid two or more types of VHA services for these reasons.
The services that were most frequently avoided were individual
counseling, general outpatient medical care, and dental care.
Among those who reported never having utilized VHA, nearly
three quarters reported that they have other health insurance, and
a small proportion cited concerns that VHA staff or patients would
not accept their sexuality. Among those who reported having
utilized VHA health care, over one third reported that their VHA
providers definitely do not know about their sexuality and one
third reported that they talk, at least sometimes, with their VHA
providers about issues related to their sexuality (see Table 3).
Univariate Associations With VHA Utilization Status
The univariate associations with lifetime and past-year VHA
utilization are presented in Table 2. Lifetime VHA utilization was
associated with female gender, older age, unemployment, annual
family income of less than $25,000, positive service connection,
greater number of years since leaving the military, positive PTSD
screen, worse physical functioning, and history of at least one
Table 2
Overall Sample Characteristics (N356) and Sample Characteristics by VHA Utilization Status
Lifetime Current
Sample characteristics
Overall sample
(N356)
VHA yes
(n162)
VHA no
(n194)
VHA yes
(n102)
VHA no
(n254)
Demographic factors
Age 45.4 (13.3) 46.8 (12.5) 44.1 (13.8)
47.2 (13.4) 44.7 (13.2)
Gender; female 30.3% 34.6% 26.8%
40.2% 26.4%
ⴱⴱⴱ
Sociocultural factors
Ethnicity; non-Hispanic white 87.9% 87.7% 88.1% 86.3% 88.6%
Sexual orientation; lesbian/gay 94.4% 93.2% 95.4% 93.1% 94.9%
Health belief factor
Concern regarding stigma at VA 25.6% 23.5% 27.3% 31.4% 23.2%
Enabling factors
Education; 4-year degree 61.8% 64.2% 59.8% 61.8% 61.8%
Employment; employed 67.1% 58.6% 74.2%
ⴱⴱⴱⴱ
49.0% 74.4%
ⴱⴱⴱⴱ
Medicare eligible; 65 or older 8.1% 8.0% 8.2% 10.8% 7.1%
Annual family income; $25,000 84.6% 79.2% 89.1%
ⴱⴱ
75.2% 88.4%
ⴱⴱⴱ
Relationship status; partnered 48.3% 48.8% 47.9% 46.1% 49.2%
Military discharge; honorable/general 96.3% 99.4% 93.6% 99.0% 94.9%
Service connection status; positive 21.9% 40.7% 6.2%
ⴱⴱⴱⴱ
50.0% 10.6%
ⴱⴱⴱⴱ
Years since left the military 16.5 (13.2) 17.8 (13.2) 15.5 (13.2)
17.4 (13.7) 16.2 (13.0)
Size of community; urban setting 74.4% 75.3% 73.7% 70.6% 76.0%
Clinical need (subjective)
PTSD diagnostic screen; positive 26.0% 32.7% 20.3%
ⴱⴱⴱ
36.3% 21.8%
ⴱⴱⴱ
MDD screen; positive 5.8% 9.4% 2.7% 13.7% 2.4%
Problem drinking screen; positive 11.8% 13.0% 10.8% 12.7% 11.4%
Physical Component Scale score 50.5 (9.5) 48.5 (10.1) 52.2 (8.6)
ⴱⴱⴱⴱ
45.8 (11.1) 52.4 (8.0)
ⴱⴱⴱⴱ
GLB military experiences
GLB-related military trauma; yes 46.3% 51.2% 42.8%
53.9% 43.7%
GLB military-initiated stressor; yes 52.5% 50.0% 54.6% 51.0% 53.1%
Degree of GLB concealment anxiety 2.6 (0.8) 2.3 (0.9) 2.4 (0.8) 2.2 (0.9) 2.4 (0.8)
ⴱⴱ
Note. Values are mean with standard deviation in parentheses, except for those labeled as percentage. VHA Veterans Health Care Administration;
PTSD posttraumatic stress disorder; MDD depressive disorder.
p.10.
ⴱⴱ
p.05.
ⴱⴱⴱ
p.01.
ⴱⴱⴱⴱ
p.001.
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227
VHA UTILIZATION AMONG GLB VETERANS
interpersonal trauma during military service related to respon-
dent’s GLB status. Past-year VHA utilization was associated with
all of the same variables as lifetime utilization except for the
following differences: years since leaving the military was not
associated with past-year utilization, whereas greater concerns
about GLB-related stigma on the part of VHA providers and
patients and greater anxiety about GLB-related concealment dur-
ing military service were positively associated with past-year
utilization. Variables that were not associated with either lifetime
or past-year VHA utilization included ethnicity, sexual orientation
(i.e., lesbian/gay vs. bisexual), educational attainment, Medicare
eligibility, relationships status, military discharge status, years
since leaving the military, size of community, depression status,
and problem drinking status.
Multivariate Predictors of Lifetime VHA Utilization
Hierarchical logistical regression analysis found that lifetime
VHA utilization was predicted by positive service connection,
positive screen for both PTSD and depression, and history of at
least one military interpersonal trauma that was related to respon-
dents’ sexual orientation (see Table 4; note that a positive PTSD
screen alone did not add significant variance to the model). Odds
ratios (ORs) indicate that whether participants were service con-
nected was the main determinant of whether they had ever used
VHA services, with those reporting service connection being more
than 11 times more likely to have received services (OR lifetime:
11.37). Additionally, those who screened positive for both PTSD
and depression were nearly twice as likely to have ever obtained
VHA care (OR lifetime: 1.77) and relatedly, those who reported at
least one interpersonal military trauma that was perceived to be
GLB-related were nearly twice as likely to have ever received
VHA care (OR lifetime: 1.82). The Hosmer and Lemesow Test for
the final model suggests that there is not a significant lack of fit (
2
statistic 2.3, df 8, p.97).
Multivariate Predictors of Past-Year VHA Utilization
Hierarchical logistical regression analysis found that past-year
VHA utilization was predicted by female gender, positive service
connection, positive screen for both PTSD and depression, lower
Table 3
GLB Veterans’ Rate of VHA Utilization and Reasons for Not
Utilizing VHA
VHA utilization information n(%)
Ever used VHA services 163 (45.8)
Physical health services only 84 (23.6)
Any mental health services 43 (12.1)
ER or other
a
only 36 (10.1)
Used VHA in past 12 months 102 (28.7)
Physical health services only 58 (16.3)
Any mental health services 22 (6.2)
ER or other
a
only 22 (6.2)
Reasons for not utilizing VHA services
b
(n187)
Other insurance coverage 140 (74.9)
Uncomfortable with atmosphere at the VHA 31 (16.6)
Concerned regarding confidentiality 21 (11.2)
Concerned that VHA staff would not accept
sexual orientation 22 (11.8)
Concerned that other VHA patients would not
accept sexual orientation 12 (6.4)
Other 38 (20.3)
Perceptions of VHA staff’s knowledge of
respondents’ sexuality and willingness to
discuss respondents’ sexuality (n122)
c
Definitely does not know 45 (36.9)
Might or probably knows but never talk about it 20 (16.4)
Knows but rarely talk about it 17 (13.9)
Sometimes or openly talk about it 40 (32.8)
Note. GLB gay, lesbian, and bisexual; VHA Veterans Health Care
Administration; ER emergency room.
a
Other includes special evaluations (e.g., agent orange, Gulf War Syn-
drome), vocational rehabilitation services, social work assistance, and
clergy/chaplain services.
b
Multiple responses were allowed.
c
Of the
160 who have received VHA services, 38 did not respond to these ques-
tions.
Table 4
Logistic Regression Predictors of Lifetime and Past-Year VHA Utilization
Predictors Lifetime OR (95% CL) (n323) Past year OR (95% CL) (n323)
Demographic and sociocultural factors
Age 1.00 [0.96, 1.03] 1.02 [0.98, 1.06]
Gender; female 1.65 [0.90, 3.02] 2.05 [1.02, 4.13]
GLB adapted health belief factor
Don’t use at least some VA due to stigma 0.54 [0.28, 1.02] 1.36 [0.68, 2.73]
Enabling factors
Family income at least $25,000 0.48 [0.21, 1.07 0.51 [0.21, 1.28
Service connected 11.37 [5.42, 23.85]
ⴱⴱ
10.35 [5.15, 20.80]
ⴱⴱ
Employed 0.76 [0.40, 1.41] 0.55 [0.27, 1.15]
Years since military discharge 1.02 [0.99, 1.06] 1.00 [0.96, 1.03]
Clinical need factors
PTSD and MDD screen; positive 1.77 [1.07, 2.92]
1.78 [1.02, 3.09]
Physical Component Scale score 0.98 [0.96, 1.01] 0.95 [0.92, 0.99]
ⴱⴱ
GLB-related military experiences
Severity of GLB military anxiety 1.06 [0.78, 1.44] 0.90 [0.61, 1.32]
At least 1 GLB military-initiated stressor 0.63 [0.35, 1.12] 0.42 [0.21, 0.87]
At least 1 GLB military trauma 1.82 [1.02, 3.24]
2.16 [1.07, 4.36]
Note. OR odds ratio; CL confidence limits; VHA Veterans Health Care Administration; MDD depressive disorder.
p.05.
ⴱⴱ
p.001.
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228 SIMPSON, BALSAM, COCHRAN, LEHAVOT, AND GOLD
physical functioning, history of at least one military interpersonal
trauma that was related to respondents’ sexual orientation, and
having no history of stressful experiences initiated by the military
to investigate or punish GLB status (see Table 4; note, again, that
a positive PTSD screen alone did not add significant variance to
the model). Again, the strongest correlate of past-year VHA utili-
zation was service connection status, with those who were positive
on this factor being more than 10 times more likely to have
received recent VHA care (OR past year: 10.35). In addition,
women were twice as likely to have used VHA services in the past
year than were men (OR past year: 2.05), those with both PTSD
and depression were nearly twice as likely to use VHA (OR past
year: 1.78), and those with worse physical health were somewhat
more likely to use VHA (OR past year: 0.95). With regard to the
GLB variables, those who had at least one stressful experience
initiated by the military to investigate or punish GLB status were
less than half as likely to have used VHA in the past year (OR past
year: 0.42), whereas those with at least one GLB-related interper-
sonal military trauma were more than two times more likely to
have used VHA in the past year (OR past year: 2.16). The Hosmer
and Lemesow Test for the final model suggests that there is not a
significant lack of fit (
2
statistic 8.2, df 8, p.41).
Discussion
The present study is the first to evaluate the rates and correlates
of self-reported VHA utilization among GLB veterans. Nearly half
(45.8%) of the GLB veterans surveyed reported lifetime VHA
utilization, and almost 29% reported VHA utilization in the past
year. The rate of past-year VHA utilization seen in our sample is
approximately 6.3% higher than the VHA Central Office estimate
of the rate of past-year VHA utilization among all veterans in
fiscal year 2005 (National Center for Veterans Analysis & Statis-
tics, 2011) and two times higher than the rate reported by Nelson
and her colleagues (Nelson et al., 2007). This finding mitigates
concerns that GLB veterans may disproportionately not utilize
VHA care.
Our findings from the multivariate hierarchical logistical regres-
sions further indicate that lifetime VHA utilization was associated
with positive service connection, positive screen for both PTSD
and depression, and history of at least one GLB-related interper-
sonal trauma while in the military. Past-year VHA utilization was
associated with positive service connection, female gender, greater
clinical need, GLB-related interpersonal trauma, but having no
history of stressful experience initiated by the military to investi-
gate or punish GLB status. Anxiety regarding the concealment of
one’s sexual orientation during military service did not add sig-
nificantly to the multivariate models nor did concerns about GLB
stigma at VHA.
It is noteworthy that positive service connection for a military-
related disability, positive screen for both PTSD and depression,
and history of military interpersonal trauma that was related to
respondents’ sexual orientation were all significantly associated
with both lifetime and past-year VHA utilization, suggesting that
the nature of a trauma adds appreciable variance to the likelihood
of utilizing care at VHA for these veterans. Although we originally
hypothesized that GLB-related military traumas would be associ-
ated with lower rates of VHA utilization, data from the civilian
sector on the impact of hate crimes against GLB individuals
suggests that distress is greater in the aftermath of such traumas
than traumas that do not involve hate crimes (Herek, Gillis, &
Cogan, 1999;Herek, Gillis, Cogan, & Glunt, 1997), and there is
some evidence that GLB-related discrimination is associated with
greater mental health care utilization (Burgess et al., 2007). It will
be important for future studies to evaluate this finding, but if
replicated, it may suggest that GLB veterans with histories of
military interpersonal trauma that was related to their sexual ori-
entation are more likely to utilize VHA than their peers without
such trauma histories. If this holds true, it will be especially
important for VHA providers to be sensitive to this added level of
trauma complexity by carefully assessing for it and taking it into
account in treatment planning (Kaysen, Lostutter, & Goines, 2005;
Martell, Safren, & Prince, 2004).
In contrast, GLB veterans who experienced at least one stressful
experience initiated by the military to investigate or punish their
GLB status, such as being interrogated regarding sexual orienta-
tion, forced to leave the military due to sexual orientation, or
isolated from one’s unit due to suspected homosexuality, were
significantly less likely to have utilized VHA in the past year. It is
possible that undergoing GLB-related stressors that were initiated
by the military led to a deeper mistrust of related structural entities
such as VHA, unlike GLB-related traumas, which were presum-
ably not initiated by the formal military structure. However, this
factor did not significantly influence lifetime VHA utilization, and
it will be important to see if the relationship with more recent VHA
utilization is replicated in other study samples.
Unexpectedly, we found that GLB veterans’ concerns about
how they would be treated at VHA did not add significantly to the
multivariate models regarding lifetime and past-year VHA utiliza-
tion, although in the univariate analyses greater concern regarding
stigma was associated with greater likelihood of utilizing VHA
health care in the past year. Again, this was contrary to our
hypotheses and should be evaluated in future studies. However,
because approximately a quarter of the overall sample reported
avoiding at least one type of VHA service due to concerns about
stigma toward GLB individuals, our findings indicate this is an
area in need of attention by VHA (Clark et al., 2003;Malebranche
et al., 2004). The types of services most frequently avoided due to
concerns about stigma included individual counseling, general
outpatient medical care, and dental care. Because concerns about
stigma may influence other outcomes of interest to VHA, includ-
ing treatment progress, patient relationships with providers, and
patient satisfaction with care, it is critical that VHA address
discriminatory practices or attitudes on the part of staff or other
veterans. It would also be beneficial for VHA to engage in direct
outreach to GLB veterans to help dispel concerns about stigma and
to foster greater confidence that they will be treated with respect
and dignity. This is especially urgent in light of recent findings
from the 2005–2010 Massachusetts State BRFSS data set indicat-
ing that GLB veterans are two times more likely than their het-
erosexual peers to be at risk for having seriously considered
suicide in the past 12 months (Blosnich, Bossarte, & Silenzio,
2012). Given the substantial increased risk for GLB veterans, these
findings suggest, along with our finding that individual counseling
may be especially avoided by GLB veterans, that it is critical that
VHA remove as many barriers to care as possible, including
perceptions that VHA may not be welcoming of GLB veterans.
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229
VHA UTILIZATION AMONG GLB VETERANS
It is also of concern that nearly 37% of the GLB veterans who
have obtained VHA services are certain that their VHA providers
do not know about their sexual orientation and that another 43% of
GLB veterans indicate that their providers might or definitely
know but that sexual orientation-related issues are rarely, if ever,
discussed. This finding is consistent with GLB patient–provider
relationships in civilian settings, where providers are often uncom-
fortable addressing issues germane to sexual orientation (Hinchliff,
Gott, & Galena, 2005), and GLB patients’ perceptions of such
provider unease have been found to negatively influence health
care utilization rates (Clark et al., 2003;Kinsler et al., 2007;Steele,
Tinmouth, & Lu, 2006). In the present study, this finding may be
due to provider discomfort or veterans themselves preferring to
keep this information private from health care providers (Mayer et
al., 2008). Lack of open communication about sexual orientation
could compromise the quality of care that GLB veterans receive as
well as their overall health; this is therefore another important
issue for VHA to address.
Consistent with Joint Commission hospital accreditation guide-
lines, VHA is in the process of revising its nondiscrimination
policies for veteran patients to include sexual orientation (www
.jointcommission.org/lgbt/;The Joint Commission, 2012). Along
with this important policy step, it is critical that VHA provide
thoughtful training to staff regarding GLB as well as transgender
veterans that facilitates providers learning how to sensitively as-
sess sexual orientation and whether it is related to any of the
veterans’ presenting complaints, as well as stresses the importance
of creating a nonjudgmental and open atmosphere that promotes
disclosure. This may be an especially important next step given our
findings that GLB veterans are in fact entering and using VHA, but
are unlikely to openly discuss their sexuality with health care
provides. Staff training in assessing the types of discriminatory
experiences these veterans may have had while in military service
as well as prior to and following service and how to document this
information in the medical record while taking into account the
individual veteran’s preferences regarding privacy is also critical.
Although the present study represents an important addition to
the literature, it also has a number of limitations. First, these
self-report data are cross-sectional, and we therefore cannot as-
sume causality between the factors in the regression models and
VHA utilization. Second, we did not include a comparison sample
of heterosexual veterans, and therefore we cannot draw firm con-
clusions about the similarities and differences between our GLB
veteran participants and other veterans with regard to their rates
and correlates of VHA utilization. Third, we did not ask all
participants whether they have health insurance other than VHA.
Fourth, although the sample was recruited from community-based
venues rather than from VHA facilities, the sample is fairly ho-
mogeneous, being composed of mostly male, gay or lesbian (as
opposed to bisexual), and white respondents. Indeed, the sample
had a greater proportion of non-Hispanic white veterans (nearly
88%) than the overall veteran population during 2005 (81%;
http://www.va.gov/vetdata/Veteran_Population.asp). Additionally,
the present sample is markedly younger than the overall veteran
population was in fiscal year 2005 (present sample mean age: 45.4;
overall veteran mean age: 59.2; http://www.va.gov/vetdata/Veteran_
Population.asp). However, it is noteworthy that the proportion of
female respondents was about 30%, which is markedly higher than
the proportion of female veterans overall during 2005 (7.1%;
http://www.va.gov/vetdata/Veteran_Population.asp). Thus, our
sample is not representative of the overall veteran population with
which we are comparing VHA utilization rates. It is possible that
the markedly larger proportion of women veterans in the present
sample relative to veterans overall is contributing to the relatively
high rates of VHA utilization reported by our sample, though this
may be offset by the fact that the present sample is, on average,
nearly 15 years younger than the average age of veterans at large.
The rate of past-year VHA utilization among the men in our
sample was 24.6%, which is only slightly greater than the rate for
veterans overall. This is in contrast with 38% of the women in our
sample reporting having used VHA services in the past year. This
finding is similar to gender differences reported in the civilian
literature, with women reporting higher medical care service uti-
lization than men (Bertakis, Azari, Helms, Callahan, & Robbins,
2000). Finally, these results are based on a convenience sample
rather than a sample of randomly identified participants. There-
fore, it may differ from the general population of GLB veterans in
additional unknown ways. As it becomes more acceptable to
include questions about sexual orientation in demographic assess-
ment instruments used in VHA and veteran studies, it will become
possible to obtain more representative samples and to identify
whether there are important differences between GLB and hetero-
sexual veterans that need to be taken into account in various
clinical settings.
In conclusion, by using official information from VHA as the
basis for comparison, we found that GLB veterans appear to access
VHA at generally the same or higher rates than the overall veteran
population. However, this finding needs to be viewed in light of
the relatively large proportion of women in our sample. We also
found that even when standard aspects of Andersen’s Emerging
Health Behavioral Model were accounted for, military interper-
sonal trauma that was related to respondents’ sexual orientation
and having no history of stressful experiences initiated by the
military to investigate or punish GLB status were associated with
use of VHA services. In addition, our findings that a substantial
proportion of GLB veterans who utilize VHA do not have open
communication with their providers about their sexual orientation
and that a sizable minority avoid using at least some VHA services
due to concerns about stigmatization suggest that VHA should
strive to bring its care of all veterans into alignment with its core
mission and values. Although DADT has now been repealed and
henceforth GLB military personnel may legally serve openly,
many GLB veterans undoubtedly carry painful memories of dis-
crimination and trauma from their military service that may influ-
ence their decisions whether to receive their health care from VA,
and it will be important that VA be welcoming and ready to meet
their needs. Those experiences of discrimination and trauma will
also need to be sensitively assessed and taken into account in
treatment planning.
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Received March 22, 2012
Revision received September 21, 2012
Accepted October 2, 2012
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232 SIMPSON, BALSAM, COCHRAN, LEHAVOT, AND GOLD
... After removing these papers, only 21 remained. Based on review articles that came up in our database search, we mined several review papers and other relevant literature (Eliason & Schope, 2001;Magnus et al., 2013;Mark et al., 2019;Simpson et al., 2013) to identify any studies we may have missed during the database search process. This manual data mining process identified 37 articles to be considered for further review. ...
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From the perspective of 445 lesbian, gay, bisexual, and transgender (LGBT) U.S. military veterans, the present study examined hypothesized relations of sexual orientation disclosure, concealment, and harassment with unit social and task cohesion. Findings indicated that sexual orientation disclosure was related positively, whereas sexual orientation concealment and harassment were related negatively to social cohesion. Also, through their links with social cohesion, each of these variables was related indirectly to task cohesion. When the set of predictors was examined together, sexual orientation disclosure had a positive direct relation with social cohesion and a positive indirect relation with task cohesion, whereas sexual orientation–based harassment had a negative direct relation with social cohesion and a negative indirect relation with task cohesion. These data provide useful groundwork for evaluating military policies and practices regarding sexual orientation.
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Cognitive-behavioral therapy (CBT) is highly effective for a wide range of problems; however, few studies address its use with lesbian, gay, or bisexual clients. Furthermore, although many cognitive-behavioral techniques are similar for heterosexual and nonheterosexual clients, cultural sensitivity and knowledge will enhance the use of CBT techniques and, if neglected, can hinder treatment. This chapter addresses the use of a culturally sensitive, affirmative CBT in treating lesbian, gay, and bisexual clients. We include two case examples to illustrate some of the presenting concerns of LGB clients and some of the ways in which CBT approaches might be implemented in a culturally sensitive manner. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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This study investigated predictors of mental and physical health care service utilization among 1,632 male (n = 1,200) and female (n = 432) Vietnam veterans who participated in the National Vietnam Veterans Readjustment Study. Using Anderson's theory as a model (Anderson & Bartkus, 1973), the authors examined both direct and mediated relationships among predisposing factors (i.e., age, marital status, and combat exposure), enabling factors (e.g., household income and insurance), and need factors (e.g., medical and psychological symptomatology) and physical and mental health care utilization outcomes. Need factors were the most consistent and strongest mediators of predisposing variables for both physical and mental health care service utilization, although there were differences between male and female veterans. For men, combat exposure indirectly predicted mental health care utilization through the need variables (with the effects of posttraumatic stress disorder being greatest). For women, physical health problems mediated the relationship between combat exposure and physical health outpatient care utilization. These findings have implications for screening and outreach efforts. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
OBJECTIVE: While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity. MEASUREMENTS: The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as “0” (not at all) to “3” (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients. RESULTS: As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score ≥10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples. CONCLUSION: In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.