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. 2023 Nov 16;57(12):1014-1023.
doi: 10.1093/abm/kaad035.

Barriers and Facilitators to Gender-affirming Hormone Therapy in the Veterans Health Administration

Hill L Wolfe  1   2   3 , Taylor L Boyer  1 , Jillian C Shipherd  4   5   6 , Michael R Kauth  4   7   8 , Guneet K Jasuja  9   10   11 , John R Blosnich  1   12
Affiliations

Barriers and Facilitators to Gender-affirming Hormone Therapy in the Veterans Health Administration

Hill L Wolfe et al. Ann Behav Med. .

Abstract

Background: In 2011, the Veterans Health Administration (VHA) established a policy for the delivery of transition-related services, including gender-affirming hormone therapy (GAHT), for transgender and gender diverse (TGD) patients. In the decade since this policy's implementation, limited research has investigated barriers and facilitators of VHA's provision of this evidence-based therapy that can improve life satisfaction among TGD patients.

Purpose: This study provides a qualitative summary of barriers and facilitators to GAHT at the individual (e.g., knowledge, coping mechanisms), interpersonal (e.g., interactions with other individuals or groups), and structural (e.g., gender norms, policies) levels.

Methods: Transgender and gender diverse patients (n = 30) and VHA healthcare providers (n = 22) completed semi-structured, in-depth interviews in 2019 regarding barriers and facilitators to GAHT access and recommendations for overcoming perceived barriers. Two analysts used content analysis to code and analyze transcribed interview data and employed the Sexual and Gender Minority Health Disparities Research Framework to organize themes into multiple levels.

Results: Facilitators included having GAHT offered through primary care or TGD specialty clinics and knowledgeable providers, with patients adding supportive social networks and self-advocacy. Several barriers were identified, including a lack of providers trained or willing to prescribe GAHT, patient dissatisfaction with prescribing practices, and anticipated or enacted stigma. To overcome barriers, participants recommended increasing provider capacity, providing opportunities for continual education, and enhancing communication around VHA policy and training.

Conclusions: Multi-level system improvements within and outside the VHA are needed to ensure equitable and efficient access to GAHT.

Keywords: Gender-affirming hormone therapy; Healthcare access; Transgender and gender diverse; Veterans Health Administration.

Plain language summary

Veterans Health Administration (VHA) policy mandates the provision of several gender-affirming health services, including gender-affirming hormone therapy (GAHT). GAHT can improve quality of life among transgender and gender diverse (TGD) patients by more closely aligning their physical self with their internal sense of self. We conducted interviews with 30 TGD patients and 22 VHA healthcare providers to gather their perspectives on barriers and facilitators to GAHT in the VHA. Findings revealed that facilitators of GAHT access included information sharing through social networks and relying on providers in primary care or specialized TGD health clinics for prescribing, while barriers included a shortage of trained providers and patient dissatisfaction with prescribing practices. Anticipating or experiencing stigma from providers and other patients was also identified as a barrier to GAHT. To overcome barriers, participants recommended increasing provider capacity, offering continuous education on GAHT prescribing, and improving communication about VHA policies and training. Comprehensive improvements at various levels, both within and outside the VHA, are necessary to improve access to this important evidence-based treatment for TGD patients.

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