Incorporating Lesbian and Bisexual Women into Women Veterans’ Health Priorities

ABSTRACT Relative to the general population, lesbian and bisexual (LB) women are overrepresented in the military and are significantly more likely to have a history of military service compared to all adult women. Due to institutional policies and stigma associated with a gay or lesbian identity, very little empirical research has been done on this group of women veterans. Available data suggest that compared to heterosexual women veterans, LB women veterans are likely to experience heightened levels of prejudice and discrimination, victimization, including greater incidence of rape, as well as adverse health and substance use disorders. They are also likely to encounter a host of unique issues when accessing health care, including fears of insensitive care and difficulty disclosing sexual orientation to Veterans Health Administration (VHA) providers. Training of staff and providers, education efforts, outreach activities, and research on this subpopulation are critical to ensure equitable and high quality service delivery.


INTRODUCTION
Lesbian, gay, and bisexual (LGB) individuals have long served in the US military, despite a variety of policies that until very recently were designed to keep them out of service. According to the 2000 census, nearly one million gay and lesbian Americans are veterans. 1 Lesbian and bisexual (LB) women, in particular, are more likely to serve than gay and bisexual men and have greater representation in the military (10.7 %) than in the general population (4.2 %). [1][2][3][4][5] Very little is known about LB women veterans' military experiences and health sequelae, though a 2004 report demonstrated that women were disproportionately impacted by Don't Ask Don't Tell (DADT), as they made up 30 % of all DADT discharges despite comprising only 14 % of the force. 6 There are only a handful of empirical studies on LGB veterans (see Table 1), 2,[7][8][9][10][11][12][13][14][15][16] and of these, only three have focused specifically on women. 8,9,14 Researchers, providers, and educators must address this subpopulation of women veterans and their specific needs if we are to fulfill the mission of serving America's women veterans and providing equitable health care.

WOMEN VETERANS AND LB WOMEN: STRIKING SIMILARITIES IN TRAUMA EXPERIENCE
Among women veterans in general, a growing body of evidence has documented high rates of trauma across the lifespan and adverse health outcomes. A review of the literature indicated that almost all women veterans report a traumatic event at some point in their lives (81-93 %), and estimates of lifetime sexual assault, childhood sexual and physical abuse, adult sexual and physical assault, and intimate partner violence exceed estimates among nationally representative samples of women. 17 Direct comparisons of women veterans to civilians parallel these findings. 18,19 Once they enter the military, women veterans may experience additional forms of violence, including military sexual trauma (MST; reported by 20-40 %) and combat exposure. 17,20 These high rates of trauma exposure appear to translate into heightened risk of poor mental health and health behaviors for women veterans. Two recent studies demonstrated that, compared to civilians, women veterans report worse health-related quality of life, worse general health, and greater likelihood of having a depressive disorder, smoking, and being overweight or obese. 21,22 Rates of posttraumatic stress disorder (PTSD) are also high, with some estimates as high as 21% 23 and 27 %, 24 which are substantially greater than the 10-12 % lifetime prevalence rate found in the general population of women. 25,26 The elevated levels of trauma exposure and increased health challenges identified for women veterans are consistent with what has been found for LB women when they are compared to heterosexual women. In the general population, several studies have demonstrated that LB women are more likely to report sexual and physical abuse in both childhood and adolescence, [27][28][29][30] as well as higher levels of sexual assault in adulthood. 28,31,32 Data from populationbased studies also indicate that sexual minority status among women is associated with hazardous drinking, 33-37 S609 smoking, 33,34,36,38 obesity, 39,40 and mood and anxiety disorders, including PTSD. 34,[41][42][43] Similarities between women veterans and LB women raise the question of whether women who are both veterans and sexual minority are at a more elevated risk for victimization and poor health than those in only one of these populations. In a recent study comparing male and female LGB and heterosexual veterans, LGB veterans were LGB Lesbian, gay, and bisexual individuals; VHA Veterans Health Administration The above studies do not include published research reports including estimates from the Census 1,4 and annual reports provided by Servicemembers Legal Defense Network 6 more likely to report suicidal ideation, and this difference was partly explained by poorer mental health and lower social and emotional support. 2 Similarly, another study that compared male and female LGB veterans to a comparison sample from a VA data warehouse found that LGB veterans were more likely to screen positive for PTSD, depression, and alcohol problems. 10 In a unique sample comparing LB and heterosexual women veterans, LB women were more likely to report worse physical health, 8 lifetime rape (73 % vs. 48 %), 9 and meet criteria for both past-year and lifetime substance use disorders. 9

PREJUDICE AND DISCRIMINATION
In the LGB literature, both distal and proximal stressors have been described as group-specific processes that may contribute to observed health disparities. 44 Distal stressors are defined as prejudice-inspired events, including violence and discrimination. Proximal stressors are internal processes that are presumed to occur following exposure to distal stressors. 45 As an example of a distal stressor, in a national probability sample of LGB adults, about 20 % reported having experienced a crime based on their sexual orientation. 46 The limited data on LGB veterans demonstrate that discrimination experiences, especially within the military, are relatively common. In a study with 379 LGB veterans, 48 % of the women indicated at least one experience of victimization related to their sexual orientation. 7 In semistructured interviews with LB women veterans from Canada, participants reported significant stigma within the military that contributed to poorer mental health. 14 Themes common to these women's experiences included being persecuted, interrogated, humiliated, and coerced during their time of service.
An important question is whether the experience of discrimination itself, in its frequency, severity, or quality, might be unique for LB women veterans compared to heterosexual women veterans or LB women civilians. This group violates cultural norms with respect to both gender (by virtue of being in the military) and heterosexuality. For LB women veterans, especially those who may be butch (e.g., present with a more masculine gender style), discrimination may be a result of gender nonconformity prejudice that is intertwined with antigay prejudice. For example, corrective rape is a term for a hate crime in which an individual is raped because of their perceived sexual or gender orientation, with the intended consequence of the rape to "correct" the individual's orientation or make them "act" more like their gender. 47 The term was coined in South Africa, and its occurrence among LB American women (or the interpretation of the assault as this type of crime) has not been extensively studied. Nonetheless, in 2010, a retired official from the a Tennessee District Attorney's office advocated corrective rape for US lesbian soldiers, 48 and this year a Ohio radio host also publicly xadvocated corrective rape for lesbians. 49 Other discriminatory experiences may include bullying due to a woman's perceived gender role nonconformity and sexuality, as well as antigay jokes and name-calling. Importantly, research has shown that hate crimes related to sexual orientation are more detrimental to mental health than nonbiased crimes. 50 Examples of proximal stressors following exposure to distal stressors include fear of rejection, internalized homophobia, and concealment of one's sexual orientation. 44 Internalized homophobia involves incorporating negative societal views of homosexuality into the self-concept, 51 and has been shown to have significant adverse effects on mental health. 52 In a military culture that values both masculinity and heterosexuality, it is possible that LB women veterans exhibit heightened feelings of self-stigma. Concealing one's orientation (until recently a requirement for active duty LB women) is another stressor that may lead to hypervigilance and social isolation, 53 as well as to poor self-reported health and depressive symptoms. 54 Poulin and colleagues found that in efforts to conceal their sexuality, LB women veterans they interviewed created "parallel" selves to maintain a heterosexual public persona, often modifying their behaviors, speech, dress, mannerisms, and social networks. 14

ACCESS TO AND EXPERIENCE OF HEALTHCARE
A particular concern is whether LB women veterans are accessing the VHA and whether the system is ready and able to provide them with high-quality, sensitive care. Data on LB women in general show that they are more likely than heterosexual women to use mental health care, 55,56 although they are also more likely to report difficulty obtaining needed medical care. 34,35 Moreover, compared to more feminine LB women, butch and more masculine LB women are significantly less likely to have routine gynecological exams and report worse treatment in healthcare settings, 57 putting them at potentially greater risk for undetected uterine or cervical cancer.
One recent study examined VHA utilization by 356 LGB veterans (30 % female). 15 Results indicated that the rate of past year VHA use (29 %) was similar to VA Central Office estimates among veterans overall, suggesting that LGB veterans are indeed accessing VHA. Nonetheless, of those who accessed VHA care, only 33 % reported open communication about their sexual orientation with VHA providers, and 25 % reported avoiding at least one VHA service because of concerns about stigma. The lack of ease in discussing sexual orientation has been found to influence healthcare utilization rates negatively among LGB civilians, 58,59 and could further compromise the quality of care that these veterans receive.

CONCLUSIONS
LB women veterans are a large and distinct part of the greater women veteran community, and their presence, military experiences, and health needs must not be overlooked. Under DADT, 14,500 service-members were discharged, 60 but in September 2011 this policy was repealed, allowing LB women to serve openly. 61 In recent years, VHA has made enormous strides to address the health needs of vulnerable groups, including women and LGB and transgender veterans. For example, in 2011 Women's Health became part of the Office of Patient Care Services 62 and VHA established a National Call Center for Women Veterans. 63 A VHA Directive established policy regarding the respectful delivery of health care to transgender and intersex veterans. 64 The VHA Office of Diversity and Inclusion held its third annual LGB and Transgender Observance Program, and is further leading the effort to establish a formal LGB and transgender special emphasis program. VHA has also created an Office of Health Equity that will address LGB healthcare issues, among others. 65 Despite these advances, other institutional policies remain in place that prevent LB women from claiming equal rights and equitable care. Because the Defense of Marriage Act defines marriage for the federal government as a union between a man and woman, many of the benefits the military extends to spouses are not available to same-sex spouses of service members during either their active duty service or when they transition to veteran status, potentially creating financial stresses following service. 66 For example, heterosexual spouses of deceased veterans are entitled to many benefits (health care, death pensions, bereavement counseling, etc.) not available to same-sex spouses. Moreover, a recent assessment of the protections granted to LGB veterans concluded that there are significant gaps in VHA's antidiscrimination policy, and thus made recommendations to VHA to provide explicit patient protections on the basis of sexual orientation or gender identity. 67 Additionally, as the number of women veterans is expected to increase, so will the number of LB women veterans who are in need of services. Cultural competency trainings are thus critical, and should provide education about LGB veterans, promote providers' awareness of their own attitudes and potential anxiety about caring for LGB patients, and address best practices on asking about sexual orientation. 68 Providers can facilitate open conversations about sexual orientation by their nonjudgmental stance and by sending a clear message that LGB veterans are welcome. For example, the Fenway Institute suggests beginning with open-ended questions, using inclusive or neutral language, and embedding further questions in the sexual history should self-disclosure not come up. 68 Such trainings may assist providers with becoming more inclusive and creating a safe atmosphere, so that patients are able to provide thorough disclosures that can improve their treatment plans and the resources available to them.
At least one recommended resource is the creation of LGB veteran support groups that recognize the individual's unique identity as both LGB and veteran. There are emerging models for this type of LGB-specific care, including VA Palo Alto's Living Out Loud/Laughing Out Loud support group for LGB and transgender veterans. 69 The group provides members with an opportunity to receive social support from peers, as well as explores a variety of topics, such as isolation, mental health, and family issues. The presence of such groups could help make VHA a provider of choice for LGB veterans, as well as increase sensitivity to and visibility of these veterans within VHA medical centers.
As demonstrated in this article, research on LB women veterans is extremely limited. We encourage researchers to include questions about sexual orientation in their research programs. Research areas of particular importance to LB veterans include information about their exposures to trauma, mental health needs, access and barriers to care, and preferences for and experiences with treatment. As data become available, researchers, providers, and policy-makers alike can ensure that we address potential disparities, as well as assess setbacks or progress in meeting this group's needs.