Still Serving in Silence: Transgender Service Members and Veterans in the National Transgender Discrimination Survey
Jack Harrison-Quintana and Jody L. Herman
On September 20, 2011, the repeal of “Don’t Ask, Don’t Tell” (DADT) went into effect in the U.S. military. The repeal marked the end of discriminatory practices in the military based on sexual orientation, but it did not end the prohibition on transgender military service. The National Transgender Discrimination Survey (NTDS) found that transgender Americans serve in the military at a high rate; 20 percent of NTDS respondents had served in the armed forces as compared to 10 percent of the U.S. general population. This study draws upon both quantitative and qualitative data about transgender soldiers and veterans who responded to the NTDS to describe who these transgender soldiers and veterans are and what their experiences have been in regard to their military service. This study outlines respondents’ reported issues in obtaining corrected identity documents, accessing military health care, and experiences of discrimination. This study finds that transgender veterans experience substantial barriers in these areas and also experience high rates of family rejection and homelessness.
Lifetime Prevalence of Pathological Gambling Among American Indian and Hispanic American Veterans
Abstract: Westermeyer et al examine the prevalence and clinical correlates of pathological gambling among 1228 American Indian and Hispanic American veterans in the southwest and north central regions of the US. A 70% lifetime comorbidity of psychiatric disorders suggests that early interventions for pathological gambling should consider common psychiatric conditions rather than focusing on pathological gambling alone.
Gender Differences in Predictors of Suicidal Thoughts and Attempts Among Homeless Veterans that Abuse Substances
Abstract: This study of 315 male and 310 female homeless military veterans in a V.A. inpatient program designed to treat substance abusers, many of whom also suffer psychiatric disorders, was designed to examine gender differences in factors associated with the odds of having suicidal thoughts, and of attempting suicide, in comparison to being nonsuicidal. A maximum likelihood estimation multinomial logistic regression showed childhood and current sexual and physical abuses, depression, fearfulness, relationship problems, limited social support, and low self-esteem was more strongly associated with suicidal thoughts and attempts for women than for men veterans. Extent of alcohol and other drug abuse, aggression, resilience, self-efficacy, combat exposure, combat-related PTSD, and work problems were more strongly associated with suicidal thoughts and attempts for men than for women. Implications of these findings for V.A. programs are discussed. [PUBLICATION ABSTRACT]
Gender Differences in Mental Health Diagnoses Among Iraq and Afghanistan Veterans Enrolled in Veterans Affairs Health Care
Abstract: We examined gender differences in sociodemographic, military service, and mental health characteristics among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans. We evaluated associations between these sociodemographic and service characteristics and depression and posttraumatic stress disorder (PTSD) diagnoses. In a retrospective, cross-sectional study, we used univariate descriptive statistics and log binominal regression analyses of Department of Veterans Affairs (VA) administrative data on 329049 OEF and OIF veterans seeking VA health care from April 1, 2002, through March 31, 2008. Female veterans were younger and more likely to be Black and to receive depression diagnoses than were male veterans, who were more frequently diagnosed with PTSD and alcohol use disorders. Older age was associated with a higher prevalence of PTSD and depression diagnoses among women but not among men. Consideration of gender differences among OEF and OIF veterans seeking health care at the VA will facilitate more targeted prevention and treatment services for these newly returning veterans.
Civilian Social Work: Serving the Military and Veteran Populations
Abstract: This article discusses social work practice areas for civilian social workers who provide services to military service members, veterans, and their families. These practice areas include education, child welfare, domestic violence, mental health, health care, substance abuse, and criminal justice. The authors examine the impact of the contemporary military lifestyle and current military operations on service members and their families in the context of these practice areas, with the goal of compelling civilian social workers to acknowledge their responsibility to competently serve military and veteran clients. [PUBLICATION ABSTRACT]
Racial/Ethnic Variations in Veterans’ Ambulatory Care Use
Abstract: We assessed racial/ethnic variations in patterns of ambulatory care use among Department of Veterans Affairs (VA) health care-eligible veterans to determine if racial/ethnic differences in health care use persist in equal-access systems. We surveyed 3227 male veterans about their health and ambulatory care use. Thirty-eight percent of respondents had not had a health care visit in the previous 12 months. Black (odds ratio [OR]=0.5), Hispanic (OR=0.4), and Asian/Pacific Islander veterans (OR=0.4) were less likely than White veterans to report any ambulatory care use. Alternately, Whites (OR=2.2) were more likely than other groups to report ambulatory care use. Being White was a greater predictor of health care use than was having fair or poor health (OR=1.4) or functional limitations (OR=1.5). In non-VA settings, racial/ethnic minorities were less likely to have a usual provider of health care. There was no VA racial/ethnic variation in this parameter. Racial/ethnic disparities in health and health care use are present among VA health care-eligible veterans. Although the VA plays an important role in health care delivery to ethnic minority veterans, barriers to VA ambulatory care use and additional facilitators for reducing unmet need still need to be investigated.
Substance Abuse-Related Mortality Among Middle-Aged Male VA Psychiatric Patients
Abstract: Objective: This study evaluated mortality and causes of death over a seven-year period among middle-aged male psychiatric patients with and without co-occurring substance use disorder. Methods: This cohort study examined mortality among 169,051 male Vietnam-era veterans ages 40 to 59 treated for psychiatric disorders by the U.S. Department of Veterans Affairs (VA) between April and September 1998. Demographic variables, diagnoses, and prior hospitalizations were obtained from VA electronic medical records. Mortality status was obtained from VA benefits records. Cause-of-death data were purchased from the National Death Index for a random sample of 3,383 decedents. Mortality among psychiatric patients with and without diagnosed co-occurring substance use disorders was compared by logistic regression, with controls for demographic factors, psychiatric and medical diagnoses, and prior hospitalizations. Causes of death for psychiatric patients with and without co-occurring disorders were compared by chi square analyses. Results were compared to age- and race-matched norms for the U.S. population. Results: The risk-adjusted probability of dying was 55% higher among psychiatric patients with co-occurring substance use disorders than among those without substance use disorders (OR=1.58-1.69). Overdoses and substance abuse-linked illnesses accounted for 27.6% of deaths among psychiatric patients with co-occurring substance use disorders, compared with only 8.8% of deaths among other psychiatric patients. Conclusions: Substance use disorders strongly contributed to premature death among male psychiatric patients. Secondary prevention is needed to reduce substance misuse and improve medical care for substance-related illnesses among psychiatric patients with co-occurring substance use disorders. (Psychiatric Services 59:290-296, 2008)
Forever Changed: Post Traumatic Stress Disorder in Female Military Veterans, A Case Study
PURPOSE: This paper examines the experience of posttraumatic stress disorder (PTSD) in a female veteran of Operation Iraqi Freedom, including the barriers to treatment she encountered in an outpatient psychiatry clinic. DESIGN AND METHODS. Case report data were obtained through review of records and interviews with a veteran combat nurse diagnosed with chronic PTSD. CONCLUSIONS. Sex differences in PTSD are controversial, but PTSD in female military veterans is a significant problem. Gender may complicate diagnosis and treatment. This case report discusses these issues and invites further research. PRACTICE IMPLICATIONS. Advanced practice psychiatric nurses increasingly will see female veterans with PTSD in their practices.
Do Faith-Based Residential Care Services Affect the Religious Faith and Clinical Outcomes of Homeless Veterans?
Abstract: Data on 1,271 clients in three residential care services funded by the Department of Veterans Affairs was used to examine: (1) how religious-oriented programs differ in their social environment from secular programs, (2) how religious-oriented programs affect the religiosity of clients, and (3) how client religiosity is associated with outcomes. Programs were categorized as: secular, secular now but religious in the past, and currently religiously oriented. Results showed (1) participants in programs that were currently religious reported the greatest program clarity, but secular services reported the most supportive environments; (2) participants in programs that were currently religious did not report increases in religious faith or religious participation over time; nevertheless (3) greater religious participation was associated with greater improvement in housing, mental health, substance abuse, and quality of life. These findings suggest religious-oriented programs have little influence on clients’ religious faith, but more religiously oriented clients have somewhat superior outcomes.[PUBLICATION ABSTRACT]
Access to Primary Care for Homeless Veterans with Serious Mental Illness or Substance Abuse: A Follow-up Evaluation of Co-Located Primary Care and Homeless Social Services
Abstract: To examine the hypothesis that a demonstration clinic integrating homeless, primary care, and mental health services for homeless veterans with serious mental illness or substance abuse would improve medical health care access and physical health status. A quasi-experimental design comparing a ‘usual VA care’ group before the demonstration clinic opened (N = 130) and the ‘integrated care’ group (N = 130). Regression models indicated that the integrated care group was more rapidly enrolled in primary care, received more prevention services and primary care visits, and fewer emergency department visits, and was not different in inpatient utilization or in physical health status over 18 months. The demonstration clinic improved access to primary care services and reduced emergency services but did not improve perceived physical health status over 18 months. Further research is needed to determine generalizability and longer term effects.
Brief Reports: Psychiatric Illness and Substance Abuse Among Homeless Asian-American Veterans
Abstract: Objectives: This study examined the proportion of Asian Americans among homeless veterans and among veterans in the general population to calculate the relative risk of homelessness among Asian-American veterans. It also examined differences in rates of psychiatric and substance use disorders between homeless racial and ethnic subgroups. Methods: Data were gathered between 1997 and 2001 from the Health Care for Homeless Veterans program and included data from administrative intake, patients’ self-reports, and clinicians’ diagnostic assessments of substance use disorders and psychiatric illness. Results: Data were examined for 67,441 veterans. Asian-American veterans had a significantly lower risk of homelessness than veterans of other ethnic groups. Alcohol abuse was significantly and consistently less prevalent among Asian Americans compared with blacks and Hispanics. However, drug abuse was less prevalent among Asian Americans than among blacks and Hispanics, but rates were similar to those of whites. Conclusions: Lower rates of alcohol abuse may protect Asian-American veterans from becoming homeless. (Psychiatric Services 57:704-707, 2006)
Associations Between Race and Ethnicity and Receipt of Advice About Alcohol Use in the Department of Veterans Affairs
Abstract: Objective: This study sought to identify racial and ethnic differences in rates of alcohol-related advice given to veterans treated in Veterans Affairs (VA) facilities. Methods: This was a cross-sectional analysis of data from the VA Survey of the Healthcare Experiences of Patients (SHEP). Participants were 255,522 veterans treated in VA ambulatory clinics in fiscal year 2005. SHEP measures included alcohol consumption questions from the Alcohol Use Disorders Identification Test and an item inquiring whether a VA clinician had given advice about drinking. Logistic regression was used to examine relationships between race and ethnicity categories and receipt of alcohol-related advice. Covariate measures included demographic characteristics and physical and mental component summary scores from the Veterans RAND Health Survey (VR-12). Results: Among veterans who consumed any alcohol, compared with veterans from the other racial or ethnic groups, Asian, Native Hawaiian, or Pacific Islander veterans were less likely to be in the medium and highest alcohol consumption categories and non-Hispanic white veterans were less likely to be in the highest alcohol consumption category (p <.001). In a model adjusting for demographic characteristics, physical and mental health status, and alcohol consumption category, among veterans who consumed any alcohol, those who were non-Hispanic black (odds ratio [OR] = 1.65, 95% confidence interval [CI] = 1.47 – 1.84), Hispanic (OR = 1.56, CI = 1.35 – 1.80), or non-Hispanic American Indian or Alaska Native (OR = 1.56, CI = 1.06 – 2.29) were more likely to report receiving alcohol-related advice, compared with non-Hispanic white veterans. Conclusions: The results suggest that veterans from certain minority groups are more likely than white veterans to report receiving alcohol-related advice in the VA, after the model is adjusted for demographic characteristics, health status, and alcohol consumption. Further research is needed to understand the underlying reasons for observed differences in receipt of alcohol-related advice and the potential clinical implications. (Psychiatric Services 60:663-670, 2009)
Suicide Among Patients in the Veterans Affairs Health System: Rural-Urban Differences in Rates, Risks, and Methods
Abstract: Using national patient cohorts, we assessed rural-urban differences in suicide rates, risks, and methods in veterans. We identified all Department of Veterans Affairs (VA) patients in fiscal years 2003 to 2004 (FY03-04) alive at the start of FY04 (n = 5 447 257) and all patients in FY06-07 alive at the start of FY07 (n = 5 709 077). Mortality (FY04-05 and FY07-08) was assessed from National Death Index searches. Census criteria defined rurality. We used proportional hazards regressions to calculate rural- urban differences in risks, controlling for age, gender, psychiatric diagnoses, VA mental health services accessibility, and regional administrative network. Suicide method was categorized as firearms, poisoning, strangulation, or other. Rural patients had higher suicide rates (38.8 vs 31.4/100 000 personyears in FY04-05; 39.6 vs 32.4/100 000 in FY07- 08). Rural residence was associated with greater suicide risks (20% greater, FY04-05; 22% greater, FY07-08). Firearm deaths were more common in rural suicides (76.8% vs 61.5% in FY07-08). Rural residence is a suicide risk factor, even after controlling for mental health accessibility. Public health and health system suicide prevention should address risks in rural areas.
