Implementing VHA Directive 2011-024: An Overview for PACT Teams and Other Clinical Staff on Providing Health Care for Tr

1. Implementing VHA Directive 2011-024: An Overview for PACT Teams and Other Clinical Staff on Providing Health Care for Transgender and Intersex Veterans Slides developed by the VHA Transgender Training Workgroup, Patient Care Services based on a PowerPoint Presentation by the Transgender Communications Workgroup

2. Purpose of the Presentation • Primary Purpose: To provide VHA PACT Team and other clinical staff with an understanding of the key points in VHA’s Directive on Providing Health Care for Transgender and Intersex Veterans. Implementation of this directive is the responsibility of all staff. • Secondary Purpose: To provide pertinent information about medical and mental health concerns and provision of health care services to transgender and intersex Veterans. • Take home point: All Veterans – including transgender and intersex Veterans – have served the United States and are deserving of the utmost respect and health care in the VA. Validating the preferences of transgender Veterans communicates respect and caring. The VA wants to be Veterans’ health care provider of choice.

3. Audience • This presentation is intended for PACT Teams and other non-mental health staff of the VHA. This includes, but is not limited to, areas such as: • Primary Care, Specialty Care, Medicine, Surgery, Endocrinology, Pharmacy, Women’s Health, and Rehabilitation • PACT Teams and other clinical staff are vital components of caring for our nation’s Veterans! We are all responsible for helping to create a SAFE and RESPECTFUL health care environment at the VA for our Veterans.

4. Learning Objectives At the conclusion of this educational offering, learners will be able to: • Articulate the key elements of VHA’s Directive on Providing Health Care for transgender and Intersex Veterans. • Articulate how this policy applies to their work and service area. • Identify physical and mental health concerns relevant to assessment and treatment of transgender Veterans in primary settings. • Identify states of transitions. • Name key ways to show respect and caring towards transgender and intersex Veterans at the VA. • State why it is important to treat all Veterans with respect and dignity.

5. The VA Policy • “It is VHA policy that medically necessary care is provided to enrolled or otherwise eligible intersex and transgender Veterans, including hormonal therapy, mental health care, preoperative evaluation, and medically necessary post-operative and long-term care following sex reassignment surgery. Sex reassignment surgery cannot be performed or funded by VHA or VA.” • “Patients will be addressed and referred to based on their self-identified gender.” • “All other health services are provided to transgender Veterans without discrimination in a manner consistent with care and management of all Veteran patients.” The VA has a zero tolerance for discrimination. Ref: VHA Directive 2011-024 Providing Health Care for Transgender and Intersex Veterans

6. Definitions • Sex = “the classification of individuals as female or male on the basis of their reproductive organs and functions” • Gender = “the behavioral, cultural, or psychological traits that a society associates with male and female sex” • In simple terms, sex refers to our biology, and gender refers to how we think about ourselves, refer to each other, dress, and behave. • Gender identity refers to the personal adoption of a male or female identity or an identity that is more ambiguous. • Gender expression refers to how one expresses gender identity in behavior and appearance. • Transgender = an umbrella term “used to describe people whose gender identity or gender expression differs from that usually associated with their sex assigned at birth” Ref: VHA Directive 2011-024 Providing Health Care for Transgender and Intersex Veterans

7. Definitions (cont.) • Transsexual = a subset of transgender persons who self-identify as such and have taken steps tolook like their preferred gender. These individuals are most likely to use or plan to use hormones or surgery to modify their body to conform with their gender identity. • “Male-to-female (MtF) transsexuals are individuals who are male sex at birth, but self-identify as female and often take steps to socially or medically transition to female.” The correct pronoun for an MtF individual is she. • “Female-to-male (FtM) transsexuals are individuals who are female sex at birth, but self-identify as male and often take steps to socially or medically transition to male.” The correct pronoun for an FtM individual is he. Ref: VHA Directive 2011-024 Providing Health Care for Transgender and Intersex Veterans

8. Definitions (cont.) • Sex reassignment surgery = “includes any of a variety of surgical procedures done simultaneously or sequentially with the explicit goal of transitioning from one gender to another.” Sex reassignment is employed to facilitate gender transition. “This term does not apply to non-surgical therapy (e.g., hormone therapy, mental health care, etc.) or Intersex Veterans in need of surgery to correct inborn conditions related to reproductive or sexual anatomy or to correct a functional defect.” • Intersex = “Intersex individuals are born with reproductive or sexual anatomy and/or chromosome pattern that doesn’t seem to fit typical definitions of male or female. People with intersex conditions are often assigned male or female gender by others at birth (e.g., doctors and parents), although the individual may or may not later identify with the assigned gender.” Ref: VHA Directive 2011-024 Providing Health Care for Transgender and Intersex Veterans

9. Sexual Orientation and Gender Identity • Sexual orientation refers to an individual’s pattern of attraction to others of the opposite sex (heterosexual), same-sex (homosexual or gay/lesbian), or both sexes (bisexual). • Transgender is not the same as being gay or lesbian. Transgender persons have a gender identity (sense of oneself as male, female, or other) that differs from their birth sex. Transgender individuals may be heterosexual, bisexual, gay/lesbian or they may choose some other label for themselves. • Transphobia = hostility and prejudice toward gender-variant and gender-nonconforming people. • Transphobia exists at individual, institutional, and cultural levels. • Transphobia can become internalized by transgender individuals from the culture.

10. What the VA Policy Means • Transgender and intersex Veterans are eligible for VA care. No aspect of a Veteran’s gender disqualifies him/her from necessary care through VA. • Sex reassignment surgery and electrolysis are not covered by the VA. All other services including hormones, evaluations for hormones and surgery, as well as post-operative care are all qualified services through VA. • While Veterans are on hospital grounds receiving their VA care, it is expected that they will be treated with the same respect as other service men and women. • If a Veteran asks to be referred to by a certain name or pronoun, this should be respected and used regardless of appearance/presentation. Ref: VHA Directive 2011-024 Providing Health Care for Transgender and Intersex Veterans

11. Why the VA Policy is Important • Prior to June 2011, there was not a clear policy on treatment services for transgender Veterans. This allowed for inconsistent provision of services and even denial of services to many transgender Veterans. • Transgender individuals are a group that have consistently been stigmatized and discriminated against in society. • Transgender Veterans, like all Veterans, deserve respect and dignity and health care services at the VA. • This directive is consistent with VA’s policy toward non-discrimination of Veterans and employees. Refs: Shipherd, J.C., Maguen, S., Skidmore, W.C., & Abramovitz, S.M. (2011). Potentially traumatic events in a transgender sample: Frequency and associated symptoms. Traumatology, 17(2), 56-67. Shipherd, J.C., Green, K.E.& Abramovitz, S. (2010). Transgender clients: Identifying and minimizing barriers to mental health treatment. Journal of Gay and Lesbian Research, 14(2) 94-108. Maguen, S. & Shipherd, J.C. (2010). Suicide risk among transgender individuals. Psychology and Sexuality, 1(1), 34-43.

12. Implementing the VA Policy Subsequent slides address the implementation of VHA Directive 2011-024 in a clinical setting, including – • Prevalence of transgender Veterans • Health disparities experienced by transgender individuals • Examples of clinical issues with transgender Veterans • Clinical resources and educational materials on transgender health care

13. Prevalence How common are transgender Veterans? • In the general population, transsexual individuals are found at rates of 1 in 11,000 for born males and 1 in 30,000 for born females.1 • MtF transsexuals are three times more common than FtM transsexuals. • Transgender individuals, including those who are not taking steps to self-identify as their preferred gender, are more common than transsexuals. Ref: 1Bakker, A, van Kesteren, PJM, Gooren, LJG, & Bezemer, PD (1993). The prevalence of transsexualism in The Netherlands. Acta Psychiatrica Scandinavica, 87, 237-238.

14. Prevalence How common are transgender Veterans? • Estimates of Veteran status in the transgender community are roughly 3x the Veteran status found in the general population.1 • Developmental theories and the structure of the military environment may help to explain these elevations.2 • The prevalence of transgender and intersex Veterans is not known. Ref: 1Shipherd, J.C., Mizock, L., Maguen, S. & Green, K.E. (2012). Male-to-Female transgender veterans and VA health care utilization. Int. J. of Sexual Health, 24(1), 78-87. 2Brown, GR. (1988). Transsexuals in the military: Flight into hypermasculinity. Arch Sex Behavior 17(6):527-537.

15. Transgender Individuals Face Multiple Health Disparities Compared to the general population, transgender or gender non-conforming / variant individuals experience: • Lower income: 4x more likely than general population to earn < $10,000 • Higher unemployment: 2x higher than general population • Significant discrimination: • 63% reported serious acts of discrimination • 23% reported catastrophic levels (e.g., at least 3 major life-disrupting events due to bias) • 19% report being denied care due to being transgender Ref: Grant, J.M., et al., J. (2011). Injustice at every turn: A report of the National Transgender Discrimination Survey. Washington, D.C.: National Center for Transgender Equality and National Gay and Lesbian Task Force. Institute of Medicine. 2011. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. National Academies Press, Washington DC.

16. Transgender Individuals Face Multiple Health Disparities Compared to the general population, transgender or gender non-conforming individuals experience: • Higher suicidal behavior: 41% have attempted suicide (vs. 1.6% in the general population) • Higher rates of depression, smoking, and drug and alcohol Ref: Grant, J.M., et al., J. (2011). Injustice at every turn: A report of the National Transgender Discrimination Survey. Washington, D.C.: National Center for Transgender Equality and National Gay and Lesbian Task Force. Institute of Medicine. 2011. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. National Academies Press, Washington DC.

17. Transgender Veterans May Be in Different States of Identity Emergence • Ref: Lev, A. I. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. Binghamton, NY: Haworth Press. • Brown, GR. (1988). Transsexuals in the military: Flight into hypermasculinity. • Arch Sex Behavior 17(6):527-537.

18. Clinical Encounters with Transgender Veterans • VA clinical staff are likely to encounter transgender Veterans in PACT teams, Specialty Care clinics, Women’s Health clinics, Mental Health programs, and Medicine units. • A separate PowerPoint Toolkit has been developed for Mental Health staff. • This PowerPoint Toolkit follows two patients through their appointments with a PACT team. In general, PACT teams may most frequently encounter transgender Veterans, who will have a variety of medical and mental health needs. • PACT team members may be involved in assessing for and monitoring cross-sex hormones and addressing requests for statements to change sex/gender in CPRS.

19. Two Transgender Veterans at PACT Team Appointments • Jim – a 28-year-old FtM Veteran with short hair and wearing a T-shirt and jeans. He wears a baseball cap with insignia of his unit in Afghanistan. Jim is going to school and has his own apartment. He has a girlfriend. Jim asks for testosterone and wants his sex changed in CPRS. • Susan – a 50-year-old MtF Veteran with long hair and wearing feminine clothes. She prefers to be called “Susan” but sometimes uses her male identity. Her sex is male in CPRS. She has used (non-prescribed) estrogen before but not regularly. Her long term goals are facial and genital surgery. She has been living with a male sexual partner since recently losing her job and apartment in part due to discrimination . Her family does not speak to her. She has been the victim of violence on several occasions.

20. Checking In with the Clerk / Medical Support Assistant • A young masculine looking Veteran who calls himself Jim is here for an appointment. His sex is female in CPRS, and the name in the record is Mary. He asks you to fix his name in the system because people keep calling him the wrong name. As the clerk, you … • A large, middle-aged individual with long hair and wearing feminine clothes checks in. Her sex is male in CPRS, but her name is listed as Susan. Other Veterans waiting in line are giving her odd looks. Some are whispering to each other. As the clerk, you …

21. Checking In with the Clerk / Medical Support Assistant • Do not express surprise or “correct” the Veteran about gender or name; accept and repeat the Veteran’s stated name (“Hello, Jim. How are you today?”) • Use other identifiers (SSN and date of birth) to confirm identity • Confirm the Veteran’s preferred name (in Jim’s case) and offer to help with correcting mistakes (“What name do you prefer to be called?”) • Pass on information to the clinical staff with a note or in person (“This Veteran‘s preferred name is Jim.”) • Maintain an atmosphere of respect, dignity, and safety for the veteran. Address and discourage any disparaging remarks, jokes, or comments from other employees or patients; do not engage them in a discussion.

22. Checking In with the Clerk / Medical Support Assistant In Susan’s case, you address the veterans waiting in line behind her: “Folks, I’m asking everyone to be respectful of all the Veterans in this clinic. I am not going to tolerate disrespect for our patients.” In Jim’s case: “I am so sorry you have had that problem. Let me print what the VA needs from you to make a name change in the medical records. ”

23. Meeting with the LPN / RN / HT • A young FtM Veteran who calls himself Jim is here for an appointment and would like to start testosterone. He doesn’t make eye contact with you, and he gives one word answers to clinical reminders. When you ask if anything is wrong, he states that he is preparing himself to meet with “another doctor who probably thinks I am a freak of nature” and states that he hates having to go through a doctor to get testosterone. You say . . . • A middle-aged MtF Veteran who identifies as Susan is here for a physical exam. When you begin to do the clinical reminders, she openly tells you that she has symptoms of PTSD and depression and has “thought about dying” recently although she denies suicidal ideation or having a suicide plan. As the RN/LPN/HT, you . . .

24. Meeting with the LPN / RN / HT • Make eye contact. Make a connection with the patient (“How was your trip to the VA?” “Was it difficult to find a parking space?” “How are you doing today?”). A personal connection can be particularly important since many transgender individuals have experienced repeated prejudice and hostility. • Show empathy if the Veteran discloses sensitive information before offering referral or making a note for the physician. • When completing clinical reminders, be sensitive to issues that involve gender but do not avoid these issues: • For example, in Jim’s case: “I’m sorry if any of these questions are inappropriate or uncomfortable for you and, if they are, please let me know. When was your last pap smear?” • For example, in Susan’s case: “I’m sorry if any of these questions are inappropriate or uncomfortable for you and, if they are, please tell me. When was your last prostate exam?”

25. Meeting with the LPN / RN / HT In Jim’s Case: “I’m sorry to hear about that, Jim. It sounds like you haven’t had good experiences with doctors before. I don’t want that to happen here. How can I help things go better today?” In Susan’s case: “I’m so sorry that you have been having such a rough time, Susan. I would like to share this information with your provider, so that we can find a way to help you feel better and get you the services you need. What else do I need to know?”

26. Meeting with the Primary Care Provider • A young FtM Veteran who calls himself Jim is here for an appointment. His sex is female in CPRS, and the name in the record is Mary. You are informed by other staff that this patient has had bad experiences with providers before and is not looking forward to this appointment; he believes he will have to “jump through hoops” to get his hormones. As the provider, you . . . • A middle-aged individual who calls herself Susan is here for a physical exam. You are informed by other clinical staff that she screened positive for PTSD and depression and has had “thoughts of death” although she denies suicidal ideation. She is also marginally housed, financially unstable, and currently unemployed. As the provider, you . . .

27. Meeting with the Primary Care Provider • Make a connection with the Veteran by asking about likes, dislikes, work, hobbies (“Tell me a bit about yourself .” “What do you do for fun?”) • Ask open-ended questions (“What brings you here today?” “What have your previous experiences with us been like?” “What are your concerns?”). • Use reflections to show the patient you heard what was said, check your understanding, and welcome more information (“It sounds like you are more interested in hormones than surgery right now.”)

28. Meeting with the Primary Care Provider • Be sensitive to gender issues during a physical exam. Explain the reasons for actions and check for permission (“We recommend everyone with a cervix be checked for pre-cancerous cells, but it is your decision. What do you think?”) • Offer information about options in a nonjudgmental and informative way. Emphasizes a partnership between you and the patient (“We can offer you hormone therapy at the VA. We do not currently offer surgery, but we can talk about your options outside the VA if that is something you would like to pursue.”)

29. Meeting with the Primary Care Provider In Jim’s case: “It sounds like you have had time to think about hormone therapy and have decided you would like to try it. Can I share some information with you on how we usually prescribe testosterone, what the steps are, and what the side effects might be?” In Susan’s case: “It seems like this has been a rough time for you. I’d like to have you talk to our social worker about your housing situation and also refer you to a mental health provider for help with your mood. How does that sound to you?”

30. Resources for Assessment and Treatment of Transgender Veterans • There are no VA Clinical Practice Guidelines for transgender care at present. • The World Professional Association for Transgender Health (WPATH) published their Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (7th edition) in 2011 (first published in 1979). • Based on expert consensus among health professionals and transgender communities. • These are flexible Clinical Guidelines, not mandates. • The WPATH Standards of Care are a resource for VA clinicians as they determine best clinical practice for their patients. Ref: World Professional Association for Transgender Health. (2011). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 7th Version.

31. Important Elements of the WPATH Standards of Care The WPATH Standards of Care recommend that mental health professionals: • Assess for gender dysphoria. • Provide information regarding options for gender identity and expression and possible medical interventions. • Assess, diagnose, and discuss treatment options for co-existing mental health concerns. • If applicable, assess eligibility, prepare, and refer for hormone therapy. • If applicable, assess eligibility, prepare, and refer for surgery. Ref: World Professional Association for Transgender Health. (2011). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 7th Version.

32. Important Elements of the WPATH Standards of Care (cont.) The WPATH Standards of Care also note: • Psychotherapy is not an absolute requirement for hormone therapy and surgery. • Psychotherapy is NOT intended to alter a person’s gender identity. • Psychotherapy is helpful for: • Clarifying and exploring preferredgender identity and role • Addressing the impact of stigma and minority stress • Facilitating a coming out process • General treatment goals are to find ways to maximize the person’s overall well-being. Ref: World Professional Association for Transgender Health. (2011). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 7th Version.

33. Requirements to Change Sex/Gender in CPRS • The VHA directive states that “The documented sex in the Computerized Patient Record System (CPRS) should be consistent with the patient’s self-identified gender.” • Veterans who have their gender or sex changed in CPRS must provide required legal documentation to the facility Privacy Officer. Sexual reassignment surgery is not a prerequisite for amendment of gender. • “…a written request and supporting documentation are required from the Veteran and are considered to be a Privacy Act ‘amendment request’ .” • One of the following is required as supporting documentation: • Legal documentation (i.e., amended birth certificate or court order), • Passport • Signed original statement on office letterhead from a licensed physician. Ref: VHA Directive 2011-024 Providing Health Care for Transgender and Intersex Veterans VHA Directive on documenting sex in CPRS (pending approval)

34. Requirements for a Physician’s Statement to Change Sex in CPRS All of the following information must be included: • Physician’s full name, address and phone number. • Medical license or certificate number and issuing state of medical license/certificate. • Drug Enforcement Administration (DEA) registration number assigned to the physician or comparable foreign designation, if applicable. • Language stating that he/she has treated the patient or reviewed and evaluated the medical history of the applicant. He/she also has a doctor/patient relationship with the applicant which is evident in having one or more clinical encounters between doctor and patient. • Language stating that the patient has had appropriate clinical treatment for gender transition to the new gender (specifying male or female). • Language stating “I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct.” Ref: VHA Directive on documenting sex in CPRS (pending approval)

35. Rationale for the Use of Cross-Sex Hormone Therapy • Untreated or undertreated Gender Identity Disorder (GID) is associated with increased morbidity and mortality. • Hormonal treatment is used to reduce or eliminate gender dysphoria symptoms through changes in hormonally sensitive sex characteristics (e.g., reducing characteristics of original sex and inducing those of the opposite sex). • May be considered across all spectrums of transition including before sex reassignment surgery, after surgery, and in patients not seeking surgery.

36. General Principles of Cross-Sex Hormone Treatment • Interdisciplinary, coordinated treatment approach is optimal (e.g., gynecology, mental health, primary and specialty care, pharmacy, urology, social work, etc.). • Individualized therapy to meet patient-desired and clinically appropriate goals. • Patient evaluation by a qualified mental healthcare professional for eligibility and readiness of cross-sex hormone treatment. • Concurrent medical and mental conditions evaluated, addressed, and adequately controlled. • Modifiable risk factors addressed prior to and during treatment. • Ongoing monitoring required. • VA PBM Documents on Cross-Sex Hormone Therapy • Available on PBM INTERnet site: www.pbm.va.gov and PBM INTRAnet site: http://vaww.national.cmop.va.gov/PBM/default.aspx

37. National PBM Criteria for Use – Inclusions • Inclusion Criteria(all must be met): • Medical and mental health evaluation conducted • Fulfills diagnostic criteria for GID made by qualified provider • Initial prescription restricted to VA provider experienced in the use of cross-sex hormone therapy • Concurrent medical/psych conditions considered and addressed • Patient informed and understands risks, benefits, limitations • Patient agrees to adhere to treatment and monitoring plan • Smoking cessation recommended if applicable • For FtM, pregnancy excluded and contraceptive counseling provided

38. MtF Cross-Sex Hormone Treatment – Effects • Expected effects include (months to years): • Body fat redistribution, decreased muscle mass • Male sexual dysfunction, decreased libido • Testicular atrophy, decreased sperm production • Decreased facial and body hair, increased scalp hair • Decreased skin oiliness • Breast growth (variable) • Emotional changes, e.g. decreased gender dysphoria, depression • Limitations: • Effects on sperm production, infertility may be permanent • Facial/body hair thinning/slowing usually not sufficient • Breast growth usually not as pronounced as in biologic females • No effect on voice

39. MtF Cross-Sex Hormone Treatment: Monitoring • Monitoring: • Ongoing monitoring required (more frequent during initiation and titration, then q6-12 mos) • Physical and mental status exam for effectiveness and adverse effects • Lab testing: • Hormone levels (testosterone <55 ng/dL; estradiol NTE 200 pg/ml) • Adverse effects (e.g., LFTs, lipids, prolactin, etc.) • Health maintenance screening • Routine health screening and physical exam (BP, weight, etc.) • Routine cancer screening (e.g., breast, prostate, testicular, etc.) • Bone mineral density screening if at risk

40. Transgender Sensitive Care Guidelines Below are suggestions for promoting a positive, welcoming health care environment for transgender Veterans: • Provide a safe and supportive environment. • Ask about the Veteran’s chosen name in addition to legal name; use preferred names and pronouns consistently, even when not in the Veteran‘s presence. • Discuss documentation preferences (e.g., “Do you have any concerns about what I write in the medical record?”). • Be relaxed and courteous. Stay mindful of your body language. Transgender Law Center. (2005). Ten Tips for Working with Transgender Individuals.

41. Transgender Sensitive Care Guidelines (cont.) Below are suggestions for promoting a positive, welcoming health care environment for transgender Veterans: • Openly acknowledge errors (e.g., using the wrong name/pronoun), apologize and take the time to process patient reactions. • Ask for clarification if uncertain about something. Don’t make assumptions or avoid the subject. • Keep focused on providing care rather than satisfying your curiosity. • Having a transgender person in the clinic is not necessarily a “training opportunity” for students and trainees. Transgender Law Center. (2005). Ten Tips for Working with Transgender Individuals.

42. Transgender Sensitive Care Guidelines (cont.) • It is inappropriate to ask about genital status if it is unrelated to the patient’s care. • Do not disclose a Veteran’s transgender status to anyone who does not explicitly need to know. • If relevant to care, use discretion and inform the patient about disclosure. • Become knowledgeable about transgender health care issues. Your patient is not your only resource! • Examineyour own knowledge, attitudes, and beliefs about transgender issues. Seek out self-education opportunities and resources. • Consult with experts in transgender health care.

43. Transgender Sensitive Care Guidelines (cont.) • Intervene if discriminatory comments are overheard. The VA has a zero tolerance policy on discrimination. • Adapt program forms for inclusion purposes (e.g., provide an option for MtF or FtM). • Provide access to single-use (“unisex”) restrooms.

44. Discussion Points • The following scenarios are intended to be topics for group discussion in a staff business meeting or staff in-service. The scenarios present possible staff-patient encounters in PACT Team or other clinical programs. Staff are encouraged to identify the most appropriate action(s) based on VHA policy, including the directive on transgender health care. • Responses to the scenarios appear at the end of this section.

45. Discussion Points • You hear a fellow staff member refer to a waiting Veteran as “the man in a dress” in front of other Veterans. What do you do? What if the staff member is a physician? How do you convey respect and dignity to all Veterans?

46. Discussion Points • A female Veteran in a women’s clinic goes to the front desk staff to complain that a Veteran who is not a “real woman” is sitting in the waiting room. You are at the front desk. What do you say to this person that conveys respect and dignity to all Veterans?

47. Discussion Points • You are talking to a transgender Veteran who wants to be called Susan. During the conversation, you slip and refer to the Veteran as he instead of she. What do you do to convey respect and dignity to this Veteran?

48. Discussion Point Responses • If you hear a fellow staff member refer to a waiting Veteran as “the man in a dress” in front of other Veterans, an appropriate response may be to say out loud that the individual is a Veteran who is here for health care and deserves to be treated with respect. • You might also take the staff member aside and explain that such behavior is disrespectful and not appropriate in a health care setting. Would you do anything different if the staff member is a physician? • What are other appropriate responses?

49. Discussion Point Responses • If any Veteran complains that another Veteran should not be in a particular clinic, an appropriate response may be to note that all Veterans are eligible for care at the VA and deserve respect and dignity. Also, you may add that Veterans are here in this clinic because they have health care needs that are appropriately treated by providers in this clinic. • What are other appropriate responses? What if the Veteran asks to file a complaint?

50. Discussion Point Responses • If you slip and use the wrong name or pronoun, an appropriate response is to acknowledge the slip. You might say something like, “I’m sorry, I’ve know you as Jim for a while, so I may slip from time to time. It may take a little time, but I’ll get it right!” • Or you might say something like, “Please bear with me, I will do my best to use your preferred name and gender. “ • What are other appropriate responses?