VA Directive 2011-024

Department of Veterans Affairs VHA DIRECTIVE 2011-024 This Veterans Health Administration (VHA) Directive establishes policy regarding the respectful delivery of health care to transgender and intersex Veterans who are enrolled in the Department of Veterans Affairs (VA) health care system or are otherwise eligible for VA care.

In accordance with the medical benefits package (title 38 Code of Federal Regulations (CFR) Section 17.38), VA provides care and treatment to Veterans that is compatible with generally accepted standards of medical practice and determined by appropriate health care professionals to promote, preserve, or restore the health of the individual. Definitions

(1)

(2)

(3)

(a) Transsexual (Male-to-Female). 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, including feminizing hormone therapy, electrolysis, and surgeries (e.g., vaginoplasty, breast augmentation).

Sex. Sex refers to the classification of individuals as female or male on the basis of their reproductive organs and functions. Gender. Gender refers to the behavioral, cultural, or psychological traits that a society associates with male and female sex. Transgender. Transgender is a term used to describe people whose gender identity (sense of themselves as male or female) or gender expression differs from that usually associated with their sex assigned at birth.

THIS VHA DIRECTIVE EXPIRES NOVEMBER 30, 2012VHA DIRECTIVE 2011-024 June 9, 2011

(b) Transsexual (Female-to-Male). Female-to-male (FTM) transsexuals are individuals who are female sex at birth, but self-identify as male and often take steps socially or medically transition to male, including masculinizing hormone therapy and surgeries (e.g., phalloplasty, mastectomy).

(4)

Sex Reassignment Surgery. Sex reassignment surgery includes any of a variety of surgical procedures (including vaginoplasty and breast augmentation in MTF transsexuals and mastectomy and phalloplasty in FTM transsexuals) done simultaneously or sequentially with the explicit goal of transitioning from one gender to another. This term includes surgical revision of a previous sex reassignment surgery for cosmetic purposes. NOTE: 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.

(5)

(6)

Gender Identity Disorder (GID). GID is a conflict between a person’s physical sex and the gender with which the person identifies. 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., parents), although the individual may or may not later identify with the assigned gender.

3. 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.

4. ACTION

a.

b.

(1) Transgender patients and intersex individuals are provided all care included in VA’s medical benefits package, including, but not limited to: hormonal therapy, mental health care, preoperative evaluation, and medically necessary post-operative and long-term care following sex reassignment surgery to the extent that the appropriate health care professional determines that the care is needed to promote, preserve, or restore the health of the individual and is in accord with generally-accepted standards of medical practice: VHA DIRECTIVE 2011-024 June 9, 2011 3

(a) Patients will be addressed and referred to based on their self-identified gender. Room assignments and access to any facilities for which gender is normally a consideration (e.g., restrooms) will give preference to the self-identified gender, irrespective of appearance and/or surgical history, in a manner that respects the privacy needs of transgender and non-transgender patients alike. Where there are questions or concerns related to room assignments, an ethics consultation may be requested.

(b) The documented sex in the Computerized Patient Record System (CPRS) should be consistent with the patient’s self-identified gender. In order to modify administrative data (e.g., name and sex) in CPRS, patients must provide official documentation as per current VHA policies on Identity Authentication for Health Care Services and Data Quality Requirements for Identity Management and Master Patient Index Functions.

(c) Sex reassignment surgery, as defined in subparagraph 2b(4), will not be provided or funded.

(d) Non-surgical, supportive care for complications of sex-reassignment surgery will be provided.

(e) While care is delivered to the Veteran based upon that Veteran’s self-identified gender, there may be health issues associated with some transgender patients that necessitate appropriate sex specific screenings and/or treatments. For example, a MTF transsexual patient over the age of 50 may require breast cancer and prostate cancer screening. A FTM transsexual patient may require screening for breast and cervical cancer.

(f) A diagnosis of GID, or other gender dysphoria diagnoses, is not a pre-condition for receiving care consistent with the Veteran’s self-identified gender.

(2) All other health services are provided to transgender Veterans without discrimination in a manner consistent with care and management of all Veteran patients.

(3) All staff, including medical and administrative staff, are required to treat as confidential any information about a patient’s transgender status or any treatment related to a patient’s gender transition, unless the patient has given permission to share this information.

(4) Mandated diversity awareness is maintained and a zero-tolerance standard for harassment of any kind.

Veterans Integrated Service Network (VISN) Director. Each VISN Director must ensure that necessary and appropriate health care is provided to all enrolled or otherwise eligible Veterans based on the Veteran’s self-identified gender, regardless of sex or sex reassignment status. Medical Center Director and Chief of Staff. The Medical Center Director and Chief of Staff are responsible for ensuring that:

5. REFERENCES

a. Title 38 CFR § 17.38 (c).

b. VHA Directive 2009-051, Plastic Reconstructive Surgery.

c. VHA Directive 2007-037, Identity Authentication for Health Care Services. VHA DIRECTIVE 2011-024 June 9, 2011 4

6. FOLLOW-UP RESPONSIBILITY.

The Office of Patient Care Services (10P4) is responsible for the contents of this Directive. Questions related to medical care may be referred to Specialty Care Services (10P4E) at (202) 461-7120. Questions related to mental health care may be referred to the Office of Mental Health Services (10P4M) at (202) 461-7310.

7. RESCISSIONS.

Robert A. Petzel, M.D.

None. This VHA Directive expires November 30, 2012.

2

Veterans Health Administration

Washington, DC 20420 June 9, 2011

PROVIDING HEALTH CARE FOR TRANSGENDER AND INTERSEX VETERANS

1. PURPOSE:

2. BACKGROUND:

a. VA provides health care for transgender patients, including those who present at various points on their transition from one gender to the next. This applies to all Veterans who are enrolled in VA’s health care system or who are otherwise eligible for VA care, including: those who have had sex reassignment surgery outside of VHA, those who might be considering such surgical intervention, and those who do not wish to undergo sex reassignment surgery, but self-identify as transgender. Intersex individuals may or may not have interest in changing gender or in acting in ways that are discordant with their assigned gender.

b. VA does not provide sex reassignment surgery or plastic reconstructive surgery for strictly cosmetic purposes.

c.