Team provides health care for transgender Veterans

Department of Veterans Affairs (VA) medical facilities all over the world recognize the health care needs of Veterans whose gender identity differs from that on their birth certificates. At VA Pittsburgh Healthcare System, an all-volunteer team of experts provides medical and psychological care to transgender Veterans throughout the VISN 4 service area.

Under the direction of clinical psychologist Dawnelle Paldino, VA Pittsburgh's 26-member Interdisciplinary Transgender Treatment Team provides gender transition counseling, hormone therapy evaluations, speech and other therapies. Psychologists determine the appropriate time to refer Veterans for gender affirming surgery, but VA does not perform or pay for the surgery.

"I cannot express just how grateful I am to be part of this team, to be working alongside such dedicated and knowledgeable individuals, and to have received support and trust from facility leadership, department chiefs and VAPHS employees," said Paldino.

Team member and social worker Sarah Merlina said VA's efforts to serve transgender Veterans started five years ago, when VA Central Office streamlined its formal guidance on transgender and intersex care for Veterans. By 2016, every VA medical center was required to have at least one LGBT Veteran care coordinator.

"Coordinators serve as a point of contact and advocate for LGBT Veterans, helping to ensure access to any needed VA care," said Merlina. "They also help educate other VA staff regarding available services and provide a welcoming environment to all Veterans."

The team includes specialists in primary care medicine, endocrinology, nursing, social work, psychology, psychiatry, pharmacy, speech pathology, creative arts therapy and spirituality. Asked why they volunteered, team members stressed inclusiveness and a desire to help an underserved Veteran population.

Dr. Molly Fisher, a women's health fellow, said she knew immediately she wanted to be on VA Pittsburgh's transgender treatment team.

"I don't think we learn enough about transgender medicine in medical school, so I was excited to jump on the chance to be on this team," said Fisher. "I'm also creating training for primary care physicians to provide comprehensive transgender care."

Most Veterans seeking transgender services initially visit primary care.

Fisher said much of her work is to refer to the transgender team all Veterans who ask about transitioning. She said it's important for health care providers to understand the transgender population's primary care issues so patients receive appropriate screenings and health care.  Veterans who wish to transition also meet with behavioral health clinicians to make sure they are ready for transition.

Psychology fellow Dr. Joanna Hayward, Ph.D., is part of the clinician team assessing Veterans.

"We're looking at psycho-social factors to see if people are eligible to receive cross-sex hormone therapy at the VA," said Hayward. "These factors include their history, risk conditions for hormones, a mental health assessment and whether they have social support."

Hayward said VA Pittsburgh also provides individual therapy for issues that come up with gender identity and LGBT status, social and otherwise.

Hormone therapy is a key factor in transition and levels must be carefully monitored, according to endocrinologist Dr. Ronald Codario.

"My main clinical responsibility is hormonal therapy, checking lab work, discussing patient goals, forming a treatment plan and making adjustments to it based on the patient's treatment goals and lab levels," said Codario.

Codario said it's important the team coordinate all aspects of care to ensure Veterans who are transitioning stay on track.  For instance, psychologists help determine the appropriate time to refer patients to speech and recreational therapy, laser hair removal or gender affirming surgical therapy, if desired.

"There's a lot of coordination with providers on the team, especially psychologists and our clinical pharmacist, who troubleshoots medications," said Codario. "We discuss with the psychologists when it's time to refer patients to speech and recreational therapy, laser hair removal and if the patient is pursuing it, gender affirming surgical therapy."

While VA does not perform or pay for gender affirming surgery, it does provide guidance, according to Merlina.

"We can provide necessary documentation, pre-op work-ups, and/or post-op care for gender affirming surgeries," said Merlina.  "Our treatment team also tries to keep a running list of surgeons and providers in the community that Veterans can reach out to or consult with regarding surgery options."

Pharmacists play a key role, advising endocrinologists on medications available at VA and how to administer and monitor them, said Amanda McQuillan, the team's clinical pharmacist.

"I also help both VA Pittsburgh and patients from local clinics get their medications. I guess you can say I'm kind of a troubleshooter when patients need refills or a medication we may not have in stock."

McQuillan also educates other VA pharmacists on the use of hormones and off-label medications in transgender therapy.

"This is so when they get a prescription, they know how to process it and what to look for," she said.

One of the most interesting positions on the team is the speech pathologist. Ronda Winans-Mitrik said speech mannerisms are vitally important for Veterans in transition.

"A big part of my work is educating and training Veterans on how to make their male voice more feminine and on safe-voice modification," said Winans-Mitrik. "Individuals using masculinizing hormone therapy will achieve a lowering of their voice as a result of the hormones. In individuals seeking feminization, female hormones do not cause the voice to change."

For men who are transitioning, it's not just the voice. Pitch is one aspect, but Winans-Mitrik said it's also about feminizing their own communication style.

"Females have a different melody to their voice, such as rising intonations when asking questions," said Winans-Mitrik. "We teach them the feminizations of coughing and laughing, and also their physical actions – how to sit as a woman does or talk with her hands."

The team also educates VA Pittsburgh staff and students and interns from area colleges and universities, said Merlina.

For Paldino, the program fulfills VA's promise to care for every Veteran – and that means every Veteran.

"Personally, I feel so honored and fortunate to be able to give so much of my attention and time to serving transgender Veterans, to get to know them, learn from them, and be a part of meeting their needs," Paldino said. "Acceptance of all and helping to promote others' potential and development to become who they truly are is deeply important to me."

For more information on transgender care at VA Pittsburgh, contact Kristen Lyons at 412-360-6645.