Despite historic policies designed to keep them out of military service, there are an estimated one million lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) veterans in the United States (U.S. Department of Veterans Affairs, 2022). These veterans are at risk of having experienced military-specific systemic and interpersonal discrimination and minority stress (e.g., downstream effects of “Don’t Ask Don’t Tell”) (Livingston et al., 2019; Salomaa et al., 2023), which may, in turn, be associated with various health challenges, particularly if they contribute to refusal or delays in seeking needed healthcare. Indeed, past research suggests that LGBTQ+ veterans exhibit elevated rates of cumulative trauma, posttraumatic stress disorder (PTSD), depression, anxiety, substance use disorders, and suicidal thoughts and behaviors (Brown & Jones, 2016; Chang et al., 2023; Lehavot et al., 2022; Livingston et al., 2022). With regard to physical health, LGBTQ+¹ military personnel and veterans have been found to have higher rates of hypertension, obesity, and human immunodeficiency virus (HIV) than their non-LGBTQ+ (e.g. cisgender, heterosexual) counterparts (Lynch, Shipherd, et al., 2022; Mark et al., 2019). Also, both chronic pain and self-assessed fair/poor health status are more prevalent among bisexual veterans under 40 years of age than among either their heterosexual or gay/lesbian peers (Houghtaling & Osypuk, 2023), suggesting that there may be important differences among subgroups of LGBTQ+ veterans (see also Carey et al., 2022).

As the single largest healthcare provider for LGBTQ+ people in the United States (Mattocks et al., 2014), the Veterans Health Administration (VHA) has prioritized the healthcare needs of LGBTQ+ veterans in the VHA’s 2022–2028 Strategic Plan, emphasizing the need for safe and welcoming facilities that are free of harassment and discrimination and that meet the specific healthcare needs of these veterans (U.S. Department of Veterans Affairs, 2022). Given this federal healthcare priority, quantifying healthcare utilization rates among different sexual orientation and gender groups of veterans as well as ascertaining factors that likely influence such utilization may shed light on gaps that need to be addressed for VHA to fulfill its mission.

An examination of the extant literature reveals that much of the research on VHA utilization by LGBTQ+ veterans is confined to those already enrolled in VHA care (Kauth et al., 2014; Mattocks et al., 2015; Shipherd et al., 2018) or lacks a cisgender, heterosexual comparison group (Shipherd et al., 2012; Simpson et al., 2013) with few exceptions (see Livingston et al., 2022; Shipherd et al., 2021). A recent study by Hahn and colleagues (2023) sought to remedy these shortcomings by using Behavioral Risk Factor Surveillance System (BRFSS) data from 17 states to compare LGBTQ+ veterans and non-LGBTQ+ veterans on their primary source of healthcare. The authors found that while LGBTQ+ veterans were somewhat less likely than their cisgender, heterosexual counterparts to view VHA or military care as their primary source of healthcare (20% and 23%, respectively), the difference was not statistically significant. However, among the youngest age group, LGBTQ+ veterans were significantly less likely than their same-age cisgender, heterosexual peers to use VHA/military care.

Although the extant literature is informative, there is still much to learn about LGBTQ+ veterans and their use (or non-use) of VHA services. The current study addresses some of the remaining gaps by reporting on the rates and correlates of past year use of VHA healthcare generally and of VHA mental health treatment specifically in a large sample comprised of subgroups of LGBTQ+ and cisgender heterosexual veterans who were recruited nationally, outside the VHA. Consistent with past research and theory on healthcare utilization demonstrating that the decision to seek healthcare is multiply-determined (e.g.,von Lengerke et al., 2014), the Andersen model of health services utilization (Andersen, 1995) was used as a framework to guide an inquiry into whether LGBTQ+ specific factors provide explanatory value above and beyond global factors.

The Andersen model considers the multitude of factors associated with healthcare utilization in that it ascertains the contributions of predisposing factors (e.g., individual characteristics such as age, sexual orientation, gender identity, race, ethnicity)², influencers of healthcare access (e.g., insurance status, employment status, service connection status, perceived barriers related to eligibility and benefits, fitting in, staff sensitivity, logistics, availability of services), and healthcare needs (e.g., physical and mental health concerns) (Andersen, 1995). It provides a framework for rigorously examining factors that may inhibit or encourage healthcare utilization by all veterans as well as factors that may be specific to LGBTQ+ veterans. Regarding factors that may influence healthcare utilization by LGBTQ+ veterans, the extant literature has demonstrated that both transgender men and LGBTQ+ women report LGBTQ+ based discrimination (Ruben et al., 2019) and other problematic encounters in VHA settings (Berke et al., 2022; Chen et al., 2017; Dietert et al., 2017). Transgender men are more likely to report feeling less welcomed by their VHA providers than are transgender women or lesbian women (Kauth et al., 2019) and, historically, less than a third of both LGBTQ+ veterans and VHA providers have viewed the VHA as welcoming to LGBTQ+ veterans (Sherman et al., 2014). More recently, Kauth (2019) surveyed lesbian, gay, and transgender veterans finding that “most VHA users described their mental health and primary care providers as somewhat or very welcoming at their last visit (64.5% and 68.2%, respectively)”, and 18.1% describing their VHA facility as generally not welcoming. Additionally, LGBTQ+ women are likely to experience heightened levels of harassment relative to LGBTQ+ men (Shipherd, 2015). These disparities contribute to the negative experiences of LGBTQ+ veterans and are associated with reluctance to disclose sexual orientation to VHA providers and lower engagement in some services (Lehavot et al., 2013; Powell et al., 2022; Shipherd et al., 2018; Simpson et al., 2013).

Several studies focused on healthcare utilization among LGBTQ+ people have relied on the Andersen model (Baldwin et al., 2017; Currin et al., 2018; Diaz et al., 2022; Griffin et al., 2020; Lerner & Robles, 2017; Li et al., 2015; Simpson et al., 2013) and largely have found that non-discrimination policies, comfort in disclosure of sexual orientation, and experiences (or lack thereof) of discrimination are influencers of healthcare utilization and satisfaction. For example, in settings with non-discrimination legislation, amongst sexual minority women, there is an increased likelihood of disclosure of sexual orientation and higher satisfaction with care (Baldwin et al., 2017). Other studies have shown disclosure to be a significant correlate of increased mental health utilization (Currin et al., 2018) and that disclosure is positively associated with the perception that healthcare needs are adequately addressed (Griffin et al., 2020). In a study of transgender individuals, lack of knowledge regarding transgender issues, inappropriate (misgendering) use of pronouns, and other negative experiences with healthcare providers proved to be barriers to healthcare even during times of distress (Lerner & Robles, 2017).

In this study, a high proportion of our sample used any VHA treatment in the past year (60.6%). However, less than one-third (29.4%) of the current sample utilized VHA mental health care in the past year. Across the men subgroups, cisgender gay men were less likely to have utilized VHA care overall than cisgender heterosexual men and transgender men, with this latter group reporting substantially higher utilization rates than the other men subgroups. Regarding past-year VHA mental health treatment, transgender men also had substantially higher utilization rates than the other men subgroups. In contrast to our a priori hypothesis, we found no between-group differences in utilization rates on either utilization outcome among the women subgroups, including the transgender women. This finding is a departure from other research indicating that transgender women are more likely to use VHA healthcare than other veterans (Shipherd et al., 2012), but the earlier investigation compared transgender women to the published utilization rate for veterans at large, a group largely comprised of cisgender men. Thus, transgender women’s VHA utilization has not previously been compared to those in their same gender group (i.e., women) and future research should further evaluate utilization rates within and across gender groups to see if this finding is supported.

Several influencing factors applicable to all veterans were related to VHA care utilization for all subgroups in both expected and unexpected ways. First, as expected, those who responded in ways that implied VHA eligibility were far more likely to have received care than those who did not. In contrast, but also as expected, challenges in navigating VHA benefits were associated with veterans being 30–40% less likely to have utilized any VHA healthcare in the past year, and these challenges were associated with lower past-year utilization of mental health treatment among men subgroups specifically. Across both the women and men subgroups, logistical barriers were associated with lower likelihood of receiving any VHA care. Perceived lack of service availability was positively related to VHA care, which although interesting, is perhaps not surprising given that people who need more care may also have interfaced with VHA regularly enough to understand which needed, or wanted, healthcare services are unavailable. Interestingly, logistical barriers and perceived lack of availability of care were not associated with mental health treatment. These findings are largely consistent with predictions from the Andersen model (1995), but suggest differences between VHA utilization overall and VHA mental health treatment utilization. It is possible that VHA mental health utilization is difficult to predict given its relatively low base rate, or perhaps other factors are more impactful when predicting mental health treatment utilization. Regarding perceptions of service availability specifically, the following questions may be fruitful to pursue in future research: 1) are mental health care appointments more readily available than those for physical health care? 2) are veterans more willing to wait for mental health care than for physical health care? 3) is it harder to access mental health care in the community (i.e., outside of VHA) than it is to care for physical health issues? 4) are there barriers that prevent veterans from using VHA mental healthcare services regardless of their availability?

Regarding income, in a departure from the Andersen model we found that veterans with lower incomes were more likely than those with higher incomes to have utilized VHA care. Although research using the Andersen model typically finds that higher income is associated with greater likelihood of healthcare utilization (Andersen, 1995; Currin et al., 2018); the present finding is consistent with past research on VHA utilization (Kline et al., 2022), whereby veterans with lower income are prioritized for eligibility and tend to have fewer options to receive their care elsewhere (i.e., through employer-based insurance for example) (Cohen & Boersma, 2023; Fink et al., 2022; Meffert et al., 2019). Descriptively, in the current sample we see both lower income and lack of commercial health insurance being especially likely for bisexual men, transgender men, and gender diverse persons. Further, it is noteworthy that the responses of over one-third of the bisexual men and the gender diverse persons implied ineligibility for VHA care, suggesting that these groups may be at particular risk of not having adequate access to needed healthcare.

Our descriptive findings suggest that initiatives to increase engagement in VHA care should pay particular attention to groups that tend to utilize VHA care at lower rates relative to other groups (i.e., gender diverse individuals and cisgender gay men) as well as groups that are especially likely to have lower incomes and lack adequate healthcare access (i.e., bisexual men, transgender men, and gender diverse persons). To increase engagement, the VHA may consider promoting and advocating ways to decrease barriers to eligibility for LGBTQ+ veterans. For example, VHA could advocate that DoD follow through on plans to centrally revise veterans’ discharge statuses if based on sexual orientation (Vergun, 2023), take steps to increase awareness and clarity regarding VHA benefits, reduce logistical barriers, increase availability of care, and increase provision of and awareness about LGBTQ+ specific healthcare through outreach by the VHA LGBTQ+ Veteran Care Coordinators (VCC). LGBTQ+ VCC’s are available in every VA healthcare system to help “answer your questions, advocate for your right to quality care, handle complaints or concerns you have about your care, and help you get started with services for LGBTQ+ Veterans” (U.S. Department of Veterans Affairs, Patient Care Services, 2024).

Turning to verbal harassment, a key global influencing factor specific to the VHA environment, we found that such experiences were positively and significantly associated with VHA care overall in the women’s, but not the men’s models. Although it is counterintuitive that such negative exposures are associated with greater likelihood of having used VHA services, women veterans must have experience with VHA care to have been verbally harassed in those settings. The troublingly large proportions of such exposures across all women subgroups (19% to 25%) not only reflects the intersectional nature of such harassment (i.e., that cisgender men veterans, regardless of sexual orientation, are less likely than all women veterans to have such experiences when accessing healthcare at VA) but also indicates that VHA needs to increase efforts to address this issue to improve the care environment for all women. Moreover, the even higher rates of verbal harassment reported by transgender men (37.8%) suggest that their safety and well-being while in VHA care environments especially needs to be prioritized. From an intersectional perspective (Everett et al., 2019; Mink et al., 2014), differences in verbal harassment can be explained by differences in sexism, heterosexism, and transnegativity. LGBTQ+ veterans, as a group, have elevated odds of experiencing heterosexism, but LGBQ+ women and transgender men also have greater odds of being subjected to sexism, while transgender men must also contend with potential transnegativity. Differences in sexist and transnegative experiences based on gender may be driving the positive relationship between verbal harassment and utilization for some LGBTQ+ subgroups and not others. Although the ability to access no- or low-cost care through VHA is important to many veterans, the emotional and psychological cost of receiving care is likely quite high in environments fraught with verbal harassment and the risk of such harassment (Kauth et al., 2019; Sherman et al., 2014; Shipherd, 2015).

When it comes to LGBTQ+ specific influencing factors, our results indicate that the inclusion of all these factors together improved model fit for both VHA utilization generally and VHA mental health treatment among the women and for VHA mental health treatment among the men. However, none of the factors were significant individually. Thus, consistent with the VHA’s 2022–2028 Strategic Plan, which states that facilities need to be safe and welcoming for LGBTQ+ veterans and meet their specific healthcare needs (U.S. Department of Veterans Affairs, 2022), our results suggest that the combination of the degree of provider sensitivity to LGBTQ+ issues, availability of LGBTQ+ services, and the extent to which one has a sense of fitting in help to explain healthcare utilization patterns. Logically, it is likely that greater provider sensitivity and greater availability of LGBTQ+ services lead LGBTQ+ veterans to feel as though they are welcome and fit in, but this has yet to be experimentally tested. These findings lend support to increasing attention to the social safety perspective (Diamond & Alley, 2022), which posits that reliable social connection, inclusion, and protection are universal human needs. Recent work has explored this perspective among LGBTQ+ individuals, suggesting that even in the absence of minority stress, social safety is essential to the health of stigmatized individuals (Diamond & Alley, 2022). When combined, these LGBTQ+ factors examined in our models may work in harmony to foster that sense of social safety. The recently developed Pride In All Who Served health education group is a promising intervention for LGBTQ+ veterans (Lange et al., 2023) that could be used to systematically evaluate this supposition.

The finding that the combination of LGBTQ+ specific factors explain significant variance in models predicting VHA utilization also underscores the need to invite LGBTQ+ veterans to help inform the VHA regarding ways to ensure safe and effective healthcare that meets their needs. A particular focus should be on subgroups that report higher dissatisfaction rates and verbal harassment at the VHA. Additionally, policies and staff training are needed to mitigate the elevated rates of harassment experienced by transgender men and women overall (see Berke et al., 2022). One possibility is the expansion of the VHA’s bystander intervention training to ensure that staff and veterans can identify harassment, have practiced safe ways to intervene, and are prepared to provide support to the victims of such encounters. Of note, because VHA facilities differ in tangible and intangible ways, best practice guidelines for implementing and maintaining bystander intervention training indicate that inputs from local interested parties are needed to meet the needs at the local level (Fenwick et al., 2021; Relyea et al., 2020) Recent qualitative work by Singh and colleagues (2024) also indicates that providers have knowledge gaps in best practices for care provision for LGBTQ+ veterans and that further investment in training and ongoing consultation is needed (Singh et al., 2024). One possible way to address these provider knowledge gaps is for the VHA’s LGBTQ+ Veteran Care Coordinator program to be expanded and fully supported such that they have the time and training to do the necessary teaching and consultation, ideally directly informed by their LGBTQ+ veteran patients. However, a survey of these providers revealed that they need more basic support for their already assigned duties (see Valentine et al., 2021) so duty expansion would almost certainly require substantial institutional investment.

Additionally, given that culture change is needed on multiple levels (Sloan & Shipherd, 2019), VHAs are encouraged to be explicitly welcoming to LGBTQ+ veterans, provide inclusive materials in facilities and in educational materials, expand the availability of women’s and LGBTQ+ clinics, ensure gender inclusive restrooms, hire and retain staff that represent various identities, cultivate a safe and inclusive culture among staff and employees, and provide gender-affirming medical interventions including surgery. We also suggest that the VHA LGBTQ+ Veteran Care Coordinator be the sole job for one or more staff members at each facility to ensure they have the time and resources to provide safe and effective healthcare for all veterans.