The State of Health and Health Care for LGBTQ+ Veterans: Differences Among Sexual and Gender Minority Veterans, by Identity and State Policy Climate, 2015–2021

Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) veterans, as with LGBTQ+ civilians, may experience distinct health care needs and challenges when accessing timely and appropriate health care. Previous studies have documented disparities in health care access and health-related outcomes for LGBTQ+ veterans relative to their cisgender and heterosexual peers, but few studies have systematically reported on differences both by sexual identity and gender identity for multiple health-related outcomes. Thus, we lack data on whether and how disparities may manifest for specific groups of LGBTQ+ veterans; these data have implications for informing efforts to optimally assist groups who may have distinct needs. Furthermore, in the context of dynamic social and political climates surrounding LGBTQ+ rights and health care in many states and localities, little is known about how policies affecting LGBTQ+ individuals may contribute to health-related outcomes for LGBTQ+ veterans. Such data can provide insight into the extent to which such policies might affect ongoing federal efforts to improve health and well-being for sexual and gender minority veterans.

In this study, we use large, representative datasets (2015–2021 Behavioral Risk Factor Surveillance System [BRFSS] data) to describe prevalence estimates of health-related outcomes across multiple domains (health care access and affordability, general health status, substance use, and chronic conditions or diagnoses) for LGBTQ+ U.S. veterans. We also examine associations between state LGBTQ+ policy climates and health-related outcomes among LGBTQ+ veterans.

In age-adjusted prevalence estimates from the 2015–2021 BRFSS data, female and male sexual minority veterans—i.e., veterans who identify as lesbian, gay, bisexual, or another nonheterosexual identity—showed poorer health-related outcomes in a variety of domains when compared with age-adjusted heterosexual peers of the same sex. Similarly, transgender veterans—i.e., veterans whose gender identity or expression differs from their assigned sex at birth—showed poorer outcomes in multiple domains relative to their cisgender peers. For example:

• Among both female and male veterans, those who identify as bisexual or another nonheterosexual identity were significantly more likely to report having been unable to afford medical care in the past year than heterosexual veterans of the same sex. Transgender veterans were nearly twice as likely to report unaffordability of medical care compared with cisgender veterans.
• Lesbian or gay female veterans and gay male veterans were significantly more likely to report current cigarette smoking than heterosexual female and male veterans, respectively. Transgender veterans were significantly more likely than cisgender veterans to report current smoking.
• Male and female sexual minority veterans had significantly elevated odds of reporting a lifetime history of major depressive disorder when compared with their heterosexual peers. Similarly, transgender veterans were significantly more likely to report a lifetime history of depression when compared with cisgender veterans.
• Among both female and male veterans, all sexual minority groups were more likely to rate their mental health as “not good” for more than two weeks in the past month than their heterosexual peers were. Transgender veterans were nearly twice as likely to report that their mental health was not good for more than two weeks in the past month than cisgender veterans.
• Among male veterans, all sexual minority groups were more likely to have had a stroke than heterosexual male veterans. The lifetime prevalence of stroke was three times higher among transgender veterans when compared with cisgender veterans.
• Among both female and male veterans, all sexual minority groups were more likely than heterosexual veterans to have a lifetime diagnosis of chronic obstructive pulmonary disease (COPD), emphysema, or chronic bronchitis. Lifetime prevalence of COPD, emphysema, or chronic bronchitis was more than twice as high among transgender veterans than cisgender veterans.
• Lesbian or gay female veterans, gay male veterans, and bisexual male veterans were significantly more likely to have a lifetime diabetes diagnosis than their heterosexual veteran peers were. Transgender veterans were more likely to report a lifetime diabetes diagnosis than cisgender veterans.

Among LGBTQ+ veterans, living in a state with a more favorable LGBTQ+ policy climate (compared with a negative LGBTQ+ policy climate)—as rated by the Movement Advancement Project's 2015 state policy ratings—was associated with better health-related outcomes (in 2015–2017 BRFSS data) in some domains. For example,

• State LGBTQ+ policy climate was associated with some indicators of health care access. LGBTQ+ policy climate in 2015 was associated with health insurance status, such that individuals residing in states with more favorable policy ratings (rated as low, medium, or high favorability) were significantly more likely to report having health insurance compared with LGBTQ+ veterans residing in states with a negative LGBTQ+ policy rating. Additionally, individuals in states with more favorable LGBTQ+ policy climates were more likely than those in states with a negative policy rating to report having had a check-up visit with a health care provider in the past year.
• Few statistically significant associations between state LGBTQ+ policy climate and outcomes were observed in other domains. Individuals residing in states with low, medium, or high policy ratings were less likely to report current cigarette smoking compared with those in states with a negative LGBTQ+ policy climate in 2015. In contrast, individuals residing in states with medium policy climates were more likely than those in states with negative policy climates to report a lifetime history of angina or coronary heart disease.

In this study, we add to the growing body of literature indicating that there are significant disparities in access to health care and health-related outcomes across multiple domains for LGBTQ+ veterans compared with their heterosexual and cisgender counterparts. Our findings underscore the importance and urgency of efforts to improve health services and outcomes for LGBTQ+ veterans, including sustained actions to ensure that all LGBTQ+ veterans can access needed health care services and use the full scope of benefits for which they are eligible.