A Department of Veterans Affairs (VA) facility in Seattle, Washington requested more than half a million dollars in fiscal year 2023 to build and staff a surgical facility for performing gender transition surgeries, although the VA has yet to approve such procedures, documents obtained by the Daily Caller News Foundation show.
The facility has offered hormone therapy, minor surgeries, hair removal and other treatments for decades as part of an effort to expand procedures geared toward an estimated 12,500 nationwide veterans who have been diagnosed as gender dysphoric, according to the documents obtained by the DCNF via public records requests. But the documents and emails show that the VA medical center at Puget Sound also estimated to incur expenses of $642,562 in 2023 and more than $1.5 million by 2027 in an initial proposal to the VA’s health care system for funding to establish a genital surgery center.
Veterans Affairs Puget Sound applied to the Veteran’s Health Administration (VHA) National Surgery Office (NSO) for funding to contract surgeons, purchase equipment and hire nurses and staff for a so-called Comprehensive Gender Affirming Surgical Center (CGASC), the documents show.
It wasn’t clear from the documents whether the VA approved Puget Sound’s application, and a spokesperson for the VA said no facilities had built out CGASCs.
“No VA facilities – including VA Puget Sound – have or are developing comprehensive gender affirming care surgery centers,” VA spokesperson Terrence Hayes told the DCNF. “While the rulemaking process on gender affirming surgery at VA is still underway, VA continues to provide all other types of gender affirming care to Veterans.”
The VA has not yet implemented a proposal announced in 2021 to expand VA coverage of transgender procedures, including major surgeries. An advocacy group sued the VA on Thursday over the delay in implementing the rule, arguing that the holdup of “life saving” services for an estimated 4,000 nationwide veterans interested in major sex change procedures will compound their anxiety, Military Times reported.
But the VHA told VA Puget Sound that funding to specifically support existing transgender treatment programs was available in fiscal year 2023, which ended Sept. 30, the documents show.
“Seattle is a sanctuary city for LGBTQ+ refugees from across the United States,” the proposal read, referring to a 2022 study that found Washington State housed the fourth highest population of veterans diagnosed with gender dysphoria. “Our facility is committed to continuing and expanding these medically necessary, lifesaving services,” the proposal stated.
The two proposals viewed by the DCNF, one of which appears to be a revision of the other, are undated, but emails from April 2023 show hospital and VA staff hammering out an updated proposal following the initial response from the National Surgery Office.
The VA’s medical plan already covers a variety of transgender treatments, including gender transition hormones and prosthetics, such as chest binders, and will provide letters of support to surgeons and private insurance providers for sex change surgeries, a fact sheet shows. It can also perform surgeries to address complications arising from major sex change operations. Under Secretary Denis McDonough, the VA has come out strongly in favor of implementing major sex change surgeries, according to the website.
Such surgeries include vaginoplasty, which is the construction of a false vagina on males, and phalloplasty or metoidioplasty, two different procedures that involve surgically constructing a false penis on females.
In the first year, Puget Sound planned to hire two plastic surgeons, a urologist, nurses, social workers, psychiatrists and psychologists, a pelvic physical therapist and other staff to build out the CGASC, the proposal shows.
The facility also requested $30,000 for hospital equipment specific to conducting gender transition surgeries in the first year. In 2024, the facility planned to pay $102,000 for a laser hair removal machine. Immediate and future equipment budget requests totaled $159,000. A separate proposal among the documents obtained by the DCNF requests $149,000 in equipment.
Neither proposal was specifically dated, but the latter appeared to come later, noting that “given the anticipated scope of the gender affirming surgery program, we have decided to move up the hiring of a surgery NP/PA and wound care [nurse] to [fiscal year 2024,] which is a change from our initial proposal.”
Another budget item carved out $500 yearly for a “Veteran Stipend to participate in monthly feedback meetings,” according to the proposal.
The primary challenge in setting up a gender surgery clinic appeared to be making hair removal services available given an expected increase in demand.
Emails discussing the proposal show VA and Seattle Children’s Hospital staff and practitioners discussing ways to handle expected complications that arise from major sex change operations, which can occur in up to 50% of phalloplasty cases and less in other genital surgeries.
“Sounds like this is an opportunity for us to ask for additional resources (beyond those in the initial proposal) to strengthen our proposed program,”Alexander Skokan, a trauma and reconstructive urologist and assistant professor of urology at the University of Washington, wrote in an April 9, 2023, email after describing the complications.
“They’re probably unsure if our proposal is strong enough out [of] the gates, and thus this is probably a critical piece to shore up our application,” he added, referring to the NSO.
At the time, veterans with complications were likely getting community care referrals from the VA to University of Washington Medicine for care, according to Skokan.
While the facility was prepared to manage minor complications and some chronic issues such as post-vaginoplasty urethral stricture, the center lacked doctors with the right expertise to deal with more complex issues.
Puget Sound is “collaborating closely” with surgeons at University of Washington Medical. The doctors are “actively seeking expansion of these surgeries to the VA Puget Sound HCS,” the proposal stated.
The proposals include estimated annual salaries between $330,000 and $371,000 for the practitioners to perform the major cosmetic procedures.
McDonough, the VA secretary, said in June 2023 that the federal regulation to approve major sex change surgeries throughout the VA was sitting on his desk, but he had not yet decided to authorize it, Military.com reported.
At the time, he did not explain why other than that he wanted time to study the policy.
“As the person who called for this and as the person who will be defending the policy when we do it, when I’m ready to move ahead, I’ll do it,” he told Military Times in November.
Still, VA health centers, including the one at Puget Sound, have doubled down on catering to transgender veterans.
Under a 2018 directive, last updated in June, the VA has been “injecting concepts of gender ideology” into “clinical work,” three VA professionals wrote in a Wednesday opinion article published in The Hill.
Transgender accommodations “effectively [extinguish] the entire class of women, undermining many physical and legal protections for female veterans,” they wrote.
Puget Sound launched a so-called Gender Diversity Clinic tailored toward accommodating “gender diverse” veterans and training future transgender medical providers, which would be done through Puget Sound’s partnership with the University of Washington, according to the proposal.
“A Veteran’s primary medical and mental health providers as well as the gender affirming surgical team will play a role in addressing any medical, mental, spiritual, or social barriers preventing Veterans from accessing gender affirming surgery,” the proposal states.
VA Puget Sound was hosting two LGBTQ+ support groups and an outreach coordinator to “promote self-healing and care” on a veteran’s path to recovery, as the proposal writers stated. They also pledged to work alongside the facility’s DEI committee to improve alleged disparities in the experiences of “gender diverse” veterans.
To support its application, Puget Sound outlined plans to expand “LGBTQ+ education,” the application stated, with the goals of “ending invisibility,” improving “affirming communication” and creating a “more affirming environment in our facilities.”
Also as part of the program, the Puget Sound center’s LGBTQ+ Veteran Care Coordinator (VCC) had already begun offering trainings to all staff — including those outside the proposed surgery center — to avoid dead-naming — using a transgender person’s old name — misgendering veterans. Staff had received 38 trainings on LGBTQ+ inclusion from the VCC already, according to the proposal.
Additional efforts included changing the name of the women’s clinic to include other self-described gender identities and making places like bathrooms and lactation pods more friendly to people who chose to live as the opposite sex.
The proposal writers said the VA medical center at Puget Sound is creating fields in its electronic records for both sex and gender identity and planned to introduce media featuring transgender veterans–such as signs and posters–throughout the entire medical facility.
The center also hoped to recruit “gender diverse staff,” while making a cursory nod to nondiscrimination policies.
“Specifically for strategic hires in our gender diverse surgery program where we would intentionally recruit/hire staff who have lived experience/understanding of gender diversity,” the proposal stated.
