Medical aspects of transgender military service

Armed Forces and Society

Volumn 41, Issue 2, 2015, Pages 199-220

  Elders, M Joycelyn ^a   Brown, George R ^b   Coleman, Eli ^c   Kolditz, Thomas A ^d   Steinman, Alan M ^e  

^a UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES   (United States)

^b EAST TENNESSEE STATE UNIVERSITY   (United States)

^c UNIVERSITY OF MINNESOTA MEDICAL SCHOOL   (United States)

^d YALE SCHOOL OF MANAGEMENT   (United States)

^e U S COAST GUARD   (United States)

Author keywords

Don t tell ; Medical care; Mental health; Transgender service members; don t ask

Indexed keywords

EID: 84925099797     PISSN: 0095327X     EISSN: 15560848     Source Type: Journal    
DOI: 10.1177/0095327X14545625     Document Type: Article

References (93)

1. In an earlier, self-published version of this article, we referred to twelve countries that allow transgender military service. Since that time, scholars at the Hague Centre for Strategic Studies have published a comprehensive study of rules governing gay, lesbian, bisexual, and transgender service in 103 countries. While the report does not include a list of nations allowing transgender military service, we are grateful to its authors, who provided us with their data indicating that 18 nations allow transgender military service while 9 nations probably allow it, but could not be confirmed. The 18 confirmed cases are Australia, Austria, Belgium, Bolivia, Canada, Czech Republic, Denmark, Estonia, Finland, France, Germany, Israel, Netherlands, New Zealand, Norway, Spain, Sweden, and United Kingdom. See
2. Joshua Polchar et al., LGBT Military Personnel; A Strategic Vision for Inclusion (The Hague, the Netherlands: The Hague Centre for Strategic Studies, 2014).
3. Aaron Belkin et al., ‘‘Readiness and DADT Repeal: Has the New Policy of Open Service Undermined the Military?,’’ Armed Forces & Society 39, 4 (2013): 587-601
4. Robert MacCoun, Elizabeth Kier, and Aaron Belkin, ‘‘Does Social Cohesion Determine Motivation in Combat? An Old Question with an Old Answer,’’ Armed Forces & Society 32, 4 (2006): 646-54.
5. Veterans Health Administration (VHA) updated the policy in 2013. See Department of Veterans Affairs, VHA Directive 2013-003, Providing Health Care for Transgender and Intersex Veterans, February 8, 2013. The VHA provides cross-sex hormone therapy, but not gender-confirming surgery.
6. In this article, we do not address cross-dressing, Which is governed by grooming and uniform regulations that are distinct from the medical rules that apply to transgender military service.
7. For most people, gender identity is a stable, deep-seated component of their sense of self. For a broader discussion of gender identity, see
8. Jaime M. Grant, Lisa A. Mottet, and Justin Tanis, Injustice at Every Turn: A Report of the National Transgender Discrimination Survey (Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011), 24-25.
9. Although fewer than 20 percent of transgender women and 5 percent of transgender men have had genital reconstructive surgeries, more have had other types of genderconfirming surgery such as breast augmentation, and demand for surgeries could increase if they were affordable and available. Grant, Mottet, and Tanis, A Injustice at Every Turn, 78-79.
10. See, for example, durations associated with variants of cross-sex hormone therapy in Eli Coleman et al., ‘‘Standards of Care for the Health of Transsexual, Transgender, and Gender-nonconforming People, Version 7,’’ International Journal of Transgenderism 13, 4 (2011): 188-89.
11. Gary Gates and Jody Herman, Transgender Military Service in the United States (Los Angeles, CA: Williams Institute, 2014), accessed July 18, 2014, http://williamsinstitute.law.ucla.edu/wp-content/uploads/Transgender-Military-Service-May-2014.pdf.
12. At the time of writing, the active, Guard and Reserve components included 2,280,875 personnel.
13. In response to a recent Freedom of Information Act request for discharge data submitted by the Palm Center, a Pentagon spokesperson said that the military does not track the number of service members who have been separated for transgender-related reasons. 10. Private communication between staff of Sparta, an organization representing currently serving transgender service members, and Palm Center research staff.
14. Department of Defense Instruction (DODI) 6130.03, Medical Standards for Appointment, Enlistment, or Induction in the Military Services, April 28, 2010, Incorporating Change 1, September 13, 2011. Paraphilia is sexual arousal to an atypical object. See American Psychiatric Association, Diagnostic and Statistical Manual, 5th ed. (Arlington, VA: American Psychiatric Publishing, 2013).
15. Department of Defense Instruction (DODI) 1332.14, Enlisted Administrative Separations, August 28, 2008, Incorporating Change 3, September 30, 2011, Enclosure 3, at {3(a)8. DODI 1332.14 incorporates a list of administratively disqualifying conditions, including sexual gender and identity disorders, found in Enclosure 5 to DODI 1332.38, Physical Disability Evaluation, November 14, 1996, Incorporating Change 2, April 10, 2013.
16. Department of Defense Instruction 6130.03, Medical Standards for Appointment, Enclosure 2, at {3(b).
17. Army Regulation 40-501, Standards of Medical Fitness, December 14, 2007 (updated August 4, 2011), at {1-6(b).
18. AR 40-501, Standards of Medical Fitness, at {1-6(h).
19. See AR 40-501, Standards of Medical Fitness {{2-14, 3-35(a), (b); NAVMED P-117, U. S. Navy Manual of the Medical Department, Chapter 15, §§ 15-45, 15-46, 15-58
20. SECNAV Instruction 1850.4E, Department of the Navy Disability Evaluation Manual, Enclosure 8, § 8013(a); SECNAV Instruction 1850.4E, Enclosure 8, Attachment (b) (page 8-43); and NAVMED P-117, Chapter 18, § 18-5(3).
21. Doe v. Alexander, 510 F. Supp. 900 (D. Minn. 1981)
22. Leyland V. Orr, 828 F. 2d 584 (9th Cir. 1987)
23. DeGroat V. Townsend, 495 F. Supp. 2d 845 (S.D. Ohio 2007).
24. We consider deployability to be a medical aspect of military service because deployment regulations specifically address medical readiness. See, for example, DODI 6490.07.
25. Deployment-LimitingMedical Conditions for Service Members and DOD Civilian Employees, February 5, 2010; or Department of Defense, Assistant Secretary of Defense for Health Affairs Memorandum, Policy Guidance for Deployment-Limiting Psychiatric Conditions and Medications. (Washington, DC: Department of Defense, November 7, 2006)
26. Jillian C. Shipherd et al., ‘‘Male-to-female Transgender Veterans and VA Health Care Utilization,’’ International Journal of Sexual Health 24, 1 (2012): 85.
27. Jack Harrison-Quintana and Jody L. Herman, ‘‘Still Serving in Silence: Transgender Service Members and Veterans in the National Transgender Discrimination Survey,’’ LGBTQ Policy Journal at the Harvard Kennedy School 3, accessed July 18, 2014, http://williamsinstitute.law.ucla.edu/wp-content/uploads/Harrison-Quintana-Herman-LGBTQ-Policy-Journal-2013.pdf
28. Everett McDuffie and George R. Brown, ‘‘Seventy U.S. Veterans with Gender Identity Disturbances: A Descriptive Study,’’ International Journal of Transgenderism 12, 1 (2010): 21-30.
29. Department of Defense Instruction 6130.03 requires a reference to diagnostic codes in the International Classification of Diseases (ICD-9), and the ICD does list diagnoses for both transsexualism and gender identity disorder. Department of Defense translates DSM-IV diagnoses to the closest ICD code.
30. In theWorld Professional Association for Transgender Health Standards of Care, dysphoria refers to the distress itself, not the incongruence between gender identity and assigned sex. See Coleman A et al., ‘‘Standards of Care for the Health of Transsexual, Transgender, and Gender-nonconforming People, Version 7,’’ 168. Indeed, non-transgender people can experience gender dysphoria. For example, some men who are disabled in combat, especially if their injury includes genital wounds, may feel that they are no longer men because their bodies do not conform to their concept of manliness. Similarly, a woman who opposes plastic surgery, but who must undergo mastectomy because of breast cancer, may find that she requires reconstructive breast surgery in order to resolve gender dysphoria arising from the incongruence between her body without breasts and her sense of herself as a woman.
31. Coleman A et al., ‘‘Standards of Care for the Health of Transsexual, Transgender, and Gender-nonconforming People, Version 7,’’ 168.
32. Jack Drescher, Peggy Cohen-Kettenis, and Sam Winter, ‘‘Minding the Body: Situating Gender Identity Diagnoses in the ICD-11,’’ International Review of Psychiatry 24, 6 (2012): 575, 569, 574.
33. Ilan H. Meyer and Mary E. Northridge, eds., The Health of Sexual Minorities: Public Health Perspectives on Lesbian, Gay, Bisexual and Transgender Populations (New York: Springer, 2007).
34. Drescher, Cohen-Kettenis, and Winter, A ‘‘Minding the Body,’’ 573.
35. Coleman et al., ‘‘Standards of Care for the Health of Transsexual, Transgender, and Gender-nonconforming People, Version 7,’’ 230, citing findings of multiple studies including Richard
36. Green A and Davis Fleming, ‘‘Transsexual Surgery Follow-up: Status in the 1990s,’’ Annual Review of Sex Research 1, 1 (1990): 163-74. See Coleman et al. for additional references.
37. Anne Gaderman et al., ‘‘Prevalence of DSM-IV Major Depression Among U.S. Military Personnel,’’ Military Medicine 177, 8 (2012): 47-59.
38. Kim Murphy, ‘‘A Fog of Drugs and War,’’ Los Angeles Times, April 7, 2012, accessed July 18, 2014, http://articles.latimes.com/2012/apr/07/nation/la-na-army-medication-20120408.
39. Katherine Blakeley and Don J. Jansen, Post-traumatic Stress Disorder and Other Mental Health Problems in the Military: Oversight Issues for Congress (Washington, DC: Congressional Research Service, 2013), 2, citing ‘‘Mental Disorders and Mental Health Problems, Active Component, US Armed Forces, 2000-2011,’’ Medical Surveillance Monthly Report 19, 6 (June 2012): 11-17.
40. Paul R. Sackett and Anne S. Mavor, eds., Assessing Fitness for Military Enlistment Physical, Medical, and Mental Health Standards (Washington, DC: The National Academies Press, 2006), 144.
41. Adam F. Yerke and Valory Mitchell, ‘‘Transgender People in the Military: Don’t Ask? Don’t Tell? Don’t Enlist!,’’ Journal of Homosexuality 60, 2-3 (2013): 445. Also
42. Drescher, Cohen-Kettenis, and Winter, A, ‘‘Minding the Body,’’ 573.
43. Meyer and Northridge, The Health of Sexual Minorities, 2007.
44. Ministry of Defence, Policy for the Recruitment and Management of Transsexual Personnel in the Armed Forces (London, UK: Ministry of Defence, January 2009).
45. Although service members are not prohibited explicitly from obtaining cross-sex hormone treatment, the use of hormones to modify primary or secondary sex characteristics would almost certainly constitute evidence of having a transgender identity, which is grounds for discharge.
46. H. Asscheman et al., ‘‘A Long-term Follow-up Study of Mortality in Transsexuals Receiving Treatment with Cross-sex Hormones,’’ European Journal of Endocrinology 164, 4 (2011): 635-42
47. Paul Van Kesteren et al., ‘‘Mortality and Morbidity in Transsexual Subjects Treated with Cross-sex Hormones,’’ Clinical Endocrinology 47, 3 (1997): 337-43
48. M. Colizzi, R. Costa, and O. Todarello, ‘‘Transsexual Patients’ Psychiatric Comorbidity and Positive Effect of Cross-sex Hormonal Treatment on Mental Health: Results from a Longitudinal Study,’’ Psychoneuroendocrinology 39 (2014): 65-73.
49. H. Asscheman et al., ‘‘Venous Thrombo-embolism as a Complication of Cross-sex Hormone Treatment of Male-to-Female Transsexual Subjects: A Review,’’ Andrologia, August 14, 2013. doi: 10.1111/and.12150.
50. Tom Waddell Health Center, Protocols for Hormonal Reassignment of Gender, 2006, accessed November 6, 2013, http://www.sfdph.org/dph/comupg/oservices/medSvs/hlthCtrs/TransGendprotocols122006.pdf.
51. Department of Defense, Health Related Behaviors Survey of Active Duty Military Personnel 2011 (Washington, DC: Department of Defense, 2013), 119-20, 130-31, 248, 264-65.
52. Department of Defense, Policy Guidance for Deployment-limiting Psychiatric Conditions and Medications (Washington, DC: Department of Defense, 2006) at {4.2.3.
53. Andrew Tilghman, ‘‘‘Any Soldier Can Deploy on Anything’: Pentagon Rules Bar Some Drugs from Combat Zone, but Oversight Is Suspect,’’ Army Times, March 17, 2010, accessed July 18, 2014, http://www.armytimes.com/article/20100317/NEWS/3170310/-8216-Any-soldier-can-deploy-anything
54. Tilghman, ‘‘Any Soldier Can Deploy on Anything,’’ 2010.
55. Department of the Army, Personnel Policy Guidance for Overseas Contingency Operations (Washington, DC: Department of the Army, 2009), at {7-13(b)1.
56. See, for example, American Medical Association, Resolution 122 (8), 2008, accessed July 18, 2014, http://www.tgender.net/taw/ama_resolutions.pdf.
57. Coleman et al., ‘‘Standards of Care for the Health of Transsexual, Transgender, and Gender-nonconforming People, Version 7,’’ 170-71.
58. For a list of 313 allowable, elective cosmetic procedures, see Tricare Management Activity, Uniform Business Office, Provider’s Guide to the Elective Cosmetic Surgery Superbill. (Falls Church, VA: TRICARE Management Activity, Uniform Business Office, 2013).
59. Patel, Morris, And Gassman show that these complications may include ‘‘airway, vascular, hemorrhage, vascular compromise, neurologic, infectious, skeletal, unfavorable osteotomy, tooth injury, nonunion, postoperative malocclusion, temporomandibular joint disorders, and unfavorable aesthetic results.’’
60. P. Patel, D. Morris, and A. Gassman, ‘‘Complications of Orthognathic Surgery,’’ Journal of Craniofacial Surgery 18, 4 (2007): 975-85. The military allows personnel to have elective cosmetic surgeries on a space-available basis and at their own expense.
61. Patel, Morris, and Gassman, A ‘‘Complications of Orthognathic Surgery,’’ 2007
62. F. Kramer et al., ‘‘Intra-and Perioperative Complications of the LeFort I Osteotomy: A Prospective Evaluation of 1000 Patients,’’ Journal of Craniofacial Surgery 15, 6 (2004): 971-77
63. K. Jones, ‘‘Le Fort II and Le Fort III Osteotomies for Midface Reconstruction and Considerations for Internal Fixation,’’ in Craniomaxillofacial Reconstructive and Corrective Bone Surgery, eds. A. Greenberg and J. Prein (New York: Springer, 2006), 667-68.
64. Herman found in a recent study that the highest annualized utilization rate for large employers is 0.044 claimants per thousand employees annually (Table 8). If the military were similar to civilian firms, and given that the active, Guard and Reserve components currently include 2,280,875 personnel, then one would expect 0.044 ×2,281 ¼ 100 claimants per year if the Military Health System covered gender-confirming surgery.
65. However, transgender people are over-represented in the military (15,450/2,280,875 million ¼ 0.68 percent military as compared to 0.3 percent of the civilian adult population), and so the figure of 100 claimants per year should be adjusted upward by .68/.3 ¼ 2.3×. Hence, if the military paid for transition-related surgery, one would expect 2.3 × 100 ¼ 230 claims per year. See Jody L. Herman, Costs and Benefits of Providing Transitionrelated Health Care Coverage in Employee Health Benefits Plans (Los Angeles, CA: Williams Institute, 2013).
66. Herman, Costs and Benefits of Providing Transition-related Health Care Coverage in Employee Health Benefits Plans, 6.
67. Short-term surgical complications can include rectal injury, infection, delayed wound healing, bleeding, venous thromboembolism, and/or urethral stream abnormalities. While many of these complications are either self-limited or may be treated with local wound care, antibiotics, or anticoagulants, some, such as rectal injury, may require additional surgical procedures such as a temporary colostomy. Long-term complications can include vaginal stenosis and unsatisfactory appearance of the surgically reconstructed genitalia, and vaginal stenosis may require additional procedures such as skin grafts or intestinal transposition.
68. A. A. Lawrence, ‘‘Patient-reported Complications and Functional Outcomes of Male-tofemale Sex Reassignment Surgery,’’ Archives of Sexual Behavior 35, 6 (2006): 717-27.
69. Cameron Bowman and Joshua M. Goldberg, ‘‘Care of the Patient Undergoing Sex Reassignment Surgery,’’ International Journal of Transgenderism 9, 3-4 (2006):135-65
70. Miroslav L. Djordjevic, Dusan S. Stanojevic, and Marta R. Bizic, ‘‘Rectosigmoid Vaginoplasty: Clinical Experience and Outcomes in 86 Cases,’’ Journal of Sexual Medicine 8, 12 (2011): 3487-94
71. Ji-Xiang Wu et al., ‘‘Laparoscopic Vaginal Reconstruction Using an Ileal Segment,’’ International Journal of Gynecology and Obstetrics 107, 3 (2009): 258-61
72. L. Jarolím et al., ‘‘Gender Reassignment Surgery inMale-to-female Transsexualism: A Retrospective 3-month Follow-up Study with Anatomical Remarks,’’ Journal of Sexual Medicine 6, 6 (2009): 1635-44
73. S. V. Perovic, D. S. Stanojevic, and M. L. J. Djordjevic, ‘‘Vaginoplasty in Male Transsexuals Using Penile Skin and a Urethral Flap,’’ BJU International 86, 7 (2000): 843-50.
74. Presumably, any postoperative MTF individuals with ongoing complications would be screened out at the time of enlistment. Hence, the only MTF troops who would be unfit for duty would be those experiencing ongoing postoperative complications from genital surgeries they elected to have after joining the military. As explained previously, if the Military Health Service paid for transition-related care, one would expect 230 claimants per year. Approximately 90 percent of transgender troops are MTF’s, thus suggesting .9 × 230 ¼ 207 claimants per year for MTF transition-related coverage. If 5 percent of such claims entailed ongoing postoperative complications, this would mean that ten MTF transgender troops would become permanently unfit for duty each year.
75. For example, see S. Baumeister et al., ‘‘Phalloplasty in Female-to-male Transsexuals: Experience from 259 Cases [Article in German],’’ Handchir Mikrochir Plast Chir 43,4 (2011): 215-21
76. J. E. Terrier et al., ‘‘Surgical Outcomes and Patients’ Satisfaction with Suprapubic Phalloplasty,’’ Journal of Sexual Medicine 11, 1 (September 12, 2013): 288-98
77. P. A. Sutcliffe et al., ‘‘Evaluation of Surgical Procedures for Sex Reassignment: A Systematic Review,’’ Journal of Plastic, Reconstructive and Aesthetic Surgery 62, 3 (2009): 294-306.
78. These figures are derived from raw data that informed Grant, Mottet, and Tanis, Injustice at Every Turn, 2011.
79. Presumably, any postoperative FTM individuals with ongoing complications would be screened out at the time of enlistment. Hence, the only FTM troops who, as a class, would be unfit for duty would be those experiencing ongoing postoperative complications from genital surgeries they elected to have after joining the military. As explained previously, if the Military Health Service paid for transition-related care, one would expect 230 claimants per year. However, only 10 percent of transgender troops are FTMs, thus suggesting .1 _ 230 ¼ 23 claimants per year for FTM transition-related coverage. If one quarter of such claims entailed ongoing postoperative complications, this would mean that six FTM transgender troops would become permanently unfit for duty each year.
80. Chris Johnson, ‘‘Pentagon’s Gay-inclusive Human Goals Charter Omits Trans People,’’ Washington Blade, April 28, 2014, accessed July 18, 2014, http://www.washingtonblade.com/2014/04/28/pentagons-gay-inclusive-human-rights-charter-omits-trans-people/.
81. Department of the Army, Personnel Policy Guidance for Overseas Contingency Operations, 2009, 7-9.
82. Ministry of Defence, Policy for the Recruitment and Management of Transsexual Personnel in the Armed Forces, 2009.
83. DODI 1332.38, Physical Disability Evaluation, Enclosure 3, at {{P3.4.1.3, P3.4.3, and Enclosure 4, at {1.1.2.
84. Department of Defense, Health Related Behaviors Survey of Active Duty Military Personnel 2011, 2013.
85. United States Code, Title 10, Section 701
86. Department of Defense Instruction 1327.06, Leave and Liberty Policy and Procedures, June 16, 2009, Incorporating Change 2, effective August 13, 2013, Enclosure 2, at {1c.
87. DODI 1327.06, Leave and Liberty Policy, Enclosure 2, at {{1j(1), 1a.
88. Army Regulation 600-8-10, Leave and Passes (August 4, 2011 revision), at {5-3e.
89. Army Medical Command, OTSG/MEDCOM Policy Memo 12-076, Revised Policy for Cosmetic Surgery Procedures and Tattoo/Brand Removal/Alteration in the Military Health System (November 20, 2012), at {{5e(15), 5f(2).
90. Army Medical Command, Revised Policy for Cosmetic Surgery, at {5(e)(7).
91. See, for example, Department of the Air Force Instruction 36-2110, Assignments (Change 2, June 8, 2012), at {2.17.1.
92. Department of the Air Force Instruction 36-2110, Assignments, at {2.17.3 and table 2.2.
93. DODI 1332.38, Physical Disability Evaluation, Enclosure 3, at {P7.3.