There’s No Medical Reason to Keep Transgender People Out of the Military
SLATE | Mar. 13, 2014
Today, a commission co-chaired by former U.S. Surgeon General Joycelyn Elders and including former military officers and top scholars on gender and health, has issued a report on the subject that ought to settle that question quickly. The commission, established by the Palm Center (where I am a consultant), conducted the most thorough, expert inquiry into the reasons for the current restrictions on transgender service. It set out to assess the fairly narrow question of whether the trans ban was based on sound medical science—since the regulations, which are complicated and overlapping, are primarily expressed in medical terms. What the authors found, however, was not only that “there is no compelling medical reason for the ban” but that there’s no good rationale at all—and plenty of good reasons to end it.
The ban on transgender military service is really a string of different restrictions left over from a time when anything outside a straight and narrow norm was regarded as a mystifying and dangerous difference. Defense Department medical standards disqualify applicants with “major abnormalities or defects of the genitalia such as change of sex,” as well as what the Pentagon calls “psychosexual conditions,” which include “transsexualism, exhibitionism, transvestism, voyeurism, and other paraphilias.”
The trans restrictions are embedded, for the most part, in medical regulations whose purpose is perfectly sensible: to minimize the chances that anyone who joins the military will endanger the health of the force, lose excessive duty time, or become undeployable. (They are not, interestingly, expressed in the same terms as the DADT restrictions, which presumed that openly gay troops would so disturb other service members that they would leave or that unit cohesion would suffer.) But when the commission looked into the rationale for including transgender identity and trans-related medical procedures in the list of disqualifiers to service, they made two important discoveries—that the restrictions are hugely out of date, and that there is no documented history of why they ever existed in the first place.
It’s been 20 years since the American Psychiatric Association’s DSM-IV removed “transsexualism” as a diagnosis. When it did so, in 1994, it replaced the term with “gender identity disorder.” But in the DSM-5, the latest version of the psychiatric manual published last year, gender identity disorder has been replaced with “gender dysphoria.” The changes are not just semantics but carry real significance. Unlike either transsexualism or gender identity disorder, gender dysphoria is not a mental disorder, and it is not something that all transgender people suffer from. Instead, it refers toclinically significant distress that someone feels in conjunction with a deep cross-gender identification. And even those who do get the diagnosis are regarded as having a treatable condition, not an identity disorder.
Yet while the military routinely updates medical classifications to reflect the latest changes in the DSM, the trans prohibitions remain untouched, despite a complete absence of connection between being transgender and fitness for military service. That makes transgender identity one of the only statuses that automatically requires rejection or discharge, irrespective of ability to perform.
Now, about the missing rationale: The military does not bother to offer a reason for the ban, simply telling the Associated Press today, “At this time there are no plans to change the department's policy and regulations which do not allow transgender individuals to serve in the U.S. military.” Center for Military Readiness President Elaine Donnelly, who was spectacularly wrong on the consequences of ending DADT but whom the Associated Press still quotes obligatorily, simply repeats baseless talking points from that earlier debate about sexual assaults, privacy, and “putting an extra burden” on the military.
Because there is no written history of why the military bans transgender service, the only reasons on record come from a handful of legal challenges to the ban. In one case, the Army claimed that allowing transsexuals would require it to develop burdensome facilities and specialty knowledge to deal with risks and complications from surgery or hormonal treatment. In another case, a doctor testified for the Air Force that deploying someone who had changed sex was akin to posting someone with coronary artery disease to a far-flung location without proper care. Testimony in a third case cited risks and side effects, the possibility of duty performance problems, the need for costly specialized care, and the limitations of military medical knowledge as reasons to ban trans service. “It is neither in the best interest of the individual patient to have their access to necessary health care limited during potential Air Force duties, nor is it in the best interest of the Air Force to have to provide the medical care that these individuals may require,” concluded a doctor testifying for the Air Force.
Yet the singling out of transgender identity and conduct makes it clear that little more than discomfort and stigma account for the current ban. The military allows service by all kinds of people with all kinds of health conditions that can be risker and costlier than the hurdles that transgender people typically face. What’s unique to the trans ban is that regulations deny service members, commanders, and military doctors the chance to demonstrate that a transgender person’s situation does not impose a burden on the military or any undue risk of medical complications or loss of duty time. The commission report carefully assesses the risks of surgery and hormone treatment that some transgender people undergo—and finds they are no higher than numerous medical conditions that don’t disqualify applicants. Individuals with Attention Deficit Hyperactivity Disorder, for instance, can serve so long as they can document certain performance capacities. People with mood or anxiety disorders, even those dependent on medication, can serve if they don’t need regular hospitalization and can perform their duties.
The report, in fact, is chock full of statistics on the levels of poor mental health the military will tolerate—while summarily banning trans people. According to the report, 12 percent of deployed service members suffered from a major depressive disorder in a 2012 analysis. In 2009, more than 15,000 troops were hospitalized for mental health disorders. In 2011, more than 100,000 were taking “prescribed antidepressants, narcotics, sedatives, antipsychotics and anti-anxiety drugs.” In the past decade, nearly 1 million service members were diagnosed with a mental disorder. These cases did not spur automatic discharge. In the early years of the Iraq and Afghanistan wars, 34 percent of applicants who failed psychiatric entrance tests were granted waivers to serve anyway.
The report also points out blatant inconsistencies in how the military treats medical conditions and risks depending on whether someone is transgender or not. Many gynecological conditions that may require hormone treatment face no military restrictions (unless they affect performance), while being transgender is barred regardless of medical needs or risks. About 1.4 percent of service members report using prescription anabolic steroids. Indeed, military regulations allow the use of hormones, so long as you’re not transgender, strongly suggesting that concerns about the risks and burdens of hormone treatment are simply a rationalization for transphobia. As does the fact that the military allows risky elective cosmetic surgery and grants convalescent leave for elective procedures including Botox, but regards medically necessary gender-confirming surgery for transgender people as disqualifying.
The broad medical latitude that the military grants to pretty much anyone who isn’t transgender raises serious suspicions about drawing the line at trans people who frequently do not pose any added health care risks to the force. In any event, as with DADT, the trans ban does not succeed at keeping trans people out of the military—an estimated 15,000 transgender people are currently serving—but it does function to closet people who are already living as the opposite gender and are sometimes in need of hormone treatment. Thus, while the military justifies the ban with claims that it’s not in the “best interest” of trans people to have their health care limited during deployment, it’s actually the ban itself that limits necessary health care by keeping currently serving trans members from getting the care they need.
Among the 15,000 transgender military members, there is a wide range of health care needs and psychological states, just as there is with the rest of the force. Today’s commission report provides ample reason to reconsider the current policy, which is clearly based on prejudice rather than sound medical (or any other) reasoning. Fortunately, unlike DADT, which was passed by Congress and required Congress or the courts to reverse it, the anti-trans regulations are confined to the Pentagon and can easily be removed by the Pentagon, something the commission report recommends. Given the military’s statement today that it plans no action, it’s a good thing the report reminds Washington that the Pentagon answers to the commander in chief.