The Pentagon Is Wrong. Gender Transition Is Effective.

NEW YORK TIMES | Apr. 9, 2018 

By Nathaniel Frank

Mr. Frank is the author of “Awakening: How Gays and Lesbians Brought Marriage Equality to America.”
April 9, 2018
What does it mean to be transgender?

A Pentagon report released last month, recommending that most transgender Americans be disqualified from military service or forced to serve in their birth gender without full health care, has renewed debate over this question.

Is a person less fit to serve if he or she has a medical diagnosis of gender dysphoria — significant distress over an incongruity between one's birth sex and gender identity? Does welcoming such people threaten the cohesion of an organization like the military?

In its unsigned report, the Defense Department argues it does. Its main rationale is that people with a history of gender transition or dysphoria have higher odds of mental health conditions that unacceptably raise the risks of harm to unit cohesion, lethality, good order and overall readiness.

The Pentagon concedes that gender dysphoria is treatable, but asserts there is “considerable scientific uncertainty and overall lack of high-quality scientific evidence demonstrating the extent to which transition-related treatments” address the symptoms associated with gender dysphoria. The report mentions the high suicide rates of the transgender population as a central reason for its ban.

Yet the Pentagon is wrong.

Mounds of scholarly studies stretching back decades — and with increasing volume and quality in recent years — have been conducted on whether gender transition resolves the symptoms of gender dysphoria. That research reveals an overwhelming consensus that transgender people who have adequate access to health care can and do function effectively.

The What We Know Project, a research initiative I lead at Cornell's Center for the Study of Inequality, recently completed one of the largest comprehensive literature reviews to date on the well-being of people who underwent gender transition (which typically involves some combination of hormone therapy and surgery). The advantage of this approach is that a global database search returns the full universe of research on a given topic, making it less likely that results are biased by the selective use of outlier studies.

Our findings make it indisputable that gender transition has a positive effect on transgender well-being. We identified 56 studies published since 1991 that directly assessed the effect of gender transition on the mental well-being of transgender individuals. The vast majority of the studies, 93 percent, found that gender transition improved the overall well-being of transgender subjects, making them more likely to enjoy improved quality of life, greater relationship satisfaction and higher self-esteem and confidence, and less likely to suffer from anxiety, depression, substance abuse and suicidality.

Only four studies (7 percent) reported mixed or null findings, and none found that the transitioning created more harm than good. Despite recent media focus on anecdotes about “transgender regret,” actual regret rates across numerous studies were minuscule, generally ranging from 0.3 percent to 3.8 percent. Our review of primary research confirmed the positive findings of at least 16 previous literature reviews.

The research shows that gender transition improves well-being, and that it can redress the specific health conditions that the military claims are its primary concern, particularly suicidality. A 1999 United States study found a “marked decrease of suicide attempts” and substance use in its postoperative population. In a 2014 British study, gender transition “was shown to drastically reduce instances of suicidal ideation and attempts.” The study reported that “67 percent of respondents thought about suicide more before they transitioned and only 3 percent thought about suicide more post-transition.”

Research suggests that gender transition may resolve symptoms completely. A 2016 literature review by scholars in Sweden concluded that, most likely because of improved care over time, transgender “rates of psychiatric disorders and suicide became more similar to controls,” and that for those transitioning after 1989, “there was no difference in the number of suicide attempts compared to controls.” The corollary is also true: Another study found that withholding hormone treatment from transgender people increased the risk of depression and suicide.

While transgender people can still face disproportionate stresses after transition, research suggests that stigma and discrimination are primary causes of such “minority stress.” That's all the more reason we should provide treatment and social support rather than exclusion and barriers to care.

Suicide and mental health challenges do not, of course, define transgender people, many of whom are just as healthy as their peers. There are other populations that are plagued by suicide, including the military community itself. Children of military members are at much higher risk for suicidal ideation than both the general and the transgender population. Yet children of service members are not barred from enlisting, despite these higher risks. This suggests a double standard in which transgender people are singled out for unequal treatment not because they present an unacceptable risk but simply because of bias.

The studies we reviewed, like all research, have methodological limitations. It's virtually impossible, as well as unethical, to conduct randomized, controlled trials on transition care because of the small size of the transgender population and because it would require withholding treatment from those who need it.

Yet even with these limitations, the quality and quantity of research on gender transition are robust, showing unmistakably that it's highly effective. The only way to call this kind of a consensus “uncertainty” is to ignore all the research that doesn't support a specific agenda, which appears to be just what the Pentagon did.
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Nathaniel Frank is director of the What We Know Project at Cornell's Center for the Study of Inequality, and author of “Awakening: How Gays and Lesbians Brought Marriage Equality to America.”