Pauline Anderson

May 30, 2017

SAN DIEGO, California ― Being a transgender member of the military is more acceptable now that legislation allows enlistees who identify as being of another gender to serve openly.

But it's been a long journey, and challenges remain. Some still consider the military archaic in its treatment of LGBTQ service people.

These and other issues were discussed at a session on transgender people in the military here at the American Psychiatric Association (APA) 2017 Annual Meeting.

Speakers included Paula Neira (born male), a lawyer and nurse who served as a lieutenant in the US Navy from 1985-1991, and Shane Ortega (born female), who served in the armed forces from 2004-2016. Both excelled in the military, but at a personal cost.

Epidemiologic evidence shows that up to 150,000 trans people are on active duty or are veterans or reservists in the United States, session chair Amir K. Ahuja, MD, director of psychiatry at the Los Angeles LGBT Center, told delegates.

Dr Amir Ahuja

Interestingly, the percentage of transgender people serving in the military is higher than in the general population (22.9 per 100,000 compared to 4.3 per 100,000), said Dr Ahuja.

That may be because of their need to "overachieve" or to be "hypermasculine." Ortega described volunteering for risky positions other people were unwilling to fill and of constantly demonstrating high athleticism.

The road hasn't been easy for transgender people in the military. Dr Ahuja provided a brief history of legislation that forced them to hide their sexual identify.

For example, in 1951, all branches of the military established sodomy as "incompatible" with military service.

In 1993, the "don't ask, don't tell" (DADT) policy, which Dr Ahuja described as "compromise legislation," allowed LGBT people to serve in the military, but not openly. DADT led to 13,000 discharges, he said.

Heavy Mental, Physical Toll

Evidence suggests that a significant number of LGBT people in the military believed they would receive poorer healthcare or be discriminated against if they disclosed their sexual orientation to their healthcare provider, said Dr Ahuja.

He cited studies and surveys showing the mental and physical toll that being transgender can take. For example, a 2010 National Transgender Discrimination Survey that included 7000 transgender people showed that about 1 in 5 had been refused medical treatment, more than 25% had been verbally harassed, and another 25% had experienced delays in accessing necessary healthcare.

A 2012 National College Health Assessment survey of 27,176 people found that LGBT respondents were more than four times more likely to have attempted suicide in the past year and almost five times more likely to experience discrimination.

In 2010, the DADT was repealed, allowing lesbian, gay, and bisexual people to serve openly. But the military ban on openly transgender people continued.

The ban "was terrible for the troops and terrible for the military," said another speaker, Aaron Belkin, PhD, a political scientist and director of the Palm Center, considered one of the most effective gay rights organizations in the United States.

The rationale behind the ban was that providing healthcare to transgender people, including hormone therapy and surgery, was "too complicated," said Dr Belkin.

The argument, too, was that transgender people have a relatively high rate of psychiatric comorbidity and suicide. The policy, he said, was not based on sound evidence.

"It's a dangerous precedent when any government agency bases policy on emotion rather than science," said Dr Belkin. "When the government fires people just for who they are, for something called transsexualism, is to fire people for having an identity. In this country, to my mind, one of the very definitions, the essential elements, of being free is that we have the freedom to choose who we are."

He noted that under apartheid in South Africa, the Nazis in Germany, and slavery in the United States, people were punished on the basis of their identity.

Attitude Shift

But then the attitude about transgender individuals in the US military began to change. In 2016, the Pentagon ended the transgender ban and allowed transgender individuals to serve openly without fear of discharge.

Dr Belkin described the advocacy measures that succeeded in getting rid of the ban, which started "in earnest" in 2013.

He and his colleagues thought it would take at least 10 years to remove the transgender ban. He believes one reason the repeal happened so quickly was the momentum generated by a report, sponsored by the Palm Center and carried out by a commission co-chaired by a retired surgeon general and a former coast guard director of health and safety.

"The study found that, of course, some trans people are not fit to serve, but it also found that medical care for trans people is no more difficult or complicated than medical care the military provides all the time for nontrans people," said Dr Belkin.

Although some trans people experience depression and suicidality, the military has standards that prevent them from enlisting, and it has procedures for treating people already in the military who develop mental health problems.

As for needing hormone therapy, "the military administers hormones all the time" to, for example, postmenopausal women and has "a sophisticated restocking apparatus" to provide hormones to members in the field, he said.

Regarding surgery, "it turns out that nontransgender people require the same surgery that trans people do, including hysterectomies and 'top surgery,' " said Dr Belkin. The military already has experts in reconstructive surgery because of having to treat patients with war wounds.

All military personnel, transgender and otherwise, need to periodically take some time off for various medical conditions, added Dr Belkin.

"The report showed that trans people are just as healthy on average as nontrans people, just as fit for duty, just as fit for deployment, and their medical needs are actually not that complicated compared to what the military does all the time."

Another boost for the advocacy effort was the passing by the American Medical Association of a resolution affirming that there is no medical reason to discharge transgender troops, said Dr Belkin.

Discrimination Persists

During the session, Neira described the emotional strain of having to hide her gender identity while serving her country. "The minute I asked for help, I would have been kicked out."

Near the end of her service, Neira said she deliberately allowed herself to get out of shape. "That lessened the pain of not being able to serve because of the regulations."

Ortega remarked that although he "was applauded for being masculine," he felt compelled to get "top athletic scores," to "excessively work out," and to "overachieve."

Those efforts took a toll emotionally. "You have to exist in a shell of perfection."

Neira expressed "great pride in our military," adding that the organization "has made a lot of progress," but emphasized there is still "a long way to go."

Fear of the ramifications of disclosure continues among transgender troops. Ortega said he knows of some military personnel who "still don't come out of the closet, to this day, because of discrimination."

During a question and answer period, an army psychiatrist said he was concerned about "making this seem like psychopathology" and putting transgender people into a "diagnostic box."

Dr Belkin maintained that to receive transgender-related healthcare, it's important to be given a diagnosis based on the Diagnostic and Statistical Manual (DSM).

The DSM-5 removed the diagnosis of gender identity disorder and defined "gender dysphoria" as a separate category.

According to the APA website, gender dysphoria involves a conflict between a person's physical or assigned gender and the gender with which he/she/they identify.

"People with gender dysphoria may be very uncomfortable with the gender they were assigned, sometimes described as being uncomfortable with their body, particularly developments during puberty or being uncomfortable with the expected roles of their assigned gender."

The speakers have disclosed no relevant financial relationships.

American Psychiatric Association (APA) 2017 Annual Meeting. Symposium, Transpeople in the Military, presented May 21, 2017


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