Outrage, Protests Follow Trump Ban on Transgender Troops

Deborah Brauser

July 27, 2017

UPDATED WITH ADDITIONAL COMMENTS July 28, 2017 // President Donald Trump's announcement via Twitter that transgender individuals will not be allowed to serve in the United Stated military "in any capacity" has led to public protests in several major cities and a groundswell of outrage among medical experts and members of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community.

Dr Jack Drescher

Although Trump cited medical cost and "disruption" as reasons for the ban, Jack Drescher, MD, consultant to the Council on Communication for the American Psychiatric Association (APA) and clinical professor of psychiatry at Columbia University, New York City, told Medscape Medical News the announcement makes little sense – especially since the commander in chief previously presented himself an LGBTQ ally.

"The news is incredibly disappointing, especially because transgender people are a very vulnerable group in many ways. And to try to scapegoat them and try to go after them is really upsetting," said Dr Drescher, who is also a past chair of the APA's Committee on LGBT Issues.

"This isn't what an ally does," he said.

Washington, DC, transgender protest. (Source: Jacquelyn Martin/AP)

In an official statement, the APA said it "stands firmly" against discrimination against anyone and that this ban "unfairly casts a pall over all transgender Americans." In a tweet posted soon after the ban was announced, the association included a link to its 2012 position statement on discrimination in this population, written by a group of experts led by Dr Drescher.

"President Trump's actions are at odds with the APA's official positions," he said, adding that it is disheartening that an article written 5 years ago still needs to be referenced. "It feels like two steps forward, one step back. Hopefully it won't be two steps back."

"No Evidence"

The president of the American Psychological Association said in a statement that his organization also "questions the reasoning" behind the call to prohibit this population from military service.

"We've seen no scientific evidence that allowing transgender people to serve in the armed forces has had an adverse impact on our military readiness or unit cohesion," said Antonio E. Puente, PhD, in the statement.

"Therefore, we ask that transgender individuals continue to be allowed to serve their country," he added.

We've seen no scientific evidence that allowing transgender people to serve in the armed forces has had an adverse impact on our military readiness or unit cohesion. Therefore, we ask that transgender individuals continue to be allowed to serve their country. Dr Antonio Puente

The American Medical Association (AMA) agrees, noting in a press release that "there is no medically valid reason" to prevent this population from serving.

"Banning transgender service members from serving our country harms...those who have dedicated themselves to service to others," said APA President-elect, Altha Stewart, MD, adding that "discrimination has a negative impact on the mental health of those targeted."

Magda Houlberg, MD, chief clinical officer at Howard Brown Health, Chicago, Illinois, which describes itself as one of the nation's largest LGBTQ organizations, told Medscape Medical News their position is that "this isn't really about cost-savings, it's about excluding people."

Dr Magda Houlberg

Yesterday's news "was upsetting to patients," said Dr Houlberg. "We know that there's no real financial concern there. A lot of the evidence would prove that the military spends quite a bit more on treatment of other conditions, such as erectile dysfunction."

She added that "trans people are already serving in the military" and that they have been for some time. "And there's no evidence that that has been troublesome or complicated for the military to operationalize."

Not a Mental Disorder

The continuing firestorm, especially on social media, shows there is a lot of confusion about transgender issues, with some people asking if transgender persons are still considered to have a mental disorder.

For the fifth edition of the APA's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in 2013, the term "gender identity disorder" was removed from the listings of disorders and a chapter on "gender dysphoria" was added.

The term "gender dysphoria" does not refer to a pathologic condition but rather to "the distress that may accompany the incongruence between one's experienced or expressed gender and one's assigned gender," states the manual.

Although there has been some controversy over whether the presence of the term "gender dysphoria" in the DSM-5 creates prejudice, Dr Drescher noted that the new condition was included in order that a diagnosis code could be assigned.

"We felt that the issue of stigma, although important, was secondary to the issue of access to care," said Dr Drescher.

However, "transgender people do not have a mental disorder; thus, they suffer no impairment whatsoever in their judgment or ability to work," stressed the APA in its statement.

Dr Drescher is also a member of a committee of the World Health Organization (WHO) that is developing the 11th Revision of the International Classification of Diseases (ICD-11), which is expected to be published in 2018.

"Our committee's recommendation is that you can solve the problem of both stigma and access to care in the ICD by moving it out of the mental disorder section and into another section, which I think will probably happen," he said.

In other words, "the WHO is preparing to officially take this out of the list of mental disorders next year."

Need for More, Better Medical Education

There are about 1.4 million transgender individuals in the United States, according to a 2016 report by the Williams Institute.

However, as reported previously by Medscape Medical News, many clinicians have a lack of understanding about, and some have a bias against treating, transgender individuals, including college students.

"I think it's always hard to educate physicians and other healthcare professionals on the specific concerns of small minority groups. It's often treated as add-ons to curriculum," said Dr Drescher.

Dr Houlberg stressed that it should be a priority "to incorporate education about gender identity into our general medical training programs so clinicians are prepared. We need to make that an expectation of training."

She added that "the medical skills it takes to treat these patients are really no different than any other primary care activity. Many of the medications we use in transgender care are the same for common conditions that medical providers treat every day."

That said, Dr Drescher recommended that clinicians who are uncomfortable in their knowledge of how to treat a transgender patient receive expert consultation or that they refer the patient to an expert in the field. He also noted that the peer-reviewed journal Transgender Health began publishing in 2016.

"It's important to realize not all transgender people are the same; not everyone wants hormones or surgery. Different people have different needs in terms of their clinical presentation."

In addition, he noted that many people probably wouldn't seek to undergo surgery while serving in the military. "They may just want to simply be able to present themselves in the gender they feel themselves to be."

"Let's Meet Face to Face"

According to a report released by the RAND Corporation in 2016, there are approximately 2450 transgender personnel on active duty in the armed forces.

Last year, President Barack Obama announced that these individuals could, for the first time, serve openly in the military. But recent debates have been waged over payments for gender transition and other medical treatment.

In his tweets, President Trump said the US military "cannot be burdened with the tremendous medical costs and disruption that transgender in the military would entail."

However, the RAND report estimates that only "between 29 and 129" of the active duty service members will seek transition-related care. And there would be an annual increase of just 0.04% to 0.13% to provide healthcare coverage for this population, the report adds.

David O. Barbe, MD, president of the AMA, noted in a statement that the organization's policy is to support public and private health insurance coverage for treatment of gender dysphoria, as recommend by the patient's physician.

"According to the RAND study, the financial cost is a rounding error in the defense budget and should not be used as an excuse to deny patriotic Americans an opportunity to serve their country. We should be honoring their service, not trying to end it," said Dr Barbe.

As for being a disruption, former Navy SEAL Team 6 member and transgender advocate Kristin Beck, in responding to the tweets in an interview with the Business Insider, said that being transgender shouldn't matter.

Let's meet face to face and you tell me I'm not worthy. Kristin Beck

Born Christopher Beck, the decorated veteran received a Purple Heart and the Bronze Star while serving on combat missions. She wrote about her experiences in the Navy and about coming out as Kristin upon retirement in the book Warrior Princess. "Let's meet face to face and you tell me I'm not worthy," said Beck in a message to Trump.

Other transgender US military veterans have spoken out fervently against the ban, especially on Twitter, using the hashtag #transban. Carla Lewis, a veteran of the US Air Force Space Command, wrote in an editorial for the Huffington Post, "I'm a trans veteran and I fought for your right to hate me."

Medical organizations and politicians continue to weigh in with their opinions.

Wendy Armstrong, MD, chair of the HIV Medicine Association, said in a statement that her organization "decries" the military ban and firmly opposes any laws that discriminate against the LGBTQ community.

"Stigma and discrimination too frequently drive transgender persons away from engaging in healthcare and too often contribute to late diagnoses, poor outcomes, and often higher healthcare costs for a number of health conditions, including HIV infection," said Dr Armstrong.

"We strongly urge the Administration to reconsider this regressive stance and any future policy changes that abandon protections based on gender identify that will only serve to divide and weaken us as a country and will seriously undermine our nation's public health."

Silver Lining?

Senator John McCain (R-Ariz), chairman of the Senate Armed Services Committee, also released a statement noting that President Trump's message was "unclear" and confusing.

"The President's tweet...regarding transgender Americans in the military is yet another example of why major policy announcements should not be made via Twitter," said Senator McCain.

He added that there are many transgender individuals already "serving honorably" and that they should be allowed to continue doing so. "There is no reason to force service members who are able to fight, train, and deploy to leave the military – regardless of their gender identity."

Senator McCain noted that the Department of Defense is currently conducting a study regarding transgender personnel, possible medical obligations, and the possible impact of transgender personnel on military readiness.

"I do not believe that any new policy decision is appropriate until that study is complete and thoroughly reviewed by the Secretary of Defense, our military leadership, and the Congress."

APA CEO and Medical Director Saul Levin, MD, noted that the organization is heartened by recent announcements.

"We are encouraged by Joints Chiefs of Staff Chairman Joseph Dumford's statement that there are no modifications to the current policy, and we call upon Defense Secretary Mattis to allow transgender service members to continue to serve," said Dr Levin.

These are individuals who are willing to give their lives for our country. To exclude them on the basis of their gender identity is very concerning, and it represents the sanctioning of discrimination. Dr Magda Houlberg

"These are individuals who are willing to give their lives for our country. They're giving the thing that's most precious to them in service to others," said Dr Houlberg. "To exclude them on the basis of their gender identity is very concerning, and it represents the sanctioning of discrimination."

Interestingly, Dr Drescher said there may be a bit of a silver lining in all of this, noting that it has created opportunities "to educate people, not just those who make decisions but also the general public.

"Perhaps we can make lemonade out of the lemons," he concluded.

Follow Deborah Brauser on Twitter: @MedscapeDeb . For more Medscape Psychiatry news, join us on Twitter and Facebook.

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