Years after the repeal of “don’t ask, don’t tell”: how are we protecting transgender individuals in the military?

Research continues to show that transgender individuals face worse mental health outcomes than their cisgender counterparts, including higher rates of suicide attempts and serious psychological distress. Gender-affirming care (i.e. social, psychological, behavioral, and medical interventions designed to support and affirm an individual’s gender identity) has been shown to improve mental health outcomes and reduced anxiety and depression symptoms.

Veterans and active-duty service members are also known to experience worse mental health outcomes compared to non-veterans and civilians, including higher rates of completed suicide and increased prevalence of PTSD. Transgender veterans and service members therefore experience compounded risks as well as face additional stigma and prejudice. Active-duty service members who identified as transgender comprised 0.6% of the military population in 2015, proportionate to the number of transgender individuals in the civilian population.

LGBTQ+ individuals have long experienced discrimination and unfair treatment in the military. Gay men were banned from military service until 1993 when the “Don’t Ask, Don’t Tell” policy was first introduced. While gay service members were technically permitted to serve under this policy, the overall anti-LGBTQ+ sentiment persisted in military culture and forced LGB service members to hide their sexual identity. The “Don’t Ask, Don’t Tell” policy was eventually repealed in 2010, and LGB individuals could serve openly in the military without fear of discharge based on their sexual identity.

The discrimination that transgender individuals faced, though, has been particularly insidious. Identifying as transgender was previously classified as a mental health disorder that disqualified an individual from military service. This medical disqualification was lifted in 2016, but this decision was reversed promptly in 2018.

It was not until 2021 that transgender individuals were allowed to openly join the military again and could not be denied reenlistment or discharged based on their gender identity. The Veterans Health Administration also established an LGBTQ+ health program to provide inclusive and affirming care and work towards improving the health of LGBTQ+ veterans.

Despite these policy changes in recent years, there is still much work to be done to ensure the equality of transgender individuals in the military.

Armed with this knowledge in combination with the extensive history of discrimination that this population has faced, our country must improve the systems in place to ensure better mental health outcomes in the future by routinely providing gender-affirming care, administering early mental health screenings, and educating healthcare providers. The VA currently offers medical gender-affirming care, including hormone therapy, but does not provide gender-affirming surgical procedures to transgender veterans. In 2021, a rulemaking process was initiated to expand coverage to include gender-affirming surgery, but this change has not yet been incorporated two years later. It is vital to offer comprehensive gender-affirming care to transgender veterans, including both medical and surgical interventions to improve health outcomes.

By Dr. Kerry B. O’Leary, psychiatry resident PGY4, psychiatry and behavioral sciences – education, Baylor College of Medicine

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