Military ban will risk the health and well-being of transgender Americans

As physicians who collectively care for thousands of transgender children, adolescents and adults in Philadelphia, we are deeply troubled by the president’s new policy that bans transgender Americans from joining the military and immediately stops gender-affirming medical care for those in active duty.

The reasoning for such a policy outlined earlier by the president — that the military “cannot be burdened with the tremendous medical costs and disruption that transgender in the military would entail” — is not supported by scientific evidence or by our experiences with transgender patients.

{mosads}This reasoning implies that care to support transgender individuals’ medical transition is necessarily invasive and expensive. In fact, for our patients, the most common interventions include supporting social transition and prescribing hormones, like estrogen or testosterone, which cost less than $50 per month.

Despite higher costs for procedures like gender reassignment surgery, which only a minority of transgender individuals undergo, a report by the RAND corporation and a recent study published in the New England Journal of Medicine confirm that the overall cost to the military to care for transgender soldiers would be negligible. 

Actually, most gender-affirming treatment for transgender individuals will in the end save the health care system money. A report by PolicyLab at Children’s Hospital of Philadelphia (CHOP) details how treatments like puberty blockers and mental health support services for transgender children and adolescents can actually prevent the need for some expensive procedures later in life.

These treatments also lead to better health outcomes as adults by shielding patients from the high costs of mental health conditions or substance abuse that might result from untreated gender dysphoria. Further restricting such treatments as the ban proposes could have unintended consequences.

As stated in our recent qualitative studies published in Journal of Adolescent Health and Transgender Health, we found that many young transgender women described lack of access to gender-affirming hormone therapy as a barrier to receiving other essential preventive and cost-saving care, such as mental health support or HIV Pre-exposure Prophylaxis,a daily pill to prevent HIV infection.

Transgender women are at nearly 50 times the risk for HIV infection compared to the average person.

Beyond this flawed over estimation of health care costs, and underestimation of potential savings, any message of “you are not welcome here” can cause major harm to the mental and physical well-being of transgender individuals, which make up one percent of the U.S. population. Transgender people have high rates of depression and anxiety, and as many of 40 percent have attempted suicide. These and other physical health problems are not due to their identity, but rather a result of shame, stigma and isolation when one’s identity is not affirmed.  

When caring for transgender children and adolescents, we talk to them about what they want to be when they grow up. They have the same hopes and dreams as other kids.

Take, for example, one 18-year-old patient who during his first visit to the CHOP Gender and Sexuality Development Clinic disclosed that despite being born assigned female sex at birth, he knew he was a boy since age four. At that young age, he had begun walking around with his shirt off because he felt he was a boy like his dad and couldn’t understand why he was being told to put it back on. He also said that he has always wanted to serve our country in the military, just like his father.

But, we can’t only be concerned for those who have hopes of serving their country; if enacted, this directive could have particularly grave consequences for the thousands of transgender individuals already serving in the military.

The current U.S. Department of Defense policy states that transgender individuals can serve openly and cannot be discharged solely on the basis of being transgender.

This policy helped a patient, who we are calling Sarah, at Philadelphia’s Mazzoni Center transition socially and medically while continuing to serve in the military. She was able to start hormones safely under medical supervision, and she had the full support of her fellow service members and her commanding officer. Without this policy, Sarah would have been forced to decide between her duty to her country and hiding her true self.

The policy also allowed a patient, here referred to as Michelle, at the University of Pennsylvania Health System begin to affirm her female gender via hormone therapy while actively serving her country. Michelle was able to seek civilian medical care for gender affirmation in collaboration with her base physicians and supervising officers. Though she enlisted as male, Michelle said that the reception to her transgender identity on the base was overwhelmingly positive, especially among her peers. She considers her status as a member of the U.S. military as integral to her identity as her gender, and has always hoped it would be her lifelong career.   

Clearly this policy does not align with the real stories that we, as physicians, confront every day when we talk to patients for whom this is a deeply personal matter. Even if you disregard stories like our patients’, there is no evidence to support the idea that allowing transgender individuals to serve in our military would burden us with medical costs, and there could be major negative effects to health and well-being of those currently serving if gender-affirming medical care is restricted. Our patients, and any transgender individuals, who wish to bravely serve their country should continue to be able to do so.

Nadia Dowshen, MD, MSHP is a pediatrician and adolescent medicine specialist who is co-founder of the Children’s Hospital of Philadelphia Gender (CHOP) and Sexuality Development Clinic, a faculty member at PolicyLab at CHOP and assistant professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania.

Allison Myers, MD, MPH is a family medicine physician and clinical assistant professor of family medicine and community health at the University of Pennsylvania where she specializes in the care of LGBTQ patients.

Lin-Fan Wang, MD, MPH is a family medicine physician at Mazzoni Center Family & Community Medicine, which provides comprehensive health care with a primary focus on the needs of lesbian, gay, bisexual, and transgender individuals.

The views expressed by contributors are their own and are not the views of The Hill.