By Sandra Basu
WASHINGTON—Citing “tremendous medical costs and disruption,” President Donald Trump recently announced that he was reinstating a ban on transgenders in the military.
It was the latest volley in a battle of ideas about the healthcare implications of allowing transgender Americans to serve in the U.S. military.
Trump’s announcement came after a ban on transgenders in the military was lifted on June 30, 2016. As part of that decision, the MHS has been required to provide transgender troops with all medically necessary care related to gender transition as of Oct. 1, 2016.
Under an Aug. 25 executive order, DoD and DHS must halt funding for “sex reassignment surgical procedures for military personnel, except to the extent necessary to protect the health of an individual who has already begun a course of treatment to reassign his or her sex.” This part of the executive order will take effect on March 23, 2018.
When the ban was lifted last year, DoD cited a RAND Corp. study it commissioned as aiding the decision. That study estimated the number of transgender individuals currently serving in the active component of the U.S. military at between 1,320 and 6,630 out of a total of about 1.3 million service members.
The study estimated “that between 30 and 140 new hormone treatments could be initiated a year and 25 to 130 gender transition-related surgeries could be utilized a year among active component service members. Additional health care costs could range between $2.4 million and $8.4 million, representing an approximate 0.13-percent increase.”
“Only a small portion of servicemembers would likely seek gender transition-related medical treatments that would affect their deployability or health care costs,” Agnes Gereben Schaefer, lead author of the study and a senior political scientist at RAND, said in a statement at the time.
In July, the military services were planning to begin accepting transgender members, but, prior to Trump’s announcement, Defense Secretary Jim Mattis approved a recommendation to delay accessing transgender applicants into the military until Jan. 1, 2018, after further review.
In an Aug 29th statement Mattis said that DoD will establish a study and implementation plan in regards to the ban and that in the interim, “current policy with respect to currently serving members will remain in place.”
“Our focus must always be on what is best for the military’s combat effectiveness leading to victory on the battlefield. To that end, I will establish a panel of experts serving within the Departments of Defense and Homeland Security to provide advice and recommendations on the implementation of the president’s direction,” he said.
Trump’s announcement drew criticism from a variety of sectors. For example, American Medical Association President David O. Barbe, MD, said “there is no medically valid reason to exclude transgender individuals from military service.”
“Transgender individuals are serving their country with honor, and they should be allowed to continue doing so,” Barbe said in a statement.
Meanwhile, on Capitol Hill, Rep. Vicky Hartzler (R-MO), who supported Trump’s decision, argued that the “costs incurred by funding transgender surgeries and the required additional care it demands should not be the focus of our military resources.”
Days prior to Trump’s surprise announcement, controversy over whether DoD should pay for transgender surgeries had already been brewing on Capitol Hill because of amendment Hartzler introduced to the 2018 National Defense Authorization Act (NDAA). That amendment would bar DoD funding to be used to provide medical treatment (other than mental health treatment) related to gender transition. The amendment lost in a close House vote of 209 to 214.
“This does not preclude service by the transgendered,” Hartzler said. “This simply says that we are not going to have taxpayers pay for this surgery. This is different than somebody going in and having a cold, because this is a major surgery that requires a medical diagnosis that is going to render someone nondeployable. Just the recovery from the surgery alone is 287 days, and then the ongoing treatment precludes them from certain abilities to serve overseas.”
A supporter, Rep. Duncan Hunter (R-CA) said during a July debate, “We are not saying that transgender people can’t serve, but if you are going to take the big step of serving in the U.S. military, figure out whether you are a man or a woman before you join up,”
Disagreeing with the amendment, Rep. Sean Patrick Maloney (D-NY) said it “would single out and rob a small group of military servicemembers and their families of their healthcare merely because these folks or members of their family experience gender a little differently.”
Another opponent, Rep. Jerrold Nadler (D-NY) argued, meanwhile, that “when a military physician determines that hormones, surgery or other transition related care is necessary, we must treat it as we would any other medical care. “
“Anything less is an abdication of our duty to provide healthcare to those who have chosen to serve our country,” Nadler said.
In response to those arguments, Rep. Scott Perry (R-CA), who supported the amendment, pointed out that “sex reassignment patients also require specialized medicine following the procedure.”“I find that interesting, in the face of the fact that I just had a young gentleman come to my office who wants to serve, but he can’t serve because he has got a peanut allergy. … He can’t go downrange because we can’t have the medicine downrange, and that doesn’t cost the taxpayers anything, but we are going to spend $3.7 billion over the next 10 years on sex reassignment surgery,” Perry said.
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.
When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.