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Transgender military ban prompts discussion on treatment costs, burden
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The decision by President Donald Trump to reinstitute a ban on transgender adults serving in the U.S. military, citing “tremendous medical costs,” has brought criticism from endocrinologists, who are quick to note that any treatment costs related to transgender care are far from excessive.
In a series of Twitter posts July 26, Trump stated that, after consulting with generals and military experts, the government will not “accept or allow” transgender individuals to serve in any capacity in the U.S. military.
“Our military must be focused on decisive and overwhelming victory and cannot be burdened with the tremendous medical costs and disruption that transgender [persons] in the military would entail,” Trump wrote.
In a presidential memorandum issued Aug. 25, Trump directed the military to “return to the longstanding policy and practice on military service by transgender individuals that was in place prior to June 2016,” adding that the Secretary of Defense and the Secretary of Homeland Security extended the deadline to alter any policy to January 2018, while the departments continue to study the issue.
The remarks reverse a policy by the Obama administration, announced in June 2016, that stated that transgender people can serve openly in the military.
The secretary of defense at the time, Ash Carter, said the process would occur in stages. In June, the Trump administration announced that it would delay any decision to allow transgender people to enlist in the military for 6 months, citing a need for more time to evaluate the impact of such a change.
The July 26 announcement of an outright ban caught many experts by surprise. Wylie C. Hembree, MD, a retired professor of medicine with the College of Physicians and Surgeons at Columbia University, who participated in a June panel discussion on transgender military service policy for the New York Bar Association, said the June postponement of a decision was concerning, but most experts ultimately expected that transgender members would be allowed to serve.
“At most, we thought there might be a delay to make sure all the services were consistent in their responses,” Hembree, also chair of the Endocrine Society Transgender Task Force, told Endocrine Today. “So yes, I’m quite surprised.”
Joshua D. Safer, MD, endocrinologist and medical director of the Center for Transgender Surgery and Medicine at Boston Medical Center, called the administration’s decision illogical.
“Providing appropriate medical care for our troops is not really something that ought to be a political decision or conversation,” Safer told Endocrine Today. “Creating an environment that maximizes the largest number of Americans to be able to serve their country doesn’t, to me, sound like a controversial thing.
“The reason for this stated in the tweet — that there is a cost issue — is not true,” Safer said.
‘The numbers are trivial’
Estimates vary on how many transgender individuals currently serve in the U.S. military. According to a 2016 report produced by the RAND National Defense Research Institute, there are an estimated 1,320 to 6,630 active component service members who are transgender out of approximately 1.3 million overall. Of these, only a small subset will seek gender transition-related treatment, according to the report; estimates from survey data and private health insurance claims data indicate that, each year, between 29 and 129 service members in the active component will seek transition-related care that could disrupt their ability to deploy.
In a May article published in JAMA, researchers estimated that nearly 13,000 transgender individuals are currently serving, 200 of whom will seek gender dysphoria-related treatment each year.
“The major treatment for most transgender service members would be hormones, which are among the least expensive medications out there,” Safer said. “For those where surgeries would be indicated at some point, the surgeries are substantially less expensive than most similar surgeries and are done once. And the number of people involved is small.”
The cost of maintaining hormone therapy over time is also small, Hembree said.
“With the exception of [gender reassignment] surgery, which many transgender people appropriately choose to have, there is no reason to think that any of the care that is provided for transgender individuals is excessively costly,” Hembree said. “It simply is not. Any sort of evaluation and follow-up care, whether it is for a young adolescent or someone eligible for joining the armed forces, is simply not expensive at all — and that includes cost for estrogens or androgens.”
To determine the budgetary implications of gender transition-related treatment for military health system health care costs, researchers behind the RAND report used data from the private health insurance system on the cost of extending coverage to the transgender personnel population. The report found that active component military health system costs would increase by between $2.4 million and $8.4 million annually, out of a current budget of approximately $6 billion.
“They came up with costs that were in the millions, but that is still something like 0.04% to 0.1% of the military medical budget,” Safer said. “The numbers are trivial. We’re essentially talking about a rounding error.”
A greater cost
A ban on transgender individuals serving in the military does not eliminate transgender members from the armed forces, according to experts. Instead, these individuals may forgo receiving medical care, including preventive services.
“The cost of not treating is a substantial mental health price and may mean that some of these individuals don’t serve, which is a loss to the overall readiness and strength of our military,” Safer said.
The RAND report, completed before the Obama administration opened the military to transgender individuals, acknowledged that transgender members were already serving.
“Little question remains that there are transgender personnel currently serving in the [active component],” the report stated. “Adverse consequences of not providing transition-related health care to transgender personnel could include avoidance of other necessary health care, such as important preventive services, as well as increased rates of mental and substance use disorders, suicide and reduced productivity.”
In addition, Safer said, the cost to seek out and ban transgender members could ultimately be greater than providing treatment for these individuals.
“We in the medical and scientific world should be baffled by the entire thought process.” Safer said. “Transgender members serving would be disruptive? It would be disruptive to try to weed out these individuals. And it will be more expensive to weed out these individuals than to treat them with the relatively inexpensive therapies that we’re using.”
A long way to go
In a commentary published in JAMA in May, Jamie L. Henry, MD, of Walter Reed National Military Medical Center in Bethesda, Maryland, recalled the “isolation, shame and fear” she felt while serving as a transgender soldier in the U.S. Army during a time when openness about gender identity could mean discharge from the military.
That all changed, she wrote, in 2016, but much work still needs to be done.
“Although the situation has improved markedly, there is still a long way to go,” Henry wrote. “We need better protocols for individuals who wish to transition while active duty, for retirees, and their family members. We need to aid them in preserving their fertility, and we need to foster an environment of openness where no soldier feels like he or she is isolated from fellow service members owing to gender identity.”
In June 2015, the American Medical Association passed a resolution affirming that there is no medically valid reason that transgender individuals cannot serve in the military. Henry’s hope, she wrote, was that more clinicians will receive proper training to care for transgender military patients.
“Although I completed my medical training as a male, today I serve as a female physician in every respect within the Department of Defense,” Henry wrote. “Last month, I graduated the Army Medical Department’s Advanced Course with honors, and now I look forward to the second half of my military career being treated like any other capable military physician. My hope is that, over time, all clinicians gain comfort and skill in treating transgender persons.” – by Regina Schaffer
- References:
- Presidential memorandum for the Secretary of Defense and the Secretary of Homeland Security. August 25, 2017. Available at: www.whitehouse.gov/the-press-office/2017/08/25/presidential-memorandum-secretary-defense-and-secretary-homeland. Accessed Aug. 28, 2017.
- RAND Corporation. Assessing the implications of allowing transgender personnel to serve openly. Available at: www.rand.org/pubs/research_ reports/RR1530.html. Accessed July 26, 2017.
- Schvey NA, et al. JAMA Intern Med. 2017;doi:10.1001/jamainternmed.2017.0136.
- For more information:
- Wylie Hembree, MD, can be reached at wch2@columbia.edu.
- Joshua D. Safer, MD, can be reached at the BMC Center for Transgender Medicine and Surgery, 1 Boston Medical Center Place Boston, MA 02118; email: jsafer@bu.edu.
Disclosures: Hembree, Henry and Safer report no relevant financial disclosures.