On the issue of transgenders in the military, President Donald J. Trump and Defense Secretary James Mattis have done the right thing, for the right reasons.  Together they have seized the high ground, but now they will have to fight in the federal courts to keep it.

On February 22, 2018, Secretary Mattis submitted recommendations on the eligibility of persons who identify as transgender to serve in uniform.  Mattis’ 3-page Memorandum promotes sound priorities: mission readiness and combat lethality.  “[P]ersonal characteristics, including age, mental acuity, and physical fitness – among others – matter to field a lethal and ready force.”:

Mattis Memorandum for the President: Military Service by Transgender Individuals

Secretary Mattis also submitted a 44-page report, produced by a panel of military and medical experts, which cited Department of Defense (DoD) data documenting high health care costs and other issues affecting morale, cohesion, and readiness to deploy worldwide on short notice:

DoD Report and Recommendations on Military Service by Transgender Persons

Following recommendations from the Secretaries of Defense and Homeland Security (representing the Coast Guard), President Trump endorsed the new policy on March 23:

Memorandum to Secretary of Defense and Secretary of Homeland Security

Trump Transgender Policy Promotes Military Readiness, Not Political Correctness

The Mattis memo and DoD report proposed a nuanced approach that would a) Allow persons identifying as “transgender” but without gender dysphoria to serve in their biological gender, if they have been “stable” for 36 months and meet requirements for deployability; b) Disqualify persons with gender dysphoria from military service; and c) Retain “grandfathered” personnel identifying as transgender and receiving treatment under previous administration policies.

Some issues remain unresolved, but the clear departure from policies imposed by the Obama Administration marks a major step toward ending political correctness in the military.

Policy Based on Fitness for Combat

The Mattis/DoD report (page numbers noted throughout) states, “Fitness for combat must be the metric against which all standards and requirements are judged.  To give all Service members the best chance of success and survival in war, the Department must maintain the highest possible standards of physical and mental health and readiness across the force.”  (p. 2)

The Mattis/DoD report notes that time-consuming sex-change “transition” mandates had been imposed despite “the considerable scientific uncertainty and overall lack of high quality scientific evidence” that hormone treatments and “sex reassignment” surgery work to remedy psychological problems associated with gender dysphoria. (p. 5)

DoD Discredits 2016 RAND Report Cost Estimates

Many media reports have quoted the 2016 RAND report as if it were a definitive source of information on this issue.  But Secretary Mattis criticized "significant shortcomings" in the RAND report, which the Obama Defense Department paid for, because it relied upon “limited and heavily caveated data that glossed over the impacts of healthcare costs, readiness, and unit cohesion."

The DoD panel of experts noted, “Because of the RAND report’s macro focus . . . it failed to analyze the impact at the micro level of allowing gender transition by individuals with gender dysphoria . . .[T]he report did not examine the potential impact on unit readiness, perceptions of fairness and equity, personnel safety, and reasonable expectations of privacy at the unit and sub-unit levels, all of which are critical to unit cohesion.”  (p. 14)  

"Nor did the report meaningfully address the significant mental health problems that accompany gender dysphoria -- from high rates of comorbidities and psychiatric hospitalizations to high rates of suicide ideation and suicidality -- and the scope of the scientific uncertainty regarding whether gender transition treatment fully remedies those problems." (p. 14)

In addition, RAND is faulted for selective and misleading interpreting the experiences of Australia, Canada, Israel, and the United Kingdom with transgenders in their militaries, and for failing to note distinctions between foreign forces and the American military.  (p. 38-39)

In 2016 RAND admitted there would be an “adverse impact on health care utilization and costs, readiness, and unit cohesion,” but failed to support their claim that transition-related health care costs would be “negligible” and “marginal,” increasing “only between $2.4 million and $8.4 million annually.” 

The DoD Panel of Experts cited data and information from the Military Health System Data Repository, based on actual DoD experience between Oct 2015 and July 2017.  This data contradicts estimates and projections in the RAND report, which the Obama Administration relied upon in changing the policy in July 2016:

RAND had estimated that there were between 2,150 to 10,790 transgender personnel, and their loss would cause a readiness crisis.  The Mattis/DoD report reveals that 937 active-duty service members have been diagnosed with gender dysphoria since June 30, 2016. (p. 7, Footnote #10)

In the same Footnote #10, the Mattis/DoD report suggests that there might be 8,980 servicemembers claiming to be transgender.  This apparently precise number is only an estimate, however.  The number was extrapolated from the 1% of respondents to an anonymous, self-reported online survey, not an actual head count.

• From October I, 2015, to October 3, 2017, 994 active duty Service members diagnosed with gender dysphoria accounted for 30,000 mental health visits. (p. 22)

• Since implementation of the Carter policy, the medical costs for Service members with gender dysphoria have increased nearly three times -- or 300%.  (p. 41)

• “[C]urrently available in-service data already show that, cumulatively, transitioning Service members in the Army and Air Force have averaged 167 and 159 days of limited duty, respectively, over a one-year period. (p. 33)

• “Endocrine Society guidelines for cross-sex hormone therapy recommend quarterly blood work and laboratory monitoring of hormone levels during the first year of treatment.  Of the 424 approved Service member treatment plans available for study, almost all of them – 91.5% – include the prescription of cross-sex hormones. (p. 33)

RAND claimed that negative effects on readiness would be minimal because of the small number of transgender servicemembers who would seek transition-related treatment.  But the Mattis/DoD report, focusing on military effectiveness and combat lethality, found that disqualifying conditions such as bipolar disorder or schizophrenia also involve relatively small numbers.  “And yet, that is no reason to allow persons with those conditions to serve.” (p. 35)

Lost Time and Non-Deployability

The Mattis/DoD Report provided even more information about significant losses of time associated with transgender treatments. 

• Recovery times for genital surgeries range between six weeks and three months. “When combined with 12 continuous months of hormone therapy . . . prior to genital surgery, the total time necessary for surgical transition can exceed a year. (p. 23)

• Even RAND admitted that 6% to 20% of those receiving [male-to-female] genital surgeries experience complications and long-term disability, and as many as 25% (one in four) of those receiving [female to male] surgeries will have complications. (pp. 23-24)

• “Transition-related treatment that involves cross-sex hormone therapy or sex reassignment surgery could render Service members with gender dysphoria non-deployable for a significant period of time – perhaps even a year – if the theater of operations cannot support the treatment.” (p. 33)

• Some commanders reported that it has been necessary to divert operational and maintenance funds to pay for currently-serving transgender servicemembers' extensive travel throughout the United States to obtain specialized medical care. (p. 41)

None of the above costs in terms of time and money improve military readiness in any way.

The Science Surrounding Transgender Treatments Is Not Settled

Findings in the Mattis/DoD report suggest that the high human and operational costs associated with treatments may not be helpful to people with psychological problems and gender dysphoria.  The Centers for Medicare and Medicaid Services (CMS) recently conducted a comprehensive review of over 500 articles. studies, and reports, to determine if there was ‘sufficient evidence to conclude that gender reassignment surgery improves health outcomes for Medicare beneficiaries with gender dysphoria . . .’ “ (p. 24)

• “‘Overall,’ according to CMS, ‘the quality and strength of evidence were low due to mostly observational study designs with no comparison groups, subjective endpoints . . . small sample sizes, lack of validated assessment tools, and a considerable [number of study subjects] lost to follow-up.’”  (p. 24)

• “ . . . CMS concluded that there was ‘not enough high quality evidence to determine whether gender reassignment surgery improves health outcomes for Medicare beneficiaries with gender dysphoria’ “  (p. 24)

• Even the 2016 RAND report conceded the lack of evidence that treatments are effective:  “ ’In the absence of quality randomized trial evidence,’ RAND concluded, '’it is difficult to fully assess the outcomes of treatment for [gender dysphoria].’ "  (pp. 26-27)

One of the few credible longitudinal studies, done in Sweden, followed transgender patients who had undergone sex reassignment surgery for more than ten years, comparing them to a healthy control group.  The Centers for Medicare and Medicaid Services reported:  ''The [Sweden study] mortality was primarily due to completed suicides (19.1-fold greater than in the control group) . . .  We note, mortality from this patient population did not become apparent until after 10 years.”  (p. 25)

The following facts demonstrate why people who are gender-confused deserve compassion and competent, reality-based mental health care, not politicized health care that pushes psychologically troubled adults and sometimes children to proceed only in the direction of sex-change hormones and/or surgeries.

• “Transgender persons with gender dysphoria suffer from high rates of mental health conditions such as anxiety, depression, and substance use disorders.  High rates of suicide ideation, attempts, and completion among people who are transgender are also well documented in the medical literature, with lifetime rates of suicide attempts reported to be as high as 41 % (compared to 4.6% for the general population).”  (p. 21)

•  “A review of the administrative data indicates that Service members with gender dysphoria are eight times more likely to attempt suicide than Service members as a whole (12% versus 1.5%). (p. 21)

• Furthermore, “Service members with gender dysphoria are also nine times more likely to have mental health encounters than the Service member population as a whole.  (28.l average encounters versus 2.7 average encounters per Service member) (p. 22)

• None of the prevailing remedies for gender dysphoria “account for the added stress of military life, deployments, and combat.” (p. 24)

• The Mattis/DoD report warns, “Given the scientific uncertainty surrounding the efficacy of transition-related treatments for gender dysphoria, it is imperative that the Department proceed cautiously in setting accession and retention standards for persons with a diagnosis or history of gender dysphoria.” (p. 27)

People who are struggling with their gender identity deserve compassionate health care from a concerned and competent health care professional willing to look at all the treatment modalities and help the individual select the best course.  In many cases irreversible hormone therapy and/or surgeries do not solve underlying problems, but do cause irreversible harm and a lifetime of regret.

Placing the scientific unknowns surrounding treatment of gender dysphoria in the life and death struggle on the battlefield does not promote military effectiveness and combat lethality, the goal of all military personnel policies.

Personal Privacy & Morale

Obama-era mandates regarding transgenders reflect unscientific beliefs that changes in physical appearance and bureaucratic “gender markers” can change men into women, and women into men.  Under Obama-era mandates, women objecting to biological men in their private facilities and showers essentially were told to just “get used to it.”  The Defense Health Agency warns of the consequences of privacy violations in gender-separate military facilities:

• “[O]f the 424 approved Service member treatment plans available for study, 388 included cross-sex hormone treatment, but only 34 non-genital sex reassignment surgeries and one genital surgery have been completed thus far.  Only 22 Service members have requested a waiver for a genital sex reassignment surgery.” (p. 31)

• “Low rates of full sex reassignment surgery and the otherwise wide variation of transition-related treatment . . .  weigh in favor of maintaining a bright line based on biological sex – not gender identity.” (p. 31)

• “[A] biological male who identifies as female could remain a biological male in every respect and still be governed by female standards. Not only would this result in perceived unfairness by biological males who identify as male, it would also result in perceived unfairness by biological females who identify as female.” (p. 36)

• Citing the International Olympic Committee, the report endorses separate standards in sports competitions organized around gender-specific standards.  “Biological females who may be required to compete against such transgender females in training and athletic competition would potentially be disadvantaged.” (p. 29, FN #110, and p. 36)

• The report also endorses uniform and grooming standards that “flow from longstanding societal expectations regarding differences in attire and grooming for men and women.”  (p. 30)

The Department of Defense concluded that even negligible harms should not be incurred, “given the Department's grave responsibility to fight and win the Nation's wars in a manner that maximizes . . . effectiveness, lethality, and survivability of our most precious assets – our Soldiers, Sailors, Airmen, Marines, and Coast Guardsmen.” 

The Mattis/DoD report concludes, “[T]he Department’s professional military judgment is that the risks associated with maintaining the [previous] Carter policy – risks that are continuing to be better understood as new data become available – counsel in favor of the recommended approach.”  (p. 44)

CMR POLICY ANALYSIS

President Trump and Secretary Mattis have taken carefully considered steps to formulate rational policies that will strengthen our military, but several unresolved issues should be clarified, in pursuit of that objective.

1.  The Need to Defend Sound Policies in Court:  Transgender activists have filed lawsuits against President Trump, accusing him of announcing policy changes without military support, even though AP reported in June 2017 that three of the four military service chiefs wanted 1-2 more years to study the issue.  In his April 12, 2018, House Armed Services Committee testimony, Secretary Mattis confirmed that he delayed full implementation of Obama-era policies for six months and began a study of the issue because the service chiefs were concerned about problems with the policy.  This occurred well before President Trump’s July tweets and August 2017 Memorandum.

Nevertheless, four federal district judges have issued orders trying to deny to President Trump Executive powers to revoke policies imposed by his predecessor.  Since lower courts have so far refused to recognize the rational basis behind Secretary Mattis’ recommendations and President Trump’s policy decisions, the Department of Justice should petition the U.S. Supreme Court for intervention and prepare to present what will be a persuasive and successful case. 

2,  Conditional Contracts:  The ultimate outcome of Justice Department appeals challenging district court orders, which the Supreme Court likely will consider, cannot be predicted with certainty.  In fairness, enlistment and re-enlistment contracts issued under current court orders should inform persons identifying as transgender that their contracts are subject to cancellation, should the government prevail in litigation. 
 
3.  Principles and Premises:  The first paragraph in the DoD/Mattis report refers to a “bedrock principle” and a “fundamental premise” that “any eligible individual who can meet the high standards for military service without special accommodations should be permitted to serve.”  (p. 2) The statement sounds harmless, but clarification is needed to avoid misinterpretations that could be misused to nullify military priorities that are otherwise consistent throughout the report. 
 
4.  Application of Disciplinary Rules:  The new rules say that a non-dysphoric person who identifies as transgender can serve if he/she conforms to standards of their biological gender and meets deployability requirements.  This appears to rule out Obama-era options to take time off for real life experience (RLE), living as a person of the opposite sex for 3 to 12 months prior to transgender treatments or surgeries.  It is not clear, however, whether persons who identify as transgender will be subject to disciplinary rules around the clock, 24/7, on-base and off-base.  There is a need for clarification in regulations, which should specify that designated standards apply at all times that individuals remain in the service. 

5.  Will other sexual minorities also be eligible to serve?  Footnote #10 on page 7 of the Mattis/DoD report refers to several sexual minorities, some of which are represented with the acronym “LGBTQQIAPP+.  Because use of the “umbrella” term “transgender” could be interpreted to include other gender nonconforming people, the DoD should enact disciplinary rules that apply to all individuals, including those who want to identify themselves as something other than their biological sex. 

The military, which is not just another equal opportunity employer, defends individual rights of free expression, but it must be governed by different rules.  To avoid misunderstandings, the Department of Defense should clarify acceptable behavior for all servicemembers, discontinue annual events celebrating LGBT Pride month in June, and drop time-consuming training programs that promote Obama-era policies discredited by the Mattis/DoD report.

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The full 29-page CMR Special Report titled Trump Transgender Policy Promotes Military Readiness, Not Political Correctness which includes more detailed information, can be downloaded at https://cmrlink.org/data/sites/85/CMRDocuments/CMRSR_TrumpTransgenderPolicyReport-041518A.pdf.  The Center for Military Readiness is an independent, non-partisan, 501(c)(3) public policy organization, founded in 1993, which reports on and analyzes military/social issues.  More information is available on the CMR website, www.cmrlink.org. 

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