Defense Secretary Jim Mattis is misrepresenting the effectiveness of healthcare treatment for transgender people as a justification for a new policy that would bar many from serving in the military, two leading associations of psychiatrists and psychologists say.
The Pentagon’s claim that the scientific evidence is at best “unclear” for treatment of gender dysphoria, the condition of being unhappy in your current gender, and that treatment may not relieve serious risks such as suicide is not the current medical consensus, according to the American Psychiatric Association and American Psychological Association.
“That’s really not true and it’s certainly not true among the actual experts who treat these people,” said Dr. Jack Drescher, a psychiatrist and psychoanalyst who is a distinguished fellow at the American Psychiatric Association. “We shouldn’t assume just because somebody has a psychiatric diagnosis that they are not able to function and there is no reason to believe, based on what we know of people who have gotten treatment for their gender dysphoria, that they are any different.
“If people get treatment for their gender dysphoria, then they are doing fine,” he said.
Mattis announced plans last month to bar anyone diagnosed with gender dysphoria and anyone who has undergone treatment such as hormone therapy or surgery from enlisting in the military. Troops who are diagnosed while serving would be able to stay as long as they do not require treatment.
The secretary’s 44-page review and recommendations use data from various outside research studies to make the case that people diagnosed with gender dysphoria suffer from high rates of suicide, anxiety, depression, and substance abuse and that treatment such as hormone therapy and surgery have not been proven to relieve those issues.
“While there are numerous studies of varying quality showing that this treatment can improve health outcomes for individuals with gender dysphoria, the available scientific evidence on the extent to which such treatments fully remedy all of the issues associated with gender dysphoria is unclear,” Mattis’ study concludes.
Mattis also cited other key concerns in his rationale for rolling back the Obama administration’s two-year-old policy of open service, such as the amount of time gender dysphoria treatment can sideline troops and the difficulty of integrating transgender people into military units.
The proposed policy, which remains on hold due to four federal lawsuits, came after President Trump declared last year that transgender troops would no longer be able to serve “in any capacity” because of costs of treatment and disruption. Mattis convened an expert Pentagon panel to study the issue and spent three months crafting the new policy recommendations.
In his only public comment on the proposal, Mattis said the recommendations “stand on their own right now” and declined to say more because of the lawsuits by active-duty transgender troops and rights groups. Dana White, the chief Pentagon spokesman, deflected reporters’ questions multiple times during a weekly briefing and said “to safeguard the integrity of the court process, I am unable to provide any further details at this time.”
‘Spinning out a story’
The two associations denounced the Pentagon plan as discriminatory last month. The American Psychological Association said it was “alarmed by the administration’s misuse of psychological science” as a basis to bar transgender service.
“We don’t really have the kind of population-level studies that would allow for rock-solid conclusions. But the studies we do have indicate that there is a way to treat gender dysphoria that it is effective and safe,” said Clinton Anderson, the director of the Office on Sexual Orientation and Gender Diversity at the American Psychological Association. “It’s not absolutely 100 percent, but then there are few medical treatments that are.”
Anderson said the Pentagon appears to have made up its mind about a new policy to exclude transgender people and then selectively used existing research data to back up that decision.
“It’s hard to see how they got to the conclusion they got to except by basically already prejudicially knowing the conclusion they wanted to reach and just spinning out a story to support and justify that conclusion,” Anderson said.
Mattis review leaves out context
The panel put together by Mattis and its 44-page review acknowledge “serious differences of opinion on this issue, even among military professionals,” but at times downplays or omits context from the variety of recent transgender studies it cites.
It partly based its conclusion that the effectiveness of gender reassignment surgery is “unclear” on a Medicare coverage review in 2016. Such treatment can include a range of surgeries, such as cosmetic changes or reconstruction of the genitals.
The Centers for Medicare and Medicaid Services reviewed existing research to see whether a nationwide ruling on such treatment coverage was warranted for the government healthcare program for seniors, and it did find the research was inconclusive overall because of a lack of high-quality data.
But the Mattis study did not mention that Medicare lifted a 33-year exclusion on gender reassignment surgery coverage in 2014. It mentioned only in the footnotes that Medicare permits coverage of the treatment on a case-by-case basis when it is deemed “reasonable and necessary.”
The Pentagon also reported there is “very low quality evidence” that hormone treatment treatment is effective based on a Mayo Clinic review of 28 studies. But the Mayo Clinic review also found about 80 percent of patients reported significant improvements in gender dysphoria, psychological symptoms, and quality of life.
Links to suicide and discrimination
The review also builds a case that transgender people with gender dysphoria suffer from high rates of anxiety, depression, and substance abuse. It reported that as much as 41 percent attempt suicide compared to just under 5 percent of the general population.
But one cited study noted that mental health problems improved following treatment and in many cases returned to normal levels. Three other studies pointed to discrimination as a root cause of the increased likelihood of suicide.
“We find that mental health factors and experiences of harassment, discrimination, violence and rejection may interact to produce a marked vulnerability to suicidal behavior in transgender and gender non-conforming individuals,” according to a cited 2014 survey and study by the American Foundation for Suicide Prevention and the Williams Institute.
A cited study from India came to a similar conclusion.
“The gender-based discrimination has prevented [transgender people from] obtaining education, livelihood, and housing because of which they are living in slums and have to resort to begging and sex work,” the study found. “This pitiful conditions lead them to break down further and end their life in suicide.”
A third study that identified 5,135 transgender patients in the Department of Veterans Affairs healthcare system between 1996 and 2013, when transgender troops were banned from military service, found higher rates of depression, suicidality, serious mental illnesses, and post-traumatic stress disorder.
The causes of the health differences “are likely to include, at a minimum, a history of an unwelcoming environment for [transgender] veterans at many [Veterans Health Administration] facilities, lack of knowledgeable clinical staff to provide [transgender] healthcare, and conscious and unconscious bias from healthcare providers and administrative staff,” the 2016 study concluded.
Some of the most striking new data on transgender mental health issues come from the Pentagon itself. The Mattis review says it collected the new data on transgender troops between 2015 and 2017.
Troops with gender dysphoria are eight times more likely to attempt suicide than the rest of the military population and nine times more likely to have “mental health encounters,” the Pentagon says. The 994 active-duty troops diagnosed with gender dysphoria accounted for 30,000 mental health visits over the two years — 30 visits for each service member diagnosed.
The Washington Examiner requested to see the military data cited in the review, but the Pentagon did not immediately respond.
Charges of cherry-picking data
Transgender rights groups and opponents of the Trump administration effort to roll back the Obama-era open service policy charge Mattis and the Pentagon with selectively using data to restrict service.
“Even a cursory reading of the Pentagon report shows a pattern of cherry-picking research and scientific distortion to fit a preordained conclusion tweeted by the president,” Aaron Belkin, the director of the Palm Center, which advocates for transgender rights in the military, said in a statement to the Washington Examiner. “This is discrimination trying to mask itself as science.”
In one case, the Pentagon uses a study by a transgender rights group to argue the effects of treatment can be debilitating for troops and make them unavailable for service.
A fuller reading shows the cited 2016 study by the National Center for Transgender Equality focused on national survey findings it said “reveal disturbing patterns of mistreatment and discrimination” among transgender people.
“This is one of the many instances of cherry-picking and taking data out of context that the report is riddled with,” said Harper Jean Tobin, director of policy for the rights group.
Supporters: Consistent and justified policy
For now, Mattis’ transgender policy is just a recommendation.
Opponents have won preliminary injunctions in four federal lawsuits filed in the District of Columbia, Maryland, California, and Washington state that bar the Pentagon from moving forward on any new transgender policy as the cases wind through the courts.
The Pentagon review identified 937 currently serving troops who have been diagnosed with gender dysphoria, and it proposes that all be allowed to remain in the military and receive medical treatment. About 1 percent of the active-duty force, or about 8,980 troops, identified as transgender in an anonymous workplace survey.
New recruits and newly diagnosed troops would be required to meet the new requirements proposed by Mattis, which would add gender dysphoria to other disqualifying conditions such as bipolar disorder, personality disorder, obsessive-compulsive disorder, suicidal behavior, and body dysmorphic disorder, according to the Pentagon review.
Tom Spoehr, director of the Center for National Defense at the Heritage Foundation, has called it a common-sense move that is “completely consistent” with other military recruitment policies.
“In recruiting offices across the country, recruiters and doctors discriminate every day about who comes into the military,” said Spoehr, a retired Army lieutenant general. “There is all kinds of discrimination going on in recruiting, and it’s all lawful, and it’s all for an easily justifiable purpose.”
The military disqualifies candidates who need significant medical treatment and might create a risk to themselves and other troops when deployed to difficult combat situations such as rural Afghanistan, he said.
“You don’t go to combat with all 1 million people, you go to combat in little tiny pieces,” Spoehr said. “If you are down there with 30 or 40 people and two of them go combat ineffective because they are not mentally resilient enough to put up with people actually trying to kill them, now you are into something significant.”
Mattis’ review of the existing research was a ray of hope that the military is going to discard the politicized Obama-era views of transgender service, said Elaine Donnelly, founder and president of the Center for Military Readiness, a group that advocates for conservative policies.
“The information about all the studies that discredit the transgender claims about their so-called medically necessary treatments, which really don’t cure underlying problems at all, that’s new and a welcome addition to the public debate,” said Donnelly, who has examined the 44-page Pentagon review.
She said the criticisms by the psychological and psychiatric associations that Mattis misrepresented the science are “absurd” but not surprising because the groups have become increasingly political in recent years.
“These are all issues that affect [military] readiness, and for them to deny that they are just being willfully wrong-headed about this, they don’t want to face the truth,” Donnelly said. “The report deserves praise for exposing truth that we’ve not seen before.”
