In 2015, while deployed with the Air Force in Kandahar, Afghanistan, Logan Ireland told his commander he was a transgender man.
It was a risky move. At the time, trans people could be discharged for serving openly in the military, though one 2015 study from the Williams Institute estimated as many as 15,500 troops were transgender. Another study found 20 percent of transgender people have served in the military, which is double the rate of the U.S. general population.
But “it wasn’t about my career anymore. It was about people I knew who were getting discharged left and right,” Ireland said. His commanding officer was supportive, so Ireland completed his deployment and kept speaking out about trans issues in the military.
Then, in June 2016, then-Secretary of Defense Ash Carter revised guidelines to lift the ban on openly transgender service members. For Ireland and others, the decision changed one crucial area: health care.
In March 2016, two months before the new policy took effect, researchers began looking into the preparedness of military doctors to treat trans patients. The team surveyed 180 doctors at the 2016 annual meeting of the Uniformed Services Academy of Family Physicians and found the vast majority of the group — 94.9 percent — had received “three hours or less of training on transgender care.” Three out of four doctors had received no training at all.
This trend does not differ substantially from many providers outside the military, according to Dr. Natasha Schvey, an assistant professor at the Uniformed Services University who co-authored the study published Mar. 13 in JAMA Internal Medicine.
“Across the board, we know that physicians and trainees are not yet culturally competent or medically competent in treating this population,” Schvey said.
The Pentagon’s policy change ushered in a number of new policies regarding transgender troops and their medical care, including guidelines on transition using hormones and/or surgery. Before that announcement, transgender troops had no support or resources from the military, and those who had transitioned using hormones or surgery were considered “unfit” for service. Ireland and other transgender soldiers had to pay out-of-pocket for health care.
“If I had gotten [medical care] through the military, that would have outed myself and I would have been discharged,” Ireland told the NewsHour. Now 29, Ireland said he’s completely satisfied with the care he receives at Peterson Air Force Base in Colorado Springs, Colorado.
Today, all services of the military require doctors and other service members a minimum of one to two hours of webinar training on general transgender issues. Any additional training is usually requested by different commands within each service. The Navy has also instituted mandatory face-to-face training, providing DVDs and discussion guides for units in remote areas.
But questions remain as to whether those trainings will make a substantial difference in medical competence for the thousands of military doctors.
Dr. George Brown, who trains clinicians in the Veterans Affairs system about trans issues, said his sessions typically consist of a half-day workshop to introduce doctors to the topic of transgender health. He and colleagues have conducted these trainings for seven years. They provided the first training on transgender issues to the U.S. Navy in April 2016.
While the Department of Defense’s new guidelines required force-wide training on transgender issues to be completed by July 1, 2017, it did not specify what type of training or how much. This deadline is “definitely unrealistic” if the force hopes for the same level of training provided by the VA, Brown said.
When the deadline was announced, “I thought that was an overly ambitious timeline, because we’ve been doing this for six, going on seven years in the VA, and it’s difficult to reach everybody. … but it depends on how you define ‘training,’” Brown said.
The survey showed also that 52.9 percent of doctors who responded would not administer hormone replacement therapy (HRT), a treatment that can relieve the distress of gender dysphoria. Brown pointed out the survey did not include specialists who would typically be consulted for HRT, like endocrinologists or psychiatrists.
Keeping in mind that military doctors most often receive their medical training at civilian schools, the survey results reflect a nationwide lack of medical competency around trans issues, Dr. David Klein, a co-author of the JAMA study pointed out.
“This is a well-documented phenomenon, that people just don’t get the training they need to treat trans patients unless they seek it out on their own,” said Zil Goldstein, program director at the Center for Transgender Medicine and Surgery at Mount Sinai Hospital in New York. “It’s really transgender people that end up paying the costs [in] a medical system that doesn’t acknowledge that they exist.”
The estimated 1.4 million transgender adults in the U.S. face wide health disparities, in part due to a lack of access to insurance. The 2015 U.S. Transgender Survey, the largest survey of the U.S. transgender community to date, found that one in four respondents had experienced a health insurance problem in the previous year that was related to being transgender. Insurance laws that govern coverage for transition-related issues — like surgery or hormone therapy — vary widely around the country.
Even those who make it to a doctor can face mistreatment. The 2015 U.S. Transgender survey found one-third of respondents who had gone to a health care provider in the previous year had at least one negative experience, including refusal of treatment, verbal harassment or assault. And 23 percent of respondents avoided doctors altogether in the past year because they feared being mistreated.
Major medical organizations have urged the development of training programs on transgender patients. The American Medical Association has stated that “non-judgmental recognition” of a patient’s’ sexual orientation or gender identity allows for better care and encouraged the creation of educational programs on LGBT health.”
Medical research on the trans community has been slim in the past, but the last few years have seen an increase in nationally funded research on transgender health care, Schvey said. In 2014, the Association of American Medical Colleges issued the first comprehensive guidelines for educating physicians on LGBT issues. And in August 2015, the National Institutes of Health awarded funding to a five-year study on treatments for transgender youth.
Expanding this research and education among providers will help them know how to treat those patients, Schvey said. “As people feel less stigmatized and more open in their gender identity, our providers will also have more access and experience in treating them.”