Threats to United States Fully Reviewed and Strategic Plan for Integration of Transgender Military Members Into the Armed Forces

On July 26, 2017, President Donald Trump announced via Twitter his intention to ban transgender individuals from serving in the US military “in any capacity,” citing “medical costs and disruption” as his rationale. He commented that he was doing the military a “great favor” by banning transgender personnel. This represented a sudden reversal of a fully reviewed and strategic plan for integration of transgender military members into the armed forces, originated and implemented by our military leaders to ensure cost-effectiveness and continued military readiness.

GENDER-AFFIRMING INTERVENTIONS

Transgender individuals have a gender identity that differs from their sex assigned at birth. Consequently, many transgender patients seek gender-affirming interventions to achieve concordance between physical appearance and function and their gender identity. Gender-affirming interventions include hormone therapy and gender-affirming surgical procedures such as breast or genital surgery and facial contouring.

At the Johns Hopkins Center for Transgender Health, we routinely take care of active duty and reserve military patients going through the transition process. This process does not occur instantaneously. A transgender service member, in coordination with his or her chain of command and military medical providers, develops a transition plan that incorporates the service member’s health care needs and the unit’s mission readiness; the mission always comes first. The service member cannot begin any transition-related medical treatment until the plan is reviewed and approved through the processes implemented by each service.

UNIT COHESION OR EFFECTIVENESS

Eighteen other countries allow transgender personnel to serve: Australia, Austria, Belgium, Bolivia, Canada, Czech Republic, Denmark, Estonia, Finland, France, Germany, Israel, Netherlands, New Zealand, Norway, Spain, Sweden, and the United Kingdom, all of which are Organization for Economic Cooperation and Development members, with the exception of Bolivia. A RAND study commissioned by the Pentagon during its policy review found that there was no effect on unit cohesion or effectiveness in those militaries.¹ Furthermore, the US military experience of having thousands of transgender personnel serving across the force without significant issues since transgender individuals serving openly became allowed indicates that the argument based on a disruption to the force is a pretext.

The claim that allowing transgender military personnel to serve reduces military effectiveness is not a novel one. The same false premise—that embracing a more diverse military force weakens our national defense and disrupts order—was disproven when it was applied to the integration of African American, female, and lesbian, gay, and bisexual service members.² At the heart of this argument is the belief that our service members lack the professionalism to work alongside those who are different when accomplishing the mission. This argument also questions the leadership ability of service members to direct a force that reflects the nation they serve and is disrespectful to all American military personnel.

OVERALL HEALTH CARE COSTS IN THE MILITARY

This transgender ban would have little to no effect on overall health care costs in the military. Even though transgender individuals are estimated to be overrepresented in the military compared with the general population,³ one estimate in the New England Journal of Medicine suggested that medically necessary transgender-related health care would cost the military about $5 million a year,⁴ less than a quarter of the $23 million the military spends on acne medications each year⁵ and about 0.0001 of the $49.3 billion the Department of Defense spends on health care each year.¹ Furthermore, the provision of gender-affirming care, even in the general population, has been shown to be highly cost-effective.⁶ The evidence is unambiguous: giving patients support and allowing them to embrace their identity consistently improve their quality of life.

SPEND $960 MILLION TO SAVE $10 MILLION

The cost argument is misguided because it fails to account for the cost to recruit and train replacements for thousands of productive service members with years of training and expertise who have been involuntarily discharged. A 2016 estimate suggests that the US military has between 2150 and 10 790 active and reserve transgender service members. In a recent article,⁷ current and former professors from the Naval Postgraduate School calculated that it would cost $960 million to discharge the transgender personnel who are currently serving. As such, the Department of Defense would spend $960 million to save less than $10 million in annual health care costs.^1,7

UNCONSTITUTIONAL AND IMMORAL

Furthermore, the threats to unit performance and morale by suddenly forcing out loyal personnel—who were serving their country without any issues—are likely more real than any imagined disruption from working alongside transgender individuals. Because the issue of transgender military service was fully vetted by our military leadership, and transgender personnel have served openly for the past year, the ostensible rationale for this ban put forth by the president is not rational. These service members were told just one year ago that they should be open about their gender identity and could trust their leadership not to punish them. To implement an order now to expel thousands of patriotic, mission-capable troops, using their honesty against them, is arguably asking our chain of command to do something both unconstitutional and immoral. Such an order could be far more damaging to military readiness than supporting our transgender troops.

Simply put, there is no moral, financial, medical, or military rationale to suddenly expel thousands of service members just for being transgender. Across the decades, our military has gradually but irreversibly arced in the direction of becoming more inclusive, by race, gender, sexual orientation, and now gender identity, while remaining unquestionably the most powerful and effective military fighting force in the world.