Endocrine Ethics Blog

Another ban was issued this month surrounding transgender individuals serving in the military, based on a February report signed by James Mattis. (See: https://news.usni.org/2018/03/23/pentagon-report-recommendations-transgender-troops-serving-military.)

Those diagnosed with gender dysphoria will apparently be subject to the ban. (See: https://www.military.com/daily-news/2018/03/23/new-trump-transgender-military-policy-bars-those-gender-dysphoria.html.) The ban will apply to “persons with a history or diagnosis of gender dysphoria — including individuals who the policies state may require substantial medical treatment, including medications and surgery — are disqualified from military service except under limited circumstances.”

The Pentagon is making the argument that traditional criteria for mental health and stability should apply here. This raises the clinical ethics question as to whether “gender dysphoria” be treated as a mental health issue or an endocrine issue? According to the American Psychiatric Association, gender dysphoria is what distinguishes whether distress is associated with questions about one’s gender identity. (See: https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria.)

According to the White House “The experts’ study [in the February report] sets forth a policy to enhance our military’s readiness, lethality, and effectiveness…[and] concluded that the accession or retention of individuals with a history or diagnosis of gender dysphoria — those who may require substantial medical treatment, including through medical drugs or surgery — presents considerable risk to military effectiveness and lethality.”

Ultimately, the U.S. military is closing its doors to transgender individuals. Eventually, it will probably need to be addressed by the courts, with endocrinologists needing to serve as the experts.

It’s not unusual for the 45^th President of the United States to go on a Twitter “bender” when he is unsupervised. But this month, one of his benders hit the endocrine community hard, when, on July 26, he tweeted:

“Please be advised that the United States 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 in the military would entail.”

The announcement effectively blindsided the military, which did not have plans to re-instate any such ban, and its response was swift: the military challenged the President to an intellectual exercise of drafting coherent policy that would (a) justify the ban; and (b) communicate a process. Until and unless that occurs, the military announced that transgender individuals should not be concerned about being kicked out of the military. According to the New York Times: “In a letter to the military service chiefs, Gen. Joseph F. Dunford Jr., the chairman of the Joint Chiefs of Staff, said that the policy on who is allowed to serve would not change until the White House sends the Defense Department new rules and the secretary of defense issues new guidelines. His letter stated that: “In the meantime, we will continue to treat all of our personnel with respect,” (https://www.nytimes.com/2017/07/27/us/politics/transgender-military-trump-ban.html)

Aside from the problem of dictating policy through Twitter, and the fact that it was announced on the anniversary of Harry Truman lifting the ban on African Americans serving in the military (see: https://www.vox.com/identities/2017/7/26/16034656/truman-integration-military-trump-trans), the proposed ban is not based on sound medical reasoning. According to the American Medical Association (see https://www.ama-assn.org/ama-statement-transgender-americans-military): “There is no medically valid reason to exclude transgender individuals from military service. Transgender individuals are serving their country with honor, and they should be allowed to continue doing so.”

According to a 2016 RAND Corporation study, as many as 15,000 active-duty troops may be transgender, and “have minimal impact on readiness and health care costs” for the Pentagon.

The response to the tweet was swift: the medical community issued a strong rebuke (See:

http://time.com/4875375/transgender-ban-military-doctors-react/). The public’s response – Republicans and Democrats alike — made clear that the ban was morally unacceptable, and several Republicans in Congress swiftly denounced the ban.

The main issue is the costs of gender-transition surgeries, which the Obama administration considered carefully, and decided to cover. The justification was that the costs of $2.4 million and $8.4 million annually for transition-related medical care was a drop in the bucket when compared to medical costs for the myriad of other conditions treated (see: https://www.nytimes.com/2015/06/09/opinion/what-doctors-say-about-transgender-troops.html). A study published in The New England Medical Journal (see: http://www.nejm.org/doi/full/10.1056/NEJMp1509230) concluded that “doctors agree that such care is medically necessary.”

Care for transgender patients represents a military health-care spending increase of 0.04 to 0.13 percent, which is one tenth of the annual budget of roughly $84 million the military spends on medication for erectile dysfunction. (See: https://www.theatlantic.com/health/archive/2017/07/things-that-cost-more-than-medical-care-for-transgender-soldiers/534945/)

Slate Magazine conducted an interview with Jesse Ehrenfeld, M.D., an expert in transgender health care and military service who stated: “There are some poorly done studies involving mental health that have been cited to suggest that trans individuals are at heightened risk of suicide or other mental health challenges solely because they are trans. That’s misinformation. There’s good emerging data demonstrating that when we provide a supportive environment and good high quality care to trans individuals, those issues seem to go away and people do well.” (See: http://www.slate.com/blogs/outward/2017/07/28/jesse_ehrenfeld_on_trump_s_transgender_troops_ban.html

Clearly, there are a myriad of ethical and constitutional problems with the President’s tweet; it echoed uncomfortable policies such as the ban on African Americans serving in the air force because of the risk of sickle cell (see: https://www.ncbi.nlm.nih.gov/pubmed/2197408)

Those who are oppose transgender troops raise concerns about psychological fitness, and whether mixing transgender troops into the traditional military population of troops is a social experiment. (See: https://www.nytimes.com/2017/07/26/us/politics/trump-transgender-military.html?_r=0)

If we’re going to use the “psychological fitness” argument, we need to consider the psychological fitness of a Commander –In-Chief who has poor impulse control on Twitter.

Bruce Jenner’s recent interview with Diane Sawyer was essentially a public service to endocrinology, but it may have unintended consequences for Jenner and his family. The interview can be accessed here: http://abc.go.com/shows/2020/listing/2015-04/24-bruce-jenner-the-interview

In 2009, The Endocrine Society published the first clinical practice guidelines for hormone therapy in these patients:  http://www.ncbi.nlm.nih.gov/pubmed/19509099

Long before the Jenner case became well-known, there have been concerns that endocrinologists are not being properly educated about treatment for transgender patients, as this 2014 press release for a transgender session indicates:
http://media.aace.com/press-release/transgender-patients-healthcare-dilemma-scarcity-physicians-gender-identity-expertise

The Jenner case raises several sensitive ethical issues for patients and providers:

• Confidentiality in transgender patients is often not possible after hormone therapy begins, as the transformation can be dramatic — long before the patient is ready to disclose. In high-profile patients, such as Jenner, patients may be forced to announce their treatments before they are psychosocially prepared. Discussions about confidentiality, and its limitations after treatment begins, should be part of the consent process.
• There are concerns that media coverage of the Jenner case, or other cases, needs to be respectful, as the Center for Journalism Ethics has noted here:
  https://ethics.journalism.wisc.edu/2015/04/24/getting-bruce-jenner-right/
• Endocrinologists who are treating this patient population may need to work with journalists to ensure accurate information is being reported.
• Personhood and pronouns. At what point in transition does the He become a She, or vice versa? It may be important to put together a treatment plan that includes “personhood planning”.

Ultimately, what used to be an occult practice in endocrinology is becoming part of mainstream practice. It’s time to create specific ethical standards for this unique subspecialty in endocrinology.