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Chelsea Manning's now public transition highlights the needs of a vulnerable population.

Written by Autumn Sandeen for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

When I joined the U.S. Navy back in 1980, I knew I was transgender. I didn’t know the word transgender, but I knew deep down that's what I was.


Prior to joining the Navy, in 1979, my pentecostal parents considered transgender identities and transgender expressions to be sinful, and made going to "conversion therapy" a condition of living at home. Due to my own internalized transphobia, I thought I was sinful too, so I underwent the therapy, which had the goal of having me become "ex-transgender."


A goal of both gay and transgender conversion therapy is to embrace societal gender role norms, so in my case embracing masculine norms was the goal. It should come as no surprise then that when I enlisted in the Navy in 1980, it was in part an attempt to be the man I wasn't.


Chelsea Manning, who enlisted under the name Bradley Manning—and who in August received a 35-year prison sentence for releasing classified government documents to WikiLeaks—recently gave that same explanation as to why she enlisted.


If either of us had admitted to being transgender before we joined the military, we wouldn't have been allowed to join. This is because Department of Defense Instruction 6130.03, the Medical Standards for Appointment, Enlistment, or Induction in the Military Services, states that "[c]urrent or history of psychosexual conditions, including but not limited to transsexualism, exhibitionism, transvestism, voyeurism, and other paraphilias" precludes induction.


Department of Defense (DOD) policy also discharges currently serving personnel if they admit to, or are discovered to be, transgender. For enlisted service members, Department of Defense Instruction 1332.14 (the Enlisted Administrative Separations) is the controlling regulation. The Army's applicable regulation is Army Regulation 40–501, the Standards of Medical Fitness, which states:


A history of, or current manifestations of, personality disorders, disorders of impulse control not elsewhere classified, transvestism, voyeurism, other paraphilias, or factitious disorders, psychosexual conditions, transsexual, gender identity disorder to include major abnormalities or defects of the genitalia such as change of sex or a current attempt to change sex, hermaphroditism, pseudohermaphroditism, or pure gonadal dysgenesis or dysfunctional residuals from surgical correction of these conditions render an individual administratively unfit [to serve].

This transgender exclusion is backed by case law. The first such case in which such exclusion was discussed is 1981's Doe v. Alexander. Tarynn M. Witten wrote about the case in a 2007 whitepaper entitled "Gender Identity and the Military - Transgender, Transsexual, and Intersex Identified Individuals in the U.S. Armed Forces," saying:


[T]he Army defended its policy of denying enlistment to transsexual persons, arguing that transsexual persons presented a medical problem in that their requirements for hormone supplementation might not be available at some location where they could be assigned.

The 2007 DeGroat v. Townsend decision by the U.S. Southern District Court in Ohio, Western Division, echoed the decision in Doe v. Alexander, finding Joanne E. Degroat, a member of the U.S. Armed Forces (USAF) from 1974 to 1989, medically unfit to serve. In the decision, the court stated that "USAF medical staff encouraged and counseled her to dress in female street clothing when off-base and off-duty" as part of the treatment plan for her gender dysphoria. Major DeGroat was seen attending church in female clothing, and then "was notified that she had to show cause for retention on active duty for substandard performance due to a failure to show acceptable qualities of leadership required by an officer of her grade, based on her wearing female clothing on two instances and subjecting herself to public view." Her separation for service was upheld.


The Leyland v. Orr decision is also on point. Jane Anne Leyland was honorably discharged from the Air Force Reserves as being found mentally and physically unfit to serve due to being transsexual and receiving trans-related medical treatment. As Witten wrote in her paper, "Leyland's fitness for duty recommended discharge on the grounds of psychological unsuitability, the Air Force Board for Correction of Military Records affirmed the discharge on grounds of psychological unsuitability and physical unfitness."


From the Ninth Circuit Court of Appeals ruling, Dr. Donald Novicki, a urology consultant to the Air Force surgeon general, stated that the known and potential long-term effects of a sex change constitute a risk significant enough to restrict the individual's performance of Air Force duties, especially when remote geographic assignments are involved. Dr. Novicki stated that assigning such a person to such places "would be equivalent to placing an individual with known coronary artery disease in a remote location without readily available coronary care." He added, "It has been and remains the policy of the Surgeon General that such abnormalities be identified and that such individuals be denied entry or continued active duty for their benefit and for the benefit of the United States Air Force."


Lastly, in 1988's United States v. Davis, the appellant was charged under Article 134 of the Uniform Code of Military Justice after having several Navy psychiatrists diagnose her with what the DSM-V refers to as "gender dysphoria," and was recommended for continued treatment of the condition. The U.S. Court of Military Appeals ruling on the case stated that expressing gender as one's target sex while on base in a manner as required by the relevant standard of care "virtually always would be prejudicial to good order and discipline and discrediting to the Armed Forces."


The military services have not in recent years criminalized treatment of gender dysphoria as was done in United States v. Davis, but as these court rulings indicate, being diagnosed for gender dysphoria—and being treated for gender dysphoria while serving in the military—are reasons for denying entry to transgender people, as well as initiating their separation from the military services. This is settled law.


The prohibition against medical treatment for transgender people extends beyond active service members. TRICARE, the DOD's health-care insurance program for dependents and retirees, has insurance exclusions for gender dysphoria related health-care treatment. The TRICARE policy manual includes in the program's exclusions "[s]ervices and supplies related to transsexualism or such other conditions as gender dysphoria (including, but not limited, to intersex surgery, psychotherapy, and prescription drugs), except as specifically provided in 32 [Code of Federal Regulations]."


The American Psychiatric Association, the American Psychological Association, the American Medical Association, and the World Professional Association for Transgender Health (WPATH) all support removing exclusions for treatment connected to gender dysphoria. For example, the American Medical Association stated in 2008's Resolution 122:


[I]f left untreated, [gender dysphoria] can result in clinically significant psychological distress, dysfunction, debilitating depression ... An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment for many people diagnosed with [gender dysphoria.]


Health experts in [gender dysphoria], including WPATH, have rejected the myth that such treatments are 'cosmetic' or 'experimental' and have recognized that these treatments can provide safe and effective treatment for a serious health condition[.]


Physicians treating persons with [gender dysphoria] must be able to provide the correct treatment necessary for a patient in order to achieve genuine and lasting comfort with his or her gender, based on the person’s individual needs and medical history[.]

To put all of this in perspective regarding appropriate medical treatment for Chelsea Manning, if by court order it's required that her gender dysphoria be treated in accordance with the standards of care, she'd be the only military patient diagnosed with gender dysphoria to legally receive appropriate treatment for that condition. That's not an argument against Manning receiving such treatment—rather, it highlights just how outmoded the DOD's policies are.


Chelsea Manning's request for medical treatment in Army custody is precipitating discussions about what is appropriate medical treatment for transgender people, and what transgender-related health care should be made available by the DOD for service members and by TRICARE for dependents and retirees. It's also spurred a discussion of whether U.S. government health-care exclusions for gender dysphoria are ethically defensible.


In thinking of what are ethical and appropriate health-care treatments for transgender people, we need to consider that the American Psychiatric Association has strongly questioned the efficacy of conversion therapy. In addition, the Ninth Circuit Court of Appeals affirmed  last week the right to prohibit therapy for minors that has the goal of making patients "ex-gay" or "ex-transgender." Because of the real harm such therapycan cause, one can safely state that the federal government shouldn't be in the business of engaging in conversion therapy with their transgender prisoners.


And beyond the medical considerations, the public transitions of Kristin Beck—the former Navy seal who recently came out as transgender on CNN's Anderson Cooper 360—and Chelsea Manning are generating a national discussion on open military service for transgender people.


Chelsea Manning's now public transition highlights the needs of a vulnerable population. And how we treat the most vulnerable individuals in our society is a discussion we certainly should be having.

Originally posted to RH Reality Check on Mon Sep 09, 2013 at 11:29 AM PDT.

Also republished by TransAction.

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