Should Transgender People be in the Military? An overview of relevant studies

On July 27, 2017 President Trump tweeted his intention to ban transgender people from serving in the military, a move which would reverse President Obama’s decision to allow them to serve. (Prior to Obama, trans people were not allowed to serve.) As of the writing of this post, Trump’s tweet has not become official law or policy, but it has set off a firestorm of internet debate, with everyone picking sides primarily based on whether they like trans people or not, rather than what’s actually best for the military.

So I decided to review whatever studies I could find on the subject:

CLAS (Community Alliance for Cultural and Linguistically Appropriate Services) finds:

On September 20, 2011, the repeal of “Don’t Ask, Don’t Tell” (DADT) went into effect in the U.S. military. The repeal marked the end of discriminatory practices in the military based on sexual orientation, but it did not end the prohibition on transgender military service. The National Transgender Discrimination Survey (NTDS) found that transgender Americans serve in the military at a high rate; 20 percent of NTDS respondents had served in the armed forces as compared to 10 percent of the U.S. general population.

According to 538, about 7.3% of the US population has served in the military (0.4% are active personnel; the rest are veterans.) The majority of those are male: 13.4% of men have served in the military, compared to 1.4% of women. Given the slight discrepancy in the data, I thought I’d check the NTDS numbers as well, but the PDF isn’t opening, but the Williams Institute has an article, Transgender Military Service in the US, which helpfully discusses the NTDS data in depth.

Overall, trans people are less than 1% of the population, and according to the Williams article, 60% MtF (male to female) and 40% FtM. According to 70 U.S. Veterans with Gender Identity Disturbances: A Descriptive Study, 91% of trans vets are MtF:

Retrospective descriptive data were obtained from chart reviews of 70 U.S. veterans who were evaluated by the second author for gender disturbances over a 20-year period (1987 to 2007). The modal veteran with gender identity disturbance was a natal male (91%) identifying as female, >40 years old, Caucasian, employed, with more than 12 years of education. Fifty-seven percent were parents with a history of sexual involvement with opposite sex individuals. Histories of autogynephilia were not elicited in vets interviewed since 1997. Classic “flight into hypermasculinity” was described by a majority of the natal male vets as a retrospective understanding of why they joined the military.

If we break the trans population down by gender, NTDS estimates that 30% of MtFs have served in the military and 5.5% of FtMs. (Williams cites a couple of other studies which found similarly high numbers.)

According to CNN, (which probably got its data from NTDS,) there are about 15,000 active trans troops; NTDS estimates a further 134,000 veterans. Given 1.4 million total people in the armed forces and 22 million vets, that gives us an estimate of a bit over 1% of the military and 0.6% of vets are trans. The discrepancy between current and historical numbers of trans people could be a side effect of younger people being more likely to identify as trans or of volunteer forces being more heavily trans than drafted ones. (Here is an interesting article about a trans WWII veteranCNN has a couple about active troops.)

According to a RAND Corp study commissioned by the DoD, Assessing the Implications of Allowing Transgender Personnel to Serve Openly:

  1. There Are an Estimated 1,320–6,630 Transgender Service Members in the Active Component
  2. A further 1,510 in the Selected Reserve
  3. Not all will seek gender transition–related treatment (some have already had it and some don’t want it.)
  4. Estimates derived from survey data and private health insurance claims data indicate that, each year, between 29 and 129 service members in the active component will seek transition-related care that could disrupt their ability to deploy.
  5. Even upper-bound estimates indicate that less than 0.1 percent of the total force would seek transition-related care that could disrupt their ability to deploy.
  6. Using private health insurance claims data to estimate the cost of extending gender transition–related health care coverage to transgender personnel indicated that active-component health care costs would increase by between $2.4 million and $8.4 million annually, representing a 0.04- to 0.13-percent increase in active-component health care expenditures.

They further claim that:

  1. The limited research on the effects of foreign military policies indicates little or no impact on unit cohesion, operational effectiveness, or readiness.
  2. Policy changes to open more roles to women and to allow gay and lesbian personnel to serve openly in the U.S. military have similarly had no significant effect on unit cohesion, operational effectiveness, or readiness.

Note that RAND’s estimates of the number of trans military personnel is much lower than NTDS’s, which is kind of odd, given how easy the NTDS data is to find. Forgive me a bit of cynicism, but RAND seems to be trying to minimize projected costs by excluding the very large body of trans veterans who might also qualify for treatment and failing to include non-physical psychological expenses (see discussion below.)

Washington Free Beacon has a much higher estimate of physical costs, but I must warn that their website nearly crashed my computer. Quoting:

The 2014 Williams Institute study found there were 15,500 transgender individuals actively serving, or 0.7 percent of the military population. …

Thirty percent will likely seek surgeries, or 4,473 transgender troops. The average cost per surgery is $132,000, which is a combination of the average cost of male to female ($140,450) and female to male ($124,400) surgeries.

In other words, RAND estimates a small % of a small # will seek surgery–between 29 and 129 people. The Free Beacon study estimates a much higher % of a higher #, for an estimate of 4,473 people. RAND is also calculating about $80,000 per surgery, vs. Free Beacon’s $132,000.

The cost to taxpayers for these surgeries would be $590 million, and $770 million with a 3 percent inflation rate by 2027.

If the first set of numbers they cite are correct, then $590 million is an under-estimate, because it uses the average cost of male and female surgeries, but the majority of trans people in the military are MtF and so want the more expensive surgery.

There are 178,000 new military members per year, and assuming 0.7 percent are transgender, 1,246 new transgender service members each year. Assuming 30 percent get surgeries, there would be an additional 374 surgical transitions per year, or 3,740 over 10 years. Those surgeries would cost $493 million, and with 3 percent inflation a total of $579 million by 2027.

The costs of active duty transgender surgeries and those of new recruits over a 10-year period total $1.349 billion.

And this is still not considering veterans.

What about expenses besides surgical transition? According to Mental Health and Medical Health Disparities in 5135 Transgender Veterans Receiving Healthcare in the Veterans Health Administration: A Case–Control Study:

Statistically significant disparities were present in the TG cohort for all 10 mental health conditions examined, including depression, suicidality, serious mental illnesses, and post-traumatic stress disorder. TG Veterans were more likely to have been homeless, to have reported sexual trauma while on active duty, and to have been incarcerated. Significant disparities in the prevalence of medical diagnoses for TG veterans were also detected for 16/17 diagnoses examined, with HIV disease representing the largest disparity between groups.

Trans people have really high rates of depression (62% for MtFs and 55% for FtMs,) suicide attempts (32%,) and HIV infection (35% for MtFs but only 2% of FtMs.)

I found two other potentially relevant studies, one from the Journal of Homosexuality and one from HEIN Online, but both are paywalled so I can’t read them.

So. Tentative conclusions/discussion:

The military is not a charity, nor is it a means of dealing with pre-existing health issues. The military’s primary–some would say only–purpose is to defeat America’s enemies. The military does not take people with health problems like diabetes or Asperger’s, even though there are many diabetic or aspie people who would be GREAT soldiers. There are jobs in the military that you can’t get if you wear glasses.

Some of these rules may be wrong. Maybe we should let people with high-functioning autism/Asperger’s in the military if they can hack it. The Israeli military has a special division where autists put their skills to good use monitoring surveillance footage; it also allows transgender soldiers. But Israel is a small country surrounded by hostile enemies, so it may feel it cannot afford to turn down any willing soldiers.

I propose that the military may serve a secondary purpose: allowing citizens to feel like productive, contributing members of society. Service in the IDF, for example, may have a beneficial effect on Israeli society as a whole beyond merely insuring its safety. If military service is not appropriate for a group of people, perhaps some other form of service to society is.

Trans folk are a very small percent of the military, but a surprisingly large percent of trans folk are current or former military, especially if we only look at MtFs. It seems that the military is more important to trans folks than they are to it.

It makes sense that a larger percent of FtMs than cis-women would join the military, as they would naturally be drawn to more typically “male” occupations. The MtF preference for military work is harder to explain. One study attributes it to overcompensation–that is, covering up their desire to be female by trying to be as masculine as possible. I propose a second possibility: the military pays, and trans people are disproportionately poor.

I would like to draw here on an anecdotal case study of a single individual I knew in childhood:

This friend has a rare genetic condition (Klinefelter) in which instead of having a normal set of sex chromosomes (XX for female, XY for male,) they’re XXY. Biologically, “male” and “female” are defined by gamete size–females produce large gametes (eggs) and males produce small gametes (sperm.) XXY people basically look male but don’t develop normal testicles and are often infertile, so I don’t think they really count as “male” in the biological sense.

The current vogue for asserting that “gender is a social construct” is pure nonsense, and IMO, will ultimately be harmful to trans people like my childhood friend, who has a true intersex condition. Even chimpanzees show gender roles similar to humans. There are many observed statistical differences between male and female brains, from better mental rotation (men) to lower rates of retardation (women.) These mental differences are caused by the different amounts of male and female hormones the fetal brain is exposed to at different points in its development, which trigger different aspects of brain development. There are whole books on the subject of fetal brain development if you want to know more.

Exposing a fetal brain to incorrect hormone levels–say, by taking a formerly popular anti-miscarriage medication that contains high levels of artificial estrogens–could trigger the development of a more “female” brain in a male body (or with the right hormones, the opposite.) In my friend’s case, an extra X chromosome rather than medication is to blame.

My friend identifies as “female” despite looking male. Why remains a mystery to me, as their life would be much easier if they identified as male and injected testosterone than identifying as female and injecting estrogen, but I certainly can’t naysay their sense that they “aren’t a proper male.”

But in a perhaps not odd twist, my friend is (or was) absolutely obsessed with everything military, from battleships to rifles to historical re-enactments. (Friend also has a very good memory, rendering them a walking military encyclopedia.)

Look, I acknowledge that “obsessed with the military” and “insists they are female and wants surgery in that direction” is a weird combination and I don’t understand it. Trans identity and stereotypically-male spheres overlap in a few other dimensions. People have lately been discussing an overlap between trans and autism, (which researchers often characterize as extreme male brain,) and of course Kaitlyn Jenner was, pre-transition, an Olympic Athlete. But all of that is getting a bit off topic.

“Transgender” is a vaguely defined term, and I don’t see why, even if trans people were allowed to serve in the military, the military would be required to cover the cost of transitioning. Why not declare that the military doesn’t cover it, that members aren’t allowed to put themselves out of commission by getting surgery, and that people using hormones/medications are ineligible for service (just as diabetics are ineligible).

However, the psychological co-morbidities, especially depression, are much more concerning. A group with high levels of depression, suicide, HIV, etc., sounds like a bad match for the military.

None of the studies I found really went into much detail (at least in the parts I could access) about trans soldiers’ ability to cope psychologically with the rigors of war nor their effects on group cohesion or effectiveness.

Allow me to express a bit of doubt: if people think the folks running the study want a particular outcome, they may be reluctant to complain about a fellow squad member. What I really want is a study of squad performance comparing squads with and without trans members, similar to the one highlighted in “The US Marines Tested Mixed-Gender Squads Against all Male ones, and the Results are Pretty Bleak”:

All-male squads, teams and crews and gender-integrated squads, teams, and crews had a noticeable difference in their performance of the basic combat tasks of negotiating obstacles and evacuating casualties. For example, when negotiating the wall obstacle, male Marines threw their packs to the top of the wall, whereas female Marines required regular assistance in getting their packs to the top. During casualty evacuation assessments, there were notable differences in execution times between all-male and gender-integrated groups, except in the case where teams conducted a casualty evacuation as a one-Marine fireman’s carry of another (in which case it was most often a male Marine who “evacuated” the casualty.)

The report also says that female Marines had higher rates of injury throughout the experiment.

People often argue that men and women ought to have an equal chance to try to be in the military, but what if even women who meet the military’s standards are more likely to get injured (putting their whole squad at risk) than men? Such vulnerability would call for a blanket exclusion of women from certain parts of the military (though there are many support roles, like military doctors, where they perform admirably.)