On Jan. 22, 2019, the Supreme Court decided by a 5-4 margin to allow the Trump administration’s ban on most transgender individuals serving in the military to go into effect. The justices did not take a stance on the legality of the ban, however, which allows cases that are challenging the policy to make their way into lower courts. The ban does make some exceptions for those already serving and for those who are willing to continue to serve in their “biological” sex.
There are many relevant arguments against this ban, and we thought it important that our group weigh in on some of them. For the past 48 years, the Sex and Gender Clinic at Johns Hopkins Hospital has provided affirming care to transgender individuals. Over this time we have seen the evolution of the cultural and scientific understanding of those whose assigned sex at birth does not correlate with their affirmed gender. At this point, our combined experiences have included the observation, diagnosis and treatment of literally thousands of individuals, and thus we are in a unique position to offer some comments that could enlighten the arguments.
In a characteristic tweet in 2017, Mr. Trump overnight reversed a 2016 Obama administration decision to allow transgender service members in the military. He did so by disregarding the previous research done on this question and suggested that the military and the taxpayers who fund it should not have the undue burden of covering the bill for a transgender service member’s health care. By allowing the ban to take effect, the Supreme Court is also disregarding this research.
In 2016 a RAND study concluded that the increase to the overall medical care cost to the military would be only 0.04-0.13 percent and that less than 0.1 percent of the total force would even seek such care. They further evaluated research on the effects of transgender inclusion in foreign military policies that indicated little or no impact on unit cohesion, operational effectiveness or readiness. Thus the ban is not based on any quantifiable, scientific or even rational decision but clearly on emotional and political bias.
Another issue that the Supreme Court’s decision and the ban illuminates is the lack of understanding of what constitutes our sex/gender. Indeed, many confuse the words themselves as well as their meanings. Our sex/gender is made up of chromosomal and hormonal factors that dictate our anatomical sex as well as our brain gender identity. This is not a clear cut process, and there are many potential variations. For instance, it is known that genital differentiation occurs at a different time in embryologic life than brain differentiation, thus setting the stage for differences in what our genitals tell us and what our brains tell us about who we are. Assuming there is one determinate for establishing “biological” sex defies scientific understanding.
The last and most important issue in the arguments against the ban is that of civil rights and human dignity. This ban is similar to ones that existed previously for African Americans and women, gay and lesbian individuals. Like these groups, the transgender population has been heavily marginalized.
Society, including medicine, has historically had difficulty understanding and dealing with gender variant people. These people were often pathologized and ridiculed. The medical community has moved forward. Currently all major medical and psychological organizations accept that being transgender is merely a human variant, and they have established humane and scientifically based treatment with proven effectiveness.
However, societal stigma continues to exist. Transphobia is alive and well. These attitudes have made it challenging for gender variant people in their work environments, in acceptance within their communities and their families and has led to a higher than average rate of suicide. The mission of The Sex and Gender Clinic has always been to deal with the social stigma faced by all sexual and gender minorities and to help these individuals cope with the anxieties, barriers and tensions that thwart their ability to live satisfying and productive lives.
Though the science has improved, we still do not know everything we need to know about gender. What we do know is that feeling your gender identity is at odds with your assigned birth sex is a very real feeling. It is a variant in the many possibilities that make up humankind. It is thus imperative that transgender individuals are treated with dignity, respect and compassion. Understanding what has been learned over many years about gender will go a long way to prevent further damage from laws and policies that are contrary to what we know.
Kate Thomas (firstname.lastname@example.org) is co-director of clinical services at The Sex and Gender Clinic at Johns Hopkins Hospital. Also contributing to this piece from the clinic are: Dr. Fred Berlin, director; Chris Kraft, co-director of clinical services; Dr. Chester Schmidt, medical director; and Dr. Matt Taylor, medical director.