Transgender Service Research Articles

Addressing US Military Transgender Care Inequalities: Clinical Nurse Specialist Bridging Healthcare Gaps.

There are more than 130 000 US veterans and more than 12 500 active-duty service members who identify as transgender. Lack of training in transgender and gender-affirming care among healthcare providers in the military is still reported. The article aims to explore and advocate for the unique role of advanced practice registered nurses, especially clinical nurse specialists, in providing culturally sensitive and evidence-based care to the transgender population within the US military. The clinical nurse specialists' pivotal role in policy advocacy and translation of evidence to improve the quality of care and patient outcomes for transgender service members is highlighted. The article also explores the historical journey of transgender care in the US military, addressing discriminatory policies and the implications of the ever-evolving regulations in military transgender healthcare. The article aims to create awareness of clinical nurse specialist utilization in US military healthcare services to improve the care of transgender individuals in the military. The uncertain future for transgender service members highlights the ongoing commitment needed to navigate complex military healthcare policies and foster inclusive, evidence-based practices. Therefore, the clinical nurse specialist plays a pivotal role in shaping the future of transgender healthcare within the US military.

Variation in Time-to-Gender-Affirming Hormone Therapy in the US Active Duty Service Members.

Beginning in July 2016, transgender service members in the US military were allowed to receive gender-affirming medical care, if so desired. This study aimed to evaluate variation in time-to-hormone therapy initiation in active duty Service members after the receipt of a diagnosis indicative of gender dysphoria in the Military Health System. This retrospective cohort study included data from those enrolled in TRICARE Prime between July 2016 and December 2021 and extracted from the Military Health System Data Repository. A population-based sample of US Service members who had an encounter with a relevant International Classification of Diseases 9/10 diagnosis code. Time-to-gender-affirming hormone initiation after diagnosis receipt. A total of 2439 Service members were included (Mage 24y; 62% white, 16% Black; 12% Latine; 65% Junior Enlisted; 37% Army, 29% Navy, 25% Air Force, 7% Marine Corps; 46% first recorded administrative assigned gender marker female). Overall, 41% and 52% initiated gender-affirming hormone therapy within 1 and 3 years of diagnosis, respectively. In the generalized additive model, time-to-gender-affirming hormone initiation was longer for Service members with a first administrative assigned gender marker of male relative to female (P<0.001), and Asian and Pacific Islander (P=0.02) and Black (P=0.047) relative to white Service members. In time-varying interactions, junior enlisted members had longer time-to-initiation, relative to senior enlisted members and junior officers, until about 2-years postinitial diagnosis. The significant variation and documented inequities indicate that institutional data-driven policy modifications are needed to ensure timely access for those desiring care.

Transgender older adults' prior military service: Mental health differences by gender identification.

Despite a proportionally higher likelihood of serving, the role of prior military service in the mental health of transgender individuals is understudied. Research on the impact of military service on mental health tends to be proximal. We examined the distal relationship between prior military service, identity stigma, and mental health among transgender older adults, drawing comparisons between transgender men and women. We conducted a series of weighted multivariate linear models to predict the relationships between prior military service, identity stigma, perceived stress, and depression among 183 transgender women and men aged 51-87 (M = 60.11, SD = 0.668) using 2014 data from the National Health, Aging, and Sexuality/Gender Study. Prior military service was negatively associated with depression and perceived stress; identity stigma was positively associated with both. Prior military service and lower depression and perceived stress were significant for transgender men, but not women. Identity stigma was significant with depression and perceived stress among transgender women, but not transgender men. Our preliminary findings suggest that prior military service may serve as a protective factor for mental health among transgender men, but not transgender women. We need to better understand how military experience interacts with other characteristics, such as differing gender identities influences the mental health of transgender service members. Further research is needed to inform underlying mechanisms whereby military service differentially impacts mental health by gender identity so all active-duty personnel can share in the many benefits that accrue from military service, including protective effects on mental health in later life. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Female-Specific Health Care of Military Female-Designated Service Members and Veterans: A Systematic Overview of Reviews.

Since the War in Afghanistan began in 2001, service members have faced significant health effects related to service during war, with female-designated service members facing unique challenges. Numerous high-quality review articles have been published on the health and care of female-designated service members and veterans. Given the increasing volume of literature, we completed an overview of reviews on the health and health care of female-designated military populations. Our objective was to conduct an overview of reviews on the obstetrics and gynecologic health and health care of female-designated military populations since 2000 to understand female-specific health consequences of military service during war and make clinical recommendations. On May 10, 2022, a medical librarian performed a comprehensive search across five databases (Ovid Medline, Embase, CINAHL, PsycINFO, Ovid All EBM Reviews, and Web of Science) for all relevant reviews published from 2000 to May 10, 2022. Results were limited to English language. After the removal of duplicates, 2,438 records were reviewed, and 69 studies were included in the final review. The search strategy and methods were registered with PROSPERO and are reported according to the Preferred Reporting Items for Overviews of Reviews (PRIOR) guidelines. Two independent reviewers conducted title and abstract screening and subsequent full text review using Covidence Systematic Review Software. Reviews addressing female-specific and obstetrics and gynecologic health of female-designated service members or veterans, utilizing a clear and systematic methodology, were eligible for inclusion. Quality assessment was conducted by teams of two reviewers. A total of 69 studies were included in the final review. Themes included mental health and impact of sexual assault on service members or veterans, veteran health care, issues of menstruation, pregnancy, and urogenital concerns. Areas with few reviews included occupational risks of military service and impact on obstetric outcomes, eating disorders, and menopause. There were insufficient or no reviews on the impact of military service on fertility, access to abortion care, reproductive health outcomes of lesbian, bisexual and transgender service members, surgical treatment of gynecologic conditions, and screening and treatment for breast, gynecologic, and non-pelvic organ cancers. Female-designated military populations serving during periods of war face unique health challenges that should be considered in screening practices and the delivery of trauma informed care. Further research and reviews are needed for female-specific oncology, fertility, abortion access, and sexual and non-binary and expansive gender identities to better capture female-designated service member and veteran health during wartime and beyond.

The first population size estimation of transgender and non-binary people in Georgia

Purpose Accurate data on the number of transgender and non-binary people are essential for the effectiveness of planning and implementation of transgender services, as well as for advocacy, but these data are insufficient. Our goal in this study was to estimate the number of transgender people in Georgia and compare it with estimations in other Eastern European and Central Asian (EECA) countries. Methods We used a variety of methodologies, including the mobile/web app multiplier, service multiplier, and network-based capture-recapture (Telefunken) methods, which all were included in a survey of 100 transgender people. A final estimation was obtained using the Anchored Multiplier method. We also review the existing research on estimating transgender and non-binary population sizes in EECA countries. Results The estimation final value of transgender and non-binary people in Georgia was 0.06 [0.05–0.07%] of the total adult (18–54 years) population of the country or 1,044 [870–1,219]. Conclusion Our transgender and non-binary population size estimates in Georgia are in line with those in other EECA countries. These estimates can offer useful information for planning and assessing trans specific services, including HIV prevention programs at the national level. Furthermore, we believe that our findings will close the information gap regarding regional estimates of transgender and non-binary populations.

Serving with Transgender Service Members

Several studies focusing on public attitudes toward transgender people have been conducted, but there has been minimal research on how heteronormativity might influence military-affiliated respondents’ attitudes toward transgender service members. In this qualitative study, seven United States veterans participated in phone interviews from July 2020 to January 2021, in which they shared their thoughts about working with transgender service members. Findings also included their opinions regarding transgender service as it relates to unit cohesion, military effectiveness, and national security. Overall, this study uniquely contributes to the scholarly literature by providing a firsthand account of transgender military service from the service members themselves. The findings also lay the groundwork for future and more extensive studies related to the current integration of transgender service members as they workalongside their cisgender colleagues.

Invisible No More: The State of Transgender Service Members in the U.S. Military

Invisible No More: The State of Transgender Service Members in the U.S. Military

Transgender Military Experiences: From Obama to Trump

ABSTRACT On September 20, 2011, President Barack Obama repealed the Don’t Ask, Don’t Tell (DADT) policy allowing Lesbian, Gay, and Bisexual (LGB) people to openly serve in the U.S. military even though transgender service members were not afforded the same protections. On July 23, 2015, Obama’s Secretary of Defense Ash Carter officially rescinded the transgender ban. For this study, survey data was collected from 26 transgender service members beginning in October 2018 and ending in December 2018. A second series of interviews was conducted with seven cisgender veterans beginning in August 2020 and ending in January 2021. The dual purpose of this study was to investigate transgender service members’ experiences during the Obama administration and through the first years of the Trump administration. Secondly, interviews were conducted with cisgender veterans from roughly the same service time period. Findings provide a glimpse into the lives of transgender active duty service members post-DADT and during the Trump Administration ban. Data also reveals how a sample of cisgender veterans view policy and other issues surrounding transgender active duty service personnel. Participants from both groups agreed that unit cohesion and readiness was not negatively impacted by transgender active duty military personnel and that inclusion was a positive and unifying factor.

Enhancing Gender

Transgender healthcare faces a dilemma. On the one hand, access to certain medical interventions, including hormone treatments or surgeries, where desired, may be beneficial or even vital for some gender dysphoric trans people. But on the other hand, access to medical interventions typically requires a diagnosis, which, in turn, seems to imply the existence of a pathological state—something that many transgender people reject as a false and stigmatizing characterization of their experience or identity. In this paper we argue that developments from the human enhancement debate can help clarify or resolve some of the conceptual and ethical entanglements arising from the apparent conflict between seeking medicine while not necessarily suffering from a pathology or disorder. Specifically, we focus on the welfarist account of human enhancement and argue it can provide a useful conceptual framework for thinking about some of the more contentious disagreements about access to transgender healthcare services.

Post-Admission Cognitive Therapy for a Transgender Service Member With a Recent Suicidal Crisis: A Case Study of Gender-Affirming Care

While elevated suicide risk in the American military and veteran population has led to the development of targeted interventions, the increased risk of suicidal ideation and behavior among transgender and gender diverse (TGD) Service members requires that interventions address suicide risk within the context of minority stressors and gender-affirming care. This case study presents Jordan (an alias), a transgender Service member who received inpatient psychiatric treatment following a suicide attempt precipitated by distress relating to gender dysphoria, minority status, and associated stressors. Jordan completed Post-Admission Cognitive Therapy (PACT; Ghahramanlou-Holloway, Cox, & Greene, 2012), a cognitive-behavioral intervention targeting suicide risk among military personnel and dependents psychiatrically hospitalized following a suicidal crisis. Within the context of PACT, Jordan’s treatment included identifying and addressing distress related to minority stressors (externalized stigma, internalized transphobia, anticipated rejection, gender concealment) using gender-affirming best practices. Marked changes in Jordan's self-report measures from baseline to follow-up, as well as qualitative changes reported by Jordan, demonstrate that she felt comfortable, safe, and ready to be discharged from the inpatient unit after completing PACT treatment and gaining exposure to the skills necessary to help prevent and/or manage future suicidal crises. Treatment implications and recommendations for addressing suicide risk within the context of gender-affirming care and prevalent minority stressors are discussed.

The institution of medicine and transgender identity construction: Between a doc and a hard place

AbstractResearch shows that when transgender young people are well‐supported throughout their gender transition they have similar levels of depression to their cisgender counterparts. For transgender young people who wish to transition medically, these support systems may include parents as advocates and healthcare professionals who specialize in transgender services. Decisions about steps throughout transition are made by transgender children, their parents, and their physicians. An examination of gender structure theory and medicalization literature helps to assess how medicine‐on institutional, interactional, and individual levels‐contributes to cisnormativity and enables us to reflect on the relationships among sex, gender, and science. This literature review aims to analyze how cultural ideologies influence medical processes that shape the identity construction of transgender children and it sheds light on parental involvement throughout transitions.

Acceptance matters: Disengagement and attrition among LGBT personnel in the U.S. military

LAY SUMMARY The U.S. military has undergone several changes in policies toward lesbian, gay, bisexual, and transgender (LGBT) service members over the past decade. Some LGBT service members report continued victimization and fear of disclosing their LGBT identity, which can affect retention of LGBT personnel serving in the military. However, there is little research on this population. This study uses data from a survey funded by the U.S. Department of Defense (2017-2018) and completed by 544 active-duty service members (296 non-LGBT and 248 LGBT) to better understand the career intentions of LGBT service members. Of transgender service members, 33% plan to leave the military upon completion of their commitment, compared with 20% of cisgender LGB and 13% of non-LGBT service members. LGBT service members were twice as likely as non-LGBT service members to be undecided as to their military career path. Lower perceived acceptance of LGBT service members in the workplace was associated with a higher risk of leaving among LGBT service members. Lower perceived unit cohesion was associated with attrition risk for all members, regardless of LGBT status. These findings suggest that the U.S. military can do more to improve its climate of LGBT acceptance to prevent attrition.

Perceptions of family acceptance into the military community among U.S. LGBT service members: A mixed-methods study

LAY SUMMARY There are approximately 16,000 families of lesbian, gay, bisexual, or transgender (LGBT) service members in the U.S. military, but very little is known about how accepted they feel in the communities in which they live. This study begins to address this question by considering the perspectives of LGBT service members, which they shared both in response to an online survey and in interviews. Findings suggest that many service members believe their spouses and families are accepted by their chain of command. However, a smaller but important group continued to express concerns about their family being accepted in their military community. Many service members appear concerned that family services available to them through the military are not appropriate for LGBT families. Altogether, this article highlights the need for more research to understand the well-being and needs of this group.

Evaluation of an electronic consultation service for transgender care

BackgroundAccess to transgender care in Canada is poor. Although primary care providers are ideally positioned to initiate care, many feel uncomfortable providing transgender care. This study aimed to explore the impact of an electronic consultation (eConsult) service between primary care providers and transgender care specialists on access to care and to explore the content of clinical questions that were asked.MethodsThis was a retrospective mixed methods analysis of 62 eConsults submitted between January 2017 and December 2018 by primary care providers to specialists in transgender care in a health region in eastern Ontario, Canada. A descriptive analysis was conducted to assess the average response time and the total time spent by the specialist for the eConsults. An inductive and deductive content analysis was carried out to identify common themes of clinical questions being asked to transgender specialists. A post-eConsult survey completed by primary care providers was assessed to gain insight into avoided face-to-face referrals and overall provider satisfaction.ResultsThe median specialist response time was 1.2 days (range: 1 h to 5 days) and the average time spent by specialists per eConsult was 18 min (range: 10 to 40 min). The qualitative analysis identified six major themes: 1) interpretation/management of abnormal bloodwork, 2) change in management due to lack of desired effect/hormone levels not a target, 3) initiation of hormone therapy/initial work up, 4) management of adverse effects of hormone therapy, 5) transition related surgery counseling and post-op complications, and 6) management of patients with comorbidities. Approximately one-third of eConsults resulted in an avoided face-to-face referral and 95% of primary care providers rated the value of their eConsult as a 5 (excellent value) or 4.ConclusionsThis study demonstrated that a transgender eConsult service has potential to significantly improve access to care for transgender patients. Given the importance that timely access has on improving mental health and reducing suicide attempts, eConsult has the potential to make a substantial clinical impact on this population. Identified themes of eConsult questions provides insight into potential gaps in knowledge amongst primary care providers that could help inform future continuing education events.

Mental Health and Health Risk Behaviors of Active Duty Sexual Minority and Transgender Service Members in the United States Military.

Purpose: The aim of this study was to examine health risk behaviors and mental health outcomes among sexual minority and transgender active duty military service members and their heterosexual and cisgender counterparts. Methods: Participants (N = 544) were recruited by using respondent-driven sampling between August 2017 and March 2018 and completed an online survey by using validated measures of cigarette smoking, alcohol use, anxiety, depression, post-traumatic stress disorder (PTSD), and suicidality. Bayesian random intercept multiple logistic regressions were used to understand differences between sexual minority participants and heterosexual participants as well as between transgender participants and both their cisgender sexual minority and cisgender heterosexual peers. Results: Cisgender sexual minority women service members were more likely to meet criteria for problematic alcohol use (adjusted odds ratio [aOR] = 10.11) and cigarette smoking (aOR = 7.12) than cisgender heterosexual women. Cisgender sexual minority men had greater odds of suicidality (aOR = 4.73) than their cisgender heterosexual counterparts. Transgender service members had greater odds of anxiety, PTSD, depression, and suicidality than their cisgender peers. Conclusion: Military researchers and policymakers who seek to improve the overall health and well-being of sexual minority and transgender service members should consider programs and policies that are tailored to specific health outcomes and unique sexual minority and transgender subgroups.

APA’s Government, Policy, and Advocacy Update

Back to table of contents Previous article Next article Government & LegalFull AccessAPA’s Government, Policy, and Advocacy UpdateSearch for more papers by this authorPublished Online:9 Feb 2021https://doi.org/10.1176/appi.pn.2021.2.40Biden Lifts Ban on Transgender People Enlisting in MilitaryAs one of his first acts in office, President Joe Biden signed an executive order that reversed the ban on transgender individuals enlisting in the military. When Trump issued a memo related to the ban in 2018, APA released a statement in which APA CEO and Medical Director Saul Levin, M.D., M.P.A., called the ban “a discriminatory action.” He continued: “This ban not only harms those who have chosen to serve our country, but it also casts a pall over all transgender Americans. This discrimination has a negative impact on the mental health of those targeted.”In his executive order, Biden revoked Trump’s 2018 memo, immediately prohibited involuntary discharges of transgender troops, and ordered the Pentagon to review the records of any service members who were previously forced out of the military on the basis of gender identity. The order also requires that a process be established by which transgender service members can transition while serving.“It is my conviction as commander in chief of the Armed Forces that gender identity should not be a bar to military service,” Biden’s order stated. “Therefore, it shall be the policy of the United States to ensure that all transgender individuals who wish to serve in the United States military and can meet the appropriate standards shall be able to do so openly and free from discrimination.”Executive Order Reinforces Discrimination Protections for LGBTQBiden also issued an executive order plainly stating that LGBTQ individuals are protected from discrimination in health care settings, schools, and workplaces.Last year, the Supreme Court ruled that Title VII of the Civil Rights Act of 1964 applies to LGBTQ individuals because it prohibits employee discrimination based on sex. (See Psychiatric News). Shortly before the ruling, the Trump administration had issued a rule that eliminated health care discrimination protections for LGBTQ patients, claiming that the term “sex” refers only to whether someone is male or female, as determined by biology. (See Psychiatric News). The rule was blocked by a federal judge.Biden’s order requires all federal agencies to review existing regulations and revise them to make it clear that the definition of “sex” includes gender identity and sexual orientation.“People should be able to access health care and secure a roof over their heads without being subjected to sex discrimination,” Biden’s order stated. “All persons should receive equal treatment under the law, no matter their gender identity or sexual orientation. ■ ISSUES NewArchived

Doing and Negotiating Transgender on the Front Line: Customer Abuse, Transphobia and Stigma in the Food Retail Sector

Despite growing research on LGBT+ populations, few studies have examined transgender individuals’ specific workplace experiences, whose voice is often subsumed in a wider category. This article presents the story of Kathrine, a female transgender food retail worker, and discusses the abusive, discriminatory and transphobic behaviour of customers, which has received limited attention in the sociology of service work literature. The article reveals the stigmatization of transgender employees by customers, which is expressed through micro-aggressions, such as mis-gendering, mocking and harassing, and is often neglected and/or tolerated by management. Kathrine discusses the coping strategies she utilizes to reduce the negative consequences of the stigma, and to negotiate and protect her gender identity. These include confronting and/or refusing to serve transphobic customers, reflecting her resilience towards discrimination and abuse. The article calls for further research to understand transgender service employees’ experiences and the complexity and diversity of coping strategies used by stigmatized workers.

Health and Service-related Impact of Sexual and Stalking Victimization During United States Military Service on LGBT Service Members.

Prior research among military personnel has indicated that sexual harassment, stalking, and sexual assault during military service are related to negative health sequelae. However, research specific to LGBT U.S. service members is limited. The current study aimed to explore the health, service utilization, and service-related impact of stalking and sexual victimization experiences in a sample of active-duty LGBT U.S. service members (N = 248). Respondent-driven sampling was used to recruit study participants. U.S. service members were eligible to participate if they were 18 years or older and active-duty members of the U.S. Army, U.S. Navy, U.S. Marine Corps, or U.S. Air Force. This study included a sizeable portion of transgender service members (N = 58, 23.4%). Sociodemographic characteristics, characteristics of military service, health, and sexual and stalking victimization in the military were assessed. Regression was used to examine relationships between health and service outcomes and sexual and stalking victimization during military service. Final adjusted models showed that experiencing multiple forms of victimization in the military increased the odds of visiting a mental health clinician and having elevated somatic symptoms, posttraumatic stress disorder symptomatology, anxiety, and suicidality. Sexual and stalking victimization during U.S. military service was statistically significantly related to the mental and physical health of LGBT U.S. service members. Interventions to reduce victimization experiences and support LGBT U.S. service members who experience these types of violence are indicated. Research that examines the role of LGBT individuals' experiences and organizational and peer factors, including social support, leadership characteristics, and institutional policies in the United States military is needed.

A Dialogue on Therapeutic Peer-to-Peer Models for Trans and Nonbinary Surgical Support

Abstract Transgender peer-to-peer support groups can provide an invaluable space for healing by fostering collective knowledge, resource sharing, and supportive self-determination. Historically, transgender people have facilitated these grassroots mental health and gender transition supports within their communities, picking up the slack where providers and healthcare systems have either fallen short, or worse, have actively sought to bar access. Peer models emerge from these community-based movements but have also started to become more formally integrated into some state-funded models of healthcare. The following article investigates the impacts of clinical work conducted in institutionally funded, peer-to-peer transgender mental health support groups through a narrative-driven conversation between the authors: a transgender service provider and a transgender service user. Drawing on our shared experience, we discuss the benefits and shortcomings of this innovative, yet delegitimized form of healthcare provision for transgender people.

“Even If the Policy Changes, the Culture Remains the Same”: A Mixed Methods Analysis of LGBT Service Members’ Outness Patterns

Despite repeal of the Don’t Ask, Don’t Tell policy in 2011 and the ban on open transgender service from 2016 to 2019, lesbian, gay, bisexual, and transgender (LGBT) service members may be reluctant to disclose their identities to fellow military personnel. This study used data collected through the Department of Defense–funded mixed methods research study conducted from 2016 to 2018. A sample of 248 active duty LGBT service members completed a survey, while a sample of 42 LGBT active duty service members participated in an in-depth interview. Regression analyses tested for differences in outness by demographic and military traits; a thematic analysis of qualitative data contextualizes these findings. Outness to fellow service members varied greatly by rank, military branch, education level, sexual orientation, gender identity, and marital status. The lowest outness was to chaplains (38%), while the highest outness was to LGBT unit friends (93%). Implications for military leadership and service providers are discussed.