The study’s authors acknowledge that it is difficult to know how many transgender people there are in the services because the issue has not been widely examined. To estimate those figures, the authors relied on research that tried to determine the rate of transgender people in society.

The report is written mainly in an academic tone. But the authors used some of their most pointed language to describe the negative effects of the military continuing its policy of not paying for transgender transitions.

“The discussion of health care among military transgender personnel is incomplete without considering the potential unintended effects of constraining or limiting gender transition-related treatment,” the report said. “Adverse consequences of not providing transition-related health care to transgender personnel could include avoidance of other necessary health care such as important preventive services, increased rates of mental and substance use disorders, suicide, and reduced productivity.”

Transgender people who are denied health care may turn to other solutions “such as injecting construction-grade silicon into their bodies to alter their shape,” the report said. Studies have shown that there is a dramatic reduction in suicide rates among transgender people after they receive surgery, it added.

One of the most difficult issues the Pentagon would have to confront with transgender service members would be how to deal with them in the period of time before and during their gender transition, the report said.

“DoD will need to establish policies of when individuals may use the uniforms, physical standards, and facilities (e.g. barracks, restrooms) of their target gender,” the report said. The military would need to give the members mental health screening before deployments to ensure their readiness, it added.