President Donald Trump last week directed the Pentagon to stop recruiting openly transgender people to serve in the military, and Defense Secretary James Mattis today said he will appoint an expert panel to determine whether to allow trans members currently enlisted to continue their service. Already, the American Civil Liberties Union has filed a lawsuit challenging the president's memorandum on equal-protection and substantive due process grounds.

After the president initially tweeted his intention to ban transgender individuals from serving in the military, the AMA issued a statement saying “there is no medically valid reason” for such action.

Similarly, the AMA has joined an amicus brief with several other health care-related organizations in support of transgender veterans seeking a rule change that would amend or repeal the U.S. Department of Veterans Affairs (VA) policy of not covering sex-reassignment surgery (SRS) for veterans with gender dysphoria.

“AMA policy also supports public and private health insurance coverage for treatment of gender dysphoria as recommended by the patient's physician,” AMA President David O. Barbe, MD, said in the Association’s response to the president’s tweets. “According to the Rand study on the impact of transgender individuals in the military, the financial cost is a rounding error in the defense budget and should not be used as an excuse to deny patriotic Americans an opportunity to serve their country. We should be honoring their service—not trying to end it.”

Another AMA policy affirms that “transgender service members be provided care as determined by patient and physician according to the same medical standards that apply to non-transgender personnel.” Together, these policies were included in the amicus brief the AMA joined in the case seeking the VA rule change.

The plaintiffs in the case are transgender veterans Dee Fulcher, a former Marine sergeant, and Giuliano Silva, a former member of the Army, and the Transgender American Veterans Association (TAVA), an organization formed in 2003 that now has some 2,200 members.

Suit began as rule-repeal request

They originally filed a petition with the VA seeking the rule change on May 9, 2016. Several members of Congress joined the cause and advocated for changing the rule in September 2016.

Current VA Secretary David Shulkin, MD, who was then VA under secretary for health in the Obama administration, replied with letters dated Nov. 10. Dr. Shulkin wrote that the VA “has been and will continue to explore a regulatory change that would allow the VA to perform gender-alteration surgery and a change in the medical benefits package when appropriate funding is available.”

Fulcher, Giuliano and TAVA then responded by filing their suit on Jan. 6, 2017.

Among other charges, the suit includes Giuliano’s complaint that a VA physician recommended he undergo a mastectomy to relieve back pain—an operation the VA would normally provide. But the suit alleges that the surgeon Giuliano was referred to had determined that the mastectomy would primarily be a transition-related surgery and, therefore, not covered as a VA benefit.

Related Coverage AMA takes several actions supporting transgender patients

The AMA amicus brief notes that the VA covers all medically necessary care for transgender veterans except SRS. The brief quotes Dr. Shulkin’s Nov. 10 letters stating how VA services for transgender veterans include hormonal therapy, mental health care, preoperative evaluation and medically necessary postoperative and long-term care following SRS.

“Blanket bans on SRS—such as the VA’s ban—disrupt continuity of patient care,” the brief states. “This disruption of continuity of care runs contrary to the healthcare needs of transgender veterans, which the VA well understands.”

The brief then goes on to mention that the VA has been providing transition-related care since 2011 and has opened clinics in Cleveland and Tucson, Arizona, that specialize in providing care to transgender veterans.

The brief cites cases where two different federal appellate courts reversed rulings that upheld blanket prohibitions forbidding hormone therapy and SRS for transgender prison inmates.

Policy may result in suicide risk

The VA’s blanket exclusion of SRS “denies patients with the most serious levels of gender dysphoria, like plaintiffs Dee Fulcher and Giuliano Silva, medically necessary care, placing them at substantially greater risk of serious physical and emotional trauma,” the brief argues. “When not properly treated, gender dysphoria can result in clinically significant psychological distress, dysfunction, debilitating depression, and, for some people, self-mutilation, thoughts of and attempts at suicide, and death.”

The brief mentions that Silva has attempted suicide. It also cites a case where a transgender veteran took her own life in June 2015 and mentioned in her suicide note that her inability to have her medical procedures covered was a reason for her desperation and hopelessness.

Also mentioned in the brief is a case where a transgender veteran was denied coverage of her SRS and had the procedure done in Mexico. The operation, however, was performed so poorly that she had to undergo years of post-operative care and corrective surgeries through the VA.

“The VA’s refusal to cover such care has no basis in medicine,” the brief concludes. “This blanket ban prevents medical and mental health professionals from prescribing the proper treatment and places veterans at substantially greater risk of physical and emotional harm.”

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