Staff Perspective: The Healthcare of Transgender Service Members - A Discussion on Recent Policy Developments
With the 2011 repeal of Don’t Ask, Don’t Tell, and Don’t Pursue policy, which later became known as Don’t Ask, Don’t Tell (DADT), the transgender military population was left unprotected with an increased uncertainty about their status in the US military. They were unable to join the military and if already serving, being identified as a transgender individual could be grounds for involuntary separation or denial of reenlistment (Goldbach & Castron, 2016; Kerrigan, 2012). Then, on July 13, 2015, the change began with a memorandum informing Military Departments that a working group would be developing a policy so that transgender individuals could serve openly in the military. Also, the memorandum clarified that there would be no denial of service or continued service for transgender individuals without the approval of the Secretary of Defense for Personnel and Readiness.
Less than a year later, on June 30, 2016, the Secretary of Defense ended the ban on transgender Americans serving in the United States military. Transgender Service members may serve openly and cannot be separated on the basis of being a transgender individual alone according to the Directive-Type Memorandum (DTM) 16-005 and Department of Defense Instruction (DoDI) 1300.28. To further support the DTM and DoDI, Military Services have a Commander’s Training Handbook, Medical Guidance, and Policy and Procedures for Defense Enrollment Eligibility Reporting System (DEERS), the personnel management system, to include gender marker change. The timeline from October 1, 2016 until July 1, 2017, is scheduled for commanders, medical personnel, operating forces, and recruiters to be trained to enable full implementation of the DTM and DoDI. However, there is a delay in the recruitment portion of its implementation and the branches of service will recruit transgender applicants no later than July 1, 2017, after the new DoDI 6130.03 is effective.
DoDI 1300.28 outlines the role of the Service member during the process of gender transition in the military. This includes that the Service member: 1) obtain a medical diagnosis that gender transition is medically necessary from a military medical doctor, 2) notify the commander of the diagnosis, treatment, and schedule for the treatment, and 3) notify the commander of any changes to the plan or schedule. Lastly, the Service member’s role includes to provide an estimated time when their gender marker in DEERS will be changed, ultimately defining the completion of the transition. At that point, the Service member is recognized and must meet all military standards in their “preferred” gender. It appears that the DoD emphasizes the medical transition. However, it is important that behavioral health providers do not discount the social transition that individuals undergo.
With respect to behavioral health providers, the new policy mentions that training will be provided to ensure implementation. But, there is a difference between compliance and competence. One might question their individual level of competency to treat this unique and underserved population effectively. Another might question which training and resources will guide our treatment in the absence of evidence based approaches. The limited amount of existing studies do not have a clear focus on the experience of active duty transgender Service members and clinical intervention. And yet, it is estimated that there are 15,500 transgender individuals in the military as active duty or Selected Reserve forces (Gates & Herman, 2014). A more recent RAND Corporation study provided a range of 2,150 to 10,790 transgender personnel serving in either active duty or Selected Reserve (Schaefer et al., 2016). Clearly, this identifies a large population potential requiring further understanding, research, and intervention.
Unfortunately, there continues to be misinformation about transgender individuals in not only the military, but also the civilian population. Moreover, there is a great need for education to overcome the biases and discrimination of the transgender population. It is imperative to understand the diversity within the transgender population and the variation within the options for transition (Dietert & Dentice, 2015). APA (2015) encourages providers to understand gender as a wide spectrum of gender identities, not as a binary construct. In that way, I will now change the language of “transgender” individuals to Transgender and Gender Nonconforming (TGNC) for the remainder of this blog to be more affirmative, inclusive, as well as in line with the APA Guidelines.
In order to close this gap, as the policy is implemented and providers are trained, we can begin to question how to become more competent with TGNC Service members. Providers may also begin to explore their own knowledge, skills, and awareness when responding to the needs of their TGNC patients. We’ve seen these three areas used within the tripartite theory of multicultural counseling competencies. The Gender Identity Counselor Competency Scale (GICCS) was recommended for use by providers to determine their competency with the transgender population. A recent dissertation indicated that a revised version, the GICCS-R, is a valid measure, and will help providers, along with training institutions, to understand the level of competency in working with TGNC individuals. Behavioral health providers can improve their competency through gaining more education, training in workshops, consultation, and experience with transgender patients (Cor, 2016). As the DoD begins to implement the new policy, the GICCS-R may help behavioral health providers to become more aware or reflective of their own responses in working with TGNC Service members, especially as they move toward delivering affirmative services.
Upholding a TGNC-affirmative practice also includes engaging with systems in order to improve the sociocultural worlds of our TGNC patients. This would mean that a behavioral health provider’s role is not only as an advocate, but also as an ally, which extends beyond the walls of the clinic. The role includes self-reflection, continuing education, consultation, advocating for the larger TGNC community and work environments, and engaging across disciplines and sharing with others regarding competency. It is recommended that competency in working with TGNC individuals includes the following: understand that gender is not a binary construct as gender expression could be at any point on the gender identity spectrum and do not assume that gender identity is the major concern as recognizing multiple identities is multifaceted (Campbell & Arkles, 2017).
So what can we, as behavioral health providers, do now as we await more guidance regarding implementation of this policy? We can increase the understanding of our own responses in working with TGNC Service members. We can also participate in training and consultation to include considerations from and conversation with other disciplines and systems. These two areas would help to increase our awareness and affirmative attitudes and approaches while gaining an understanding of these Service members. This would help us to understand their experience at any intersection on the gender identity spectrum and the role of TGNC concerns that may or may not be the major reason for seeking behavioral health services. An early adoption of these areas would not only help us to support the DoD, but would also create a more inclusive culture within our communities. Lastly, if you are interested in reading more about lesbian, gay, and bisexual individuals and the military, I would recommend the recent CDP Staff Perspective written by Dr. Sharon Birman.
Laura Cho-Stutler, Psy.D, is a CBT trainer working with the Military Training Programs at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
References
American Psychological Association.(2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70, 832-864.
Campbell, L.F., & Arkles, G. (2017). Ethical and legal concerns for mental health professionals. In A. A. Singh & l. m. dickey (Eds.). Handbook of trans-affirmative counseling and psychological practice (pp. 94-118). Washington, DC: American Psychological Association.
Cor, D.N. (2016). Gender Identity Counselor Competency Scale: A validation study (Doctoral dissertation). The George Washington University, 2016, 1-153. Retrieved from QPDT Open Proquest.
Dietert, M., & Dentice, D. (2015). The transgender military experience: Their battle for workplace rights. Journal of Workplace Rights, 2, 1-12.
Office of the Under Secretary of Defense for Personnel and Readiness. (2016). Department of Defense Instruction (DoDI) 1300.28: In-Service transition for Transgender Service Members.
Secretary of Defense. (2016). Directive-type Memorandum (DTM) 16-005: Military Service of Transgender Service Members
Gates, G.J., & Herman, J.L. (2014). Transgender military services in the Unites States. Retrieved from http://williamsinstitute.law.ucla.edu/wp-content/uploads/Transgender-Military-Service-May-2014.pdf
Goldbach, J.T., & Castro, C.A. (2016). Lesbian, Gay, Bisexual, and Transgender (LGBT) Service Members: Life after Don’t Ask, Don’t Tell. Current Psychiatry Reports, 18 (6), 1-7.
Kerrigan, M.F. (2012). Transgender discrimination in the military: The new Don’t Ask, Don’t Tell. Psychology, Public Policy, and Law, 18(3), 500-518.
Schaefer, Agnes Gereben, Radha Iyengar, Srikanth Kadiyala, Jennifer Kavanagh, Charles C. Engel, Kayla M. Williams and Amii Kress. (2016). Assessing the Implications of Allowing Transgender Personnel to Serve Openly. Santa Monica, CA: RAND Corporation, 2016. http://www.rand.org/pubs/research_reports/RR1530.html.
With the 2011 repeal of Don’t Ask, Don’t Tell, and Don’t Pursue policy, which later became known as Don’t Ask, Don’t Tell (DADT), the transgender military population was left unprotected with an increased uncertainty about their status in the US military. They were unable to join the military and if already serving, being identified as a transgender individual could be grounds for involuntary separation or denial of reenlistment (Goldbach & Castron, 2016; Kerrigan, 2012). Then, on July 13, 2015, the change began with a memorandum informing Military Departments that a working group would be developing a policy so that transgender individuals could serve openly in the military. Also, the memorandum clarified that there would be no denial of service or continued service for transgender individuals without the approval of the Secretary of Defense for Personnel and Readiness.
Less than a year later, on June 30, 2016, the Secretary of Defense ended the ban on transgender Americans serving in the United States military. Transgender Service members may serve openly and cannot be separated on the basis of being a transgender individual alone according to the Directive-Type Memorandum (DTM) 16-005 and Department of Defense Instruction (DoDI) 1300.28. To further support the DTM and DoDI, Military Services have a Commander’s Training Handbook, Medical Guidance, and Policy and Procedures for Defense Enrollment Eligibility Reporting System (DEERS), the personnel management system, to include gender marker change. The timeline from October 1, 2016 until July 1, 2017, is scheduled for commanders, medical personnel, operating forces, and recruiters to be trained to enable full implementation of the DTM and DoDI. However, there is a delay in the recruitment portion of its implementation and the branches of service will recruit transgender applicants no later than July 1, 2017, after the new DoDI 6130.03 is effective.
DoDI 1300.28 outlines the role of the Service member during the process of gender transition in the military. This includes that the Service member: 1) obtain a medical diagnosis that gender transition is medically necessary from a military medical doctor, 2) notify the commander of the diagnosis, treatment, and schedule for the treatment, and 3) notify the commander of any changes to the plan or schedule. Lastly, the Service member’s role includes to provide an estimated time when their gender marker in DEERS will be changed, ultimately defining the completion of the transition. At that point, the Service member is recognized and must meet all military standards in their “preferred” gender. It appears that the DoD emphasizes the medical transition. However, it is important that behavioral health providers do not discount the social transition that individuals undergo.
With respect to behavioral health providers, the new policy mentions that training will be provided to ensure implementation. But, there is a difference between compliance and competence. One might question their individual level of competency to treat this unique and underserved population effectively. Another might question which training and resources will guide our treatment in the absence of evidence based approaches. The limited amount of existing studies do not have a clear focus on the experience of active duty transgender Service members and clinical intervention. And yet, it is estimated that there are 15,500 transgender individuals in the military as active duty or Selected Reserve forces (Gates & Herman, 2014). A more recent RAND Corporation study provided a range of 2,150 to 10,790 transgender personnel serving in either active duty or Selected Reserve (Schaefer et al., 2016). Clearly, this identifies a large population potential requiring further understanding, research, and intervention.
Unfortunately, there continues to be misinformation about transgender individuals in not only the military, but also the civilian population. Moreover, there is a great need for education to overcome the biases and discrimination of the transgender population. It is imperative to understand the diversity within the transgender population and the variation within the options for transition (Dietert & Dentice, 2015). APA (2015) encourages providers to understand gender as a wide spectrum of gender identities, not as a binary construct. In that way, I will now change the language of “transgender” individuals to Transgender and Gender Nonconforming (TGNC) for the remainder of this blog to be more affirmative, inclusive, as well as in line with the APA Guidelines.
In order to close this gap, as the policy is implemented and providers are trained, we can begin to question how to become more competent with TGNC Service members. Providers may also begin to explore their own knowledge, skills, and awareness when responding to the needs of their TGNC patients. We’ve seen these three areas used within the tripartite theory of multicultural counseling competencies. The Gender Identity Counselor Competency Scale (GICCS) was recommended for use by providers to determine their competency with the transgender population. A recent dissertation indicated that a revised version, the GICCS-R, is a valid measure, and will help providers, along with training institutions, to understand the level of competency in working with TGNC individuals. Behavioral health providers can improve their competency through gaining more education, training in workshops, consultation, and experience with transgender patients (Cor, 2016). As the DoD begins to implement the new policy, the GICCS-R may help behavioral health providers to become more aware or reflective of their own responses in working with TGNC Service members, especially as they move toward delivering affirmative services.
Upholding a TGNC-affirmative practice also includes engaging with systems in order to improve the sociocultural worlds of our TGNC patients. This would mean that a behavioral health provider’s role is not only as an advocate, but also as an ally, which extends beyond the walls of the clinic. The role includes self-reflection, continuing education, consultation, advocating for the larger TGNC community and work environments, and engaging across disciplines and sharing with others regarding competency. It is recommended that competency in working with TGNC individuals includes the following: understand that gender is not a binary construct as gender expression could be at any point on the gender identity spectrum and do not assume that gender identity is the major concern as recognizing multiple identities is multifaceted (Campbell & Arkles, 2017).
So what can we, as behavioral health providers, do now as we await more guidance regarding implementation of this policy? We can increase the understanding of our own responses in working with TGNC Service members. We can also participate in training and consultation to include considerations from and conversation with other disciplines and systems. These two areas would help to increase our awareness and affirmative attitudes and approaches while gaining an understanding of these Service members. This would help us to understand their experience at any intersection on the gender identity spectrum and the role of TGNC concerns that may or may not be the major reason for seeking behavioral health services. An early adoption of these areas would not only help us to support the DoD, but would also create a more inclusive culture within our communities. Lastly, if you are interested in reading more about lesbian, gay, and bisexual individuals and the military, I would recommend the recent CDP Staff Perspective written by Dr. Sharon Birman.
Laura Cho-Stutler, Psy.D, is a CBT trainer working with the Military Training Programs at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
References
American Psychological Association.(2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70, 832-864.
Campbell, L.F., & Arkles, G. (2017). Ethical and legal concerns for mental health professionals. In A. A. Singh & l. m. dickey (Eds.). Handbook of trans-affirmative counseling and psychological practice (pp. 94-118). Washington, DC: American Psychological Association.
Cor, D.N. (2016). Gender Identity Counselor Competency Scale: A validation study (Doctoral dissertation). The George Washington University, 2016, 1-153. Retrieved from QPDT Open Proquest.
Dietert, M., & Dentice, D. (2015). The transgender military experience: Their battle for workplace rights. Journal of Workplace Rights, 2, 1-12.
Office of the Under Secretary of Defense for Personnel and Readiness. (2016). Department of Defense Instruction (DoDI) 1300.28: In-Service transition for Transgender Service Members.
Secretary of Defense. (2016). Directive-type Memorandum (DTM) 16-005: Military Service of Transgender Service Members
Gates, G.J., & Herman, J.L. (2014). Transgender military services in the Unites States. Retrieved from http://williamsinstitute.law.ucla.edu/wp-content/uploads/Transgender-Military-Service-May-2014.pdf
Goldbach, J.T., & Castro, C.A. (2016). Lesbian, Gay, Bisexual, and Transgender (LGBT) Service Members: Life after Don’t Ask, Don’t Tell. Current Psychiatry Reports, 18 (6), 1-7.
Kerrigan, M.F. (2012). Transgender discrimination in the military: The new Don’t Ask, Don’t Tell. Psychology, Public Policy, and Law, 18(3), 500-518.
Schaefer, Agnes Gereben, Radha Iyengar, Srikanth Kadiyala, Jennifer Kavanagh, Charles C. Engel, Kayla M. Williams and Amii Kress. (2016). Assessing the Implications of Allowing Transgender Personnel to Serve Openly. Santa Monica, CA: RAND Corporation, 2016. http://www.rand.org/pubs/research_reports/RR1530.html.