Washington, D.C. – Today, 83 bipartisan Members of Congress, led by Congresswoman Julia Brownley (D-CA), called on the U.S. Department of Veterans Affairs (VA) to end its ban on medically necessary treatments for our country’s transgender veterans. Currently, the VA bans certain medically prescribed procedures to treat gender dysphoria. The VA, through a recent request for comment, is seeking to justify this ban based on antiquated and discriminatory claims that these treatments can lead to suicidal thoughts. In fact, peer-reviewed evidence shows that denying patients access to these procedures can actually increase the risk of suicide.
“More than 160,000 transgender servicemembers have put their lives on the line in order to protect our constitutionally protected freedoms, including the right to live free from discrimination,” said Congresswoman Brownley, Ranking Member of the House Veterans’ Affairs Health Subcommittee. “It is simply unacceptable that we would ask our veterans to risk their lives to protect our rights, but we would refuse to defend theirs in return. The VA must put an end to this discriminatory and outdated ban on treatments for gender dysphoria and ensure that all our nation’s veterans have access to the healthcare they have earned.”
“VA’s prohibition on surgical treatment for veterans experiencing gender dysphoria is not only discriminatory on its face, it also puts the health and well-being of transgender veterans at risk. Let me be clear: denying any veteran the medical treatment they need to live healthy and productive lives is antithetical to VA’s core mission, and to do so based on a prejudiced world-view that disregards scientific consensus is disgraceful. VA should immediately reverse course and provide these veterans the care they deserve. It is the right thing to do,” said Congressman Tim Walz, Ranking Member of the House Veterans’ Affairs Committee.
“One of our government’s most sacred obligations is to support those who have served their country, regardless of their gender identity,” said Charlotte Clymer, the Human Rights Campaign’s Press Secretary for Rapid Response. “The Department of Veterans Affairs’ exclusion of many forms of transition-related health care flies in the face of every major medical authority and undermines the health and wellbeing of transgender patriots who have laid their lives on the line for this country and their families. We are grateful to Representative Brownley for her leadership on this critical issue, and thank all the Members of Congress who signed onto this letter to support transgender veterans like myself.”
“We thank Representative Brownley and Members of Congress who are calling on the VA to do the right thing by veterans. No eligible veteran should be denied the health care they have earned and that medical professionals say they need. Standing between veterans and their care would be nothing less than a moral failure,” said Mara Keisling, Executive Director of the National Center for Transgender Equality.
The letter, which is supported by the Human Rights Campaign, the National Center for Transgender Equality, Equality California, and the Palm Center, was signed by Reps. Julia Brownley (D-CA), Tim Walz (D-MN), Salud O. Carbajal (D-CA), Mark Takano (D-CA), Andre Carson (D-IN), Yvette D. Clarke (D-NY), Mark DeSaulnier (D-CA), Mike Quigley (D-IL), Nanette Barragán (D-CA), Raúl M. Grijalva (D-AZ), Eleanor Holmes Norton (D-DC-AL), Pramila Jayapal (D-WA), Joseph P. Kennedy III (D-MA), Alan Lowenthal (D-CA), Michelle Lujan Grisham (D-NM), Sean Patrick Maloney (D-NY), Chellie Pingree (D-ME), Jackie Speier (D-CA), Peter Welch (D-VT), Barbara Lee (D-CA), Nydia M. Velázquez (D-NY), Anthony G. Brown (D-MD), Daniel T. Kildee (D-MI), Alcee L. Hastings (D-FL), Dina Titus (D-NV), Niki Tsongas (D-MA), Jared Polis (D-CO), Susan Davis (D-CA), Danny K. Davis (D-IL), Earl Blumenauer (D-OR), Scott H. Peters (D-CA), Tim Ryan (D-OH), Kathleen M. Rice (D-NY), Elizabeth H. Esty (D-CT), Zoe Lofgren (D-CA), Jan Schakowsky (D-IL), Bill Foster (D-IL), Ted W. Lieu (D-CA), Lucille Roybal-Allard (D-CA), Jerrold Nadler (D-NY), Bonnie Watson-Coleman (D-NJ), A. Donald McEachin (D-VA), J. Lou Correa (D-CA), Debbie Wasserman Schultz (D-FL), Gwen Moore (D-WI), Robert A. Brady (D-PA), Darren Soto (D-FL), Colleen Hanabusa (D-HI), Adriano Espaillat (D-NY), Mark Pocan (D-WI), Jamie Raskin (D-MD), Judy Chu (D-CA), Ann McLane Kuster (D-NH), Adam B. Schiff (D-CA), José E. Serrano (D-NY), Diana DeGette (D-CO), Jimmy Panetta (D-CA), David Cicilline (D-RI), Suzan DelBene (D-WA), Frederica S. Wilson (D-FL), Donald M. Payne, Jr. (D-NJ), Jared Huffman (D-CA), Albio Sires (D-NJ), Peter A. DeFazio (D-OR), Keith Ellison (D-MN), Charlie Crist (D-FL), David E. Price (D-NC), John Yarmuth (D-KY), Karen Bass (D-CA), Suzanne Bonamici (D-OR), Ileana Ros-Lehtinen (R-FL), William R. Keating (D-MA), Paul D. Tonko (D-NY), Donald Norcross (D-NJ), Henry C. “Hank” Johnson, Jr. (D-GA), Frank Pallone, Jr. (D-NJ), Eliot L. Engel (D-NY), Ruben Kihuen (D-NV), Grace Meng (D-NY), Lois Frankel (D-FL), Eric Swalwell (D-CA), Ruben Gallego (D-AZ), and Katherine Clark (D-MA).
The full text of the letter can be found here and below.
September 7, 2018
The Honorable Robert Wilkie
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue SE
Washington, DC 20420
RE: Notice of Petition for Rulemaking and Request for Comments – Exclusion of Gender Alterations from the Medical Benefits Package
Dear Secretary Wilkie:
Our country has made a sacred commitment to care for those who have borne the battle, and that includes the more than 163,000 transgender veterans[1] who have served their country in uniform. We urge the U.S. Department of Veterans Affairs (VA) to provide our nation’s transgender veterans, all medically necessary treatments prescribed by a veterans’ physician, including medically necessary procedures to treat gender dysphoria.
The VA itself explained in a 2016 Impact Analysis that the exclusion for “gender alterations” was originally based on an assumption that surgical treatments were not medically necessary, but it agreed that “surgical procedures are now widely accepted in the medical community as medically necessary treatment for gender dysphoria.”[2] Indeed, there is an overwhelming international consensus that medical treatments, including surgical treatments, are safe, effective, and medically necessary when clinically indicated to alleviate gender dysphoria. Leading medical associations agree that such treatment should be a covered benefit in programs such as the VA.[3] America’s leading medical and mental health organizations, including the American Medical Association, the American Academy of Nursing, the American College of Physicians, the American Medical Student Association, and the American Nurses Association, have argued against the VA’s current ban on covering surgical treatment for gender dysphoria. They maintain that proper treatment of gender dysphoria, as determined between a patient and physician on a case-by-case basis, can include surgical treatment. These experts warned that by prohibiting VA physicians from recommending and providing this medically necessary care, the VA was contradicting established standards of care and placing transgender veterans at “substantially greater risk of serious physical and emotional trauma.”[4]
The VA, in its request for comment, is attempting to justify a continued ban on surgical treatment for gender dysphoria because it could lead to suicide and suicidal ideation among veterans. In particular, the VA cites the February 2018 Department of Defense report on “Military Service by Transgender Individuals” to suggest that there is “considerable scientific uncertainty” on the efficacy of medical treatments for gender dysphoria. This report was widely refuted by medical experts, who criticized its mischaracterization of the scientific consensus on the effectiveness of medical treatments for gender dysphoria.[5]
In fact, evidence shows that denying patients access to this medically-recommended procedure can increase risk of suicide. As the medical community notes in their brief: “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.” [6]
This broad medical consensus on the treatment of gender dysphoria is based on decades of peer-reviewed studies and clinical observation—including studies of veterans—that demonstrate its efficacy and substantial health benefits. Studies have found that access to medical treatment, including surgical treatments when clinically indicated, substantially contribute to decreasing rates of suicidal ideation and behavior,[7] including among transgender veterans.[8] Additionally, numerous studies have found that access to these treatments is associated with substantial improvements in other measures of mental health closely tied to suicidality, including anxiety and depression.[9]
Our nation’s veterans have put their lives on the line to defend our freedoms, including the right to equality and to protection from discrimination. That our nation would ask our veterans to protect rights that we would not afford them in return is unacceptable. It is wrong to single out any group of veterans to deny access to medically necessary care. While transgender veterans represent a small percentage of the overall veteran population, transgender Americans are twice as likely to be veterans than the general US population.[10] By excluding medically necessary treatments from its medical benefits package, the VA hurts transgender veterans who have served their country, harming their health and in some cases putting their lives at risk.
Simply put, the VA has an obligation to provide the necessary care that is prescribed to enrolled veterans by their health care practitioners. It is unconscionable to deny veterans the same access to health care services that civilians receive in the private sector, and that is available to Medicare beneficiaries and federal workers, simply because of outdated and unscientific prejudice against their gender identity.
As Members of Congress, we have repeatedly declared our commitment to caring for our veterans who have risked their lives to protect our essential freedoms. In providing this coverage through the Veterans Health Administration we affirm this commitment, ensuring our veterans will not have to face insurmountable debts and continued distress to realize their gender identity. Thank you for your attention to this important matter.
Sincerely,
[1] Janelle Downing, Conron, Herman, and Blosnich, Transgender and Cisgender US Veterans Have Few Health Differences, (July 2018) https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2018.0027
[2] VHA Chief Financial Officer, Impact Analysis for RIN 2900-AP69, Removing Gender Alterations Restriction from the Medical Benefits Package. (July 24, 2016)
[3] World Prof. Ass’n for Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. (7th ed.2011) https://www.wpath.org/publications/soc; Wylie C. Hembree, Endocrine Treatment of Gender- Dysphoric/ Gender- Incongruent Persons: An Endocrine Society Clinical Practice Guideline. (2017) 102 The Journal of Clinical Endocrinology and Metabolism 3869; Am. Medical Association, AMA Policies on GLBT Issues, Patient Centered Policy H-185.950, Removing Financial Barriers to Care for Transgender Patients. (2008) http://www.tgender.net/taw/ama_resolutions.pdf; Am. Psychiatric Association, Position Statement on Discrimination Against Transgender and Gender Variant Individuals. (2012) http://www.dhcs.ca.gov/services/MH/Documents/2013_04_AC_06d_APA_ps2012_Transgen_Disc.pdf;Am. Psychological Association, Policy on Transgender, Gender Identity and Gender Expression Non-Discrimination. (2008) http://www.apa.org/about/policy/transgender.aspx; Am. College of Physicians, Lesbian, Gay, Bisexual and Transgender Health Disparities: A Policy Position Paper from the American College of Physicians. (2012). https://www.aafp.org/dam/AAFP/documents/about_us/special_constituencies/2012RCAR_Advocacy.pdf;American College of Obstetricians and Gynecologists, Committee Opinion No. 512: Health Care for Transgender Individuals. (2011) https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Health-Care-for-Transgender-Individuals;
[4] Brief for Medical and Mental Health Professionals. et al. as Amici Curiae Supporting Petitioners, Dee Fulcher, Giuliano Silva, and the Transgender American Veterans Associations vs. Secretary of Veterans Affairs
[5] American Medical Association, Letter to Secretary Mattis. (April 3 2018) https://www.politico.com/f/?id=00000162-927c-d2e5-ade3-d37e69760000; American Psychiatric Association, APA Reiterates Its Strong Opposition to Ban of Transgender Americans from Serving in U.S. Military. (March 24 2018)https://www.psychiatry.org/newsroom/news-releases/apa-reiterates-its-strong-opposition-to-ban-of-transgender-americans-from-serving-in-u-s-military; American Psychological Association, APA Statement Regarding Transgender Individuals Serving in Military. (March 26 2018) http://www.apa.org/news/press/releases/2018/03/transgender-military.aspx; Palm Center, Six Former Surgeons General Rebut Pentagon Assertions About Medical Fitness of Transgender Troops. (April 25 2018) https://www.palmcenter.org/six-former-surgeons-general-%E2%80%8Brebut-pentagon-assertions-about-medical-fitness-of-transgender-troops
[6] Brief for Medical and Mental Health Professionals. et al. as Amici Curiae Supporting Petitioners, Dee Fulcher, Giuliano Silva, and the Transgender American Veterans Associations vs. Secretary of Veterans Affairs, Pursuant to 38 U.S.C. § 502 (2017)(No. 17-1460).
[7]. The Public Policy Research Portal Cornell University, What does the scholarly research say about the effect of gender transition on transgender wellbeing? (2018) https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-the-well-being-of-transgender-people;G Bauer, J. Pyne, M. Francino, T, R. Hammond, Suicidality among trans people in Ontario: Implications for social work and social justice. (2013) Service social (59)1, 35-62; L Bailey, S Ellis, J McNeil, Suicide risk in the UK trans population and the role of gender transition in decreasing suicidal ideation and suicide attempt. (2014) The Mental Health Review, 19(4)209-220; G De Cuypere, E Elaut, G Heylens, G Maele, V Selvaggi, Long term follow- up: Psychosocial outcome of Belgain transsexuals after sex reassignment surgery. (2006) Sexologies 15(2)126-133; C Imbimbo, P Verze, A Palmieri, N Longo, F Fusco, D Arcaniolo, V Mirone, A report from a single institute’s 14 year experience in treatment of male to female transsexuals. (2009) The Journal of Sexual Medicine, 6(10) 2736-2745; G Bauer, R Scheim, A I Pyne, J Travers, R Hammond, Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada (2015) BMC Public Health 15(1)1-15
[8] Tucker, R. P., Testa, R. J., Simpson, T. L., Shipherd, J. C., Blosnich, J., & Lehavot, K. Hormone therapy, gender affirmation surgery, and their association with recent suicidal ideation and depressive symptoms in transgender veterans. (2018) https://doi.org/10.1017/S0033291717003853
[9] C Dhejne, R Van Vlerken, G Heylens, J Arceleus, Mental health and gender dysphoria: a review of the literature. (2016) International Review of Psychiatric; HM Murad, BM Elamin, ZM Garcia, JR Mullan, A Murad, PJ Erwin, VM Montori, Homronal therapy and sex reassignment: A systematic review and meta-analysis of the quality of life and psychosocial outcomes. (2010) Clinical Endocrinology https://www.ncbi.nlm.nih.gov/pubmed/19473181; A de Vries, J McGuire, T. Steensma, E Wagenaar, T Doreleijers, P Cohen- Kettenis, Young adult psychological outcome after puberty suppression and gender reassignment. (2014). http://pediatrics.aappublications.org/content/early/2014/09/02/peds.2013-2958; S Davis, S Colton-Meier, Effects of testosterone treatment and chest reconstruction surgery on mental health and sexuality in female to male transgender people. (2014) https://www.tandfonline.com/doi/abs/10.1080/19317611.2013.833152; R Weigert, E Frison, Q Sessiecq, K Al Mutairi, V Casoli, Patient satisfaction with breasts and psychosocial, sexual and physical wellbeing after breast augmentation in male to female transsexuals. (2013) Plastic and Reconstructive Surgery, 132(6), 1421–1429; L. Schmidt and R Levine, Psychological outcomes and reproductive issues among gender dysphoric individuals (2015). Endocrinology and Metabolism Clinics of North America 44(4), 773-785.
[10] Sandy E. James, The Report of the 2015 U.S. Transgender Survey 167. (2016), www.ustranssurvey.org/report.
Issues: 115th Congress, Veterans' Affairs