It's a different army....

[Chonal Atresia]

---

Members don't see this ad.

Thought y'all might get a kick out of this email. It is 100% accurate and the only things I have changed are names (Blank). I have also deleted the hospital identifier. My buddy was cc'd on this email because he is Chief of ENT at his hospital.

This is what your tax dollars are being spent on while BAH is being cut and military physician bonuses have not been increased 1 cent in over 25 years. I'm all for letting people live their lives the way they want, but tax dollars should not be used for this bulls$%^. If this isn't a kick in the b#$%s, I don't know what is.

Enjoy.......



-----Original Message-----
From: Blank, COL USARMY MEDCOM (US)
Sent: Thursday, December 17, 2015 3:13 PM
To: Blank, CIV (US)
Cc: Blank
Subject: Speech therapist consultant for TG SM working group (UNCLASSIFIED)

Classification: UNCLASSIFIED
Caveats: NONE

Ms Blank
I need your expertise, please: long story short, I have been tasked by the
DCCS to chair the development of a local pathway to address and coordinate
the care for Soldiers who identify as transgender. I already have behavioral
health, endocrine, Ob/Gyn, Plastics, and urology consultants for my team -
now, I just need a speech therapy consultant!
I don't expect this to take a lot of your time, maybe a few hours per month
to get the clinical pathway established - then you would be our go-to
person for any speech therapy needs for this population.
Can I count you in? Please call me if you have any questions.
Thanks
Blank

Blank
COL, MC
Director, GME



Classification: UNCLASSIFIED
Caveats: NONE



Classification: UNCLASSIFIED
Caveats: NONE



<smime.p7s>

 

[TheEarDoc]

Thought y'all might get a kick out of this email. It is 100% accurate and the only things I have changed are names (Blank). I have also deleted the hospital identifier. My buddy was cc'd on this email because he is Chief of ENT at his hospital.

This is what your tax dollars are being spent on while BAH is being cut and military physician bonuses have not been increased 1 cent in over 25 years. I'm all for letting people live their lives the way they want, but tax dollars should not be used for this bulls$%^. If this isn't a kick in the b#$%s, I don't know what is.

Enjoy.......



-----Original Message-----
From: Blank, COL USARMY MEDCOM (US)
Sent: Thursday, December 17, 2015 3:13 PM
To: Blank, CIV (US)
Cc: Blank
Subject: Speech therapist consultant for TG SM working group (UNCLASSIFIED)

Classification: UNCLASSIFIED
Caveats: NONE

Ms Blank
I need your expertise, please: long story short, I have been tasked by the
DCCS to chair the development of a local pathway to address and coordinate
the care for Soldiers who identify as transgender. I already have behavioral
health, endocrine, Ob/Gyn, Plastics, and urology consultants for my team -
now, I just need a speech therapy consultant!
I don't expect this to take a lot of your time, maybe a few hours per month
to get the clinical pathway established - then you would be our go-to
person for any speech therapy needs for this population.
Can I count you in? Please call me if you have any questions.
Thanks
Blank

Blank
COL, MC
Director, GME



Classification: UNCLASSIFIED
Caveats: NONE



Classification: UNCLASSIFIED
Caveats: NONE



<smime.p7s>

Meanwhile Congress is trying to farm out more Veterans to the CHOICE program being mismanaged by two companies that previously mismanaged Tri-Care.

I swear our politicians all need placed against a wall and given copper coated salads.....

 

[j4pac]

Blahaha

 

[BlackFrancis33]

Hmm. I'm not sure this is a misallocation of tax dollars. Isn't this an attempt to pre-empt a potential new problem/challenge by establishing multi-disciplinary care? I hate committees for the sake of committees, but this seems like someone trying to establish a treatment pathway for a challenging new problem.

 

[pgg]

To be clear, your problem is with allowing transgender people in the military, no?

Because once someone is allowed to serve, they're entitled to medical care within the accepted standard of care. I don't know why speech therapy is particularly important to them, but hey, I'm no expert.

Even if you have a deeply held religious belief that transgender people are the spawn of a communist-leaning Satan, I don't see any basis for criticism of the medical corps here. Or even the military for that matter. The order to integrate LBGT people into the military didn't come from anyone wearing a uniform.

 

[notdeadyet]

Even if you have a deeply held religious belief that transgender people are the spawn of a communist-leaning Satan, I don't see any basis for criticism of the medical corps here. Or even the military for that matter. The order to integrate LBGT people into the military didn't come from anyone wearing a uniform.

True. We've seen that if the elements of inclusion left to the military, it would still be white, male, and Christian.

I give a "meh" to the hand-wringing over allowing LGBT folks in the military and downroad effects. The military had absolutely no problems with "moral waivers" when it suited their needs and talk to anyone in mental health about the downroad effects of that. That 10% makes up at least 50% of the drama.

 

[Chonal Atresia]

To be clear, your problem is with allowing transgender people in the military, no?

Because once someone is allowed to serve, they're entitled to medical care within the accepted standard of care. I don't know why speech therapy is particularly important to them, but hey, I'm no expert.

Even if you have a deeply held religious belief that transgender people are the spawn of a communist-leaning Satan, I don't see any basis for criticism of the medical corps here. Or even the military for that matter. The order to integrate LBGT people into the military didn't come from anyone wearing a uniform.

No problem with transgender people.

I do have a problem with the GOVERNMENT paying for things like sex reassignment surgery, laryngeal shaving, voice therapy, etc for this population as they are not medically necessary procedures.

If this population wants these type of procedures/treatments then they can pay for them outside of the military in the civilian sector.

 

[TheEarDoc]

No problem with transgender people.

I do have a problem with the GOVERNMENT paying for things like sex reassignment surgery, laryngeal shaving, voice therapy, etc for this population as they are not medically necessary procedures.

If this population wants these type of procedures/treatments then they can pay for them outside of the military in the civilian sector.

Not to mention I am sure when they get out of the service they will say being transgender they had PTSD secondary to MST and then take a nice 70% pension award per month for the rest of their lives.

 

[j4pac]

Yeah...I had a patient with faulty breast implants that were eroding on her chest. But because the had the puppies put on before military service...tricare wouldn't pay. Did they care that toxic, cancerous material was spewing into her? Not a bit.

They also fought tooth and nail over removing a nevus off a guy's face. He would shave over it daily cutting it, making it bleed, and it was starting to scar. They called it cosmetic surgery.

I'm going laugh my butt off watching the military try to handle this transgender topic. We will all be wear awful looking trans uniforms in no time. Will they start requiring women to shave their faces? Can men start wearing fashionable hair buns? I can't wait

 

[pgg]

No problem with transgender people.

I do have a problem with the GOVERNMENT paying for things like sex reassignment surgery, laryngeal shaving, voice therapy, etc for this population as they are not medically necessary procedures.

If this population wants these type of procedures/treatments then they can pay for them outside of the military in the civilian sector.

Man, the things I learn on the internet ... laryngeal shaving and voice therapy. Had no idea that was part of the process, but I guess it fits.

We do elective cosmetic surgery at MTFs where the patients pay for implants and some other costs. Maybe it'd be reasonable to treat this the same way. But I think they'll argue that it's "corrective" surgery to make the body match what they already are inside. I'm not sure if I'm prepared to come down on the other side of that argument. Maybe they're right.

I don't know what to make of transgender people. They seem to fit in a wholly separate category than lesbian/gay/bisexual people, whom I basically understand. I get why the four groups are natural political allies but the transgenders are definitely the odd corner of that group. I don't know any personally, at least, I don't think I do. People who've thought about it more than I care to tell me that desiring gender reassignment isn't just body dysmorphic disorder writ large. I guess I defer to their medical judgment.

I hate the phrase "slippery slope" but, well, I can't help but feel like it's a slippery slope to start making moral and value judgments on patients. Most of the health issues we deal with outside the pediatric realm are predictable consequences of self-inflicted disease or unnecessary risk taking. Total knee arthroplasties in a 350 pound people. Everything every bariatric surgeon does every day. Fem-pops for COPD'ers who keep adding a pack a day to the pack century they've already got. ORIFs for motorcycle riders. Dental work for people who can't be bothered to brush their teeth. On and on and on.

I sure don't envy or resent transgender people. They've probably spent most of their lives hating what they were and wishing they were something else. Whatever they are, they're not scammers out to defraud the system. I can't get too worked up over the government paying for what's got to be near-single-digit numbers of trangender people who want to be surgically or chemically altered. People who, whatever's wrong with them physically, biologically, chemically, or mentally, still signed up to serve their country.

 

[dr zaius]

As a urology resident I find gender reassignment surgery pretty fascinating. Purely from a surgical training standpoint I'm thrilled that they are developing a pathway similar to the bariatric surgery pathway for transgender patients.

Check out this ex-Navy (insert Navy joke here) transgender surgeon who performs male to female operations. Her before and after case pictures are pretty impressive.

http://www.drchristinemcginn.com/drmcginn/

 

[j4pac]

Can't someone say that they are a large breasted woman living in a flat chested woman's body? There absolutely is a slippery slope. I don't think that Americans should have to pay for every servicewoman's and handful of servicedude's breast implants. Now that I think of it...I would mind an ass implant. I'm entitled damnit! God short-changed me! Love it...

 

[notdeadyet]

Once you treat transgender patients for a while, you might sing a different tune.

Sexual reassignment surgery for a TG patient and breast enlargement surgery are not in the same ballpark; the slippery slope doesn't really apply.

 

[j4pac]

Once you treat transgender patients for a while, you might sing a different tune.

Sexual reassignment surgery for a TG patient and breast enlargement surgery are not in the same ballpark; the slippery slope doesn't really apply.

I think that it would depend. Is there a body image disconnect? If there is...I don't really see the difference. Either way...people should pay for their own cosmetic surgery.

Have you had the honor of treating transabled patients as well?

 

[notdeadyet]

I think that it would depend. Is there a body image disconnect? If there is...I don't really see the difference. Either way...people should pay for their own cosmetic surgery.

When transgendered patients seek out gender reassignment surgery isn't a body image disconnect, it's a gender disconnect.

Prior to evaluation for surgery, a patient needs to have gone through hormonal treatment for a year , lived as a non-birth gender for a year or two (I believe this varies by locale), and had gender dysphoria diagnosed and managed by multiple clinicians. If folks think of it as cosmetic surgery, they're not understanding the health issues at play (including psychiatric and surgical).

There's a lot of prejudice against the transgender community, so I understand if folks want to rail against "my tax dollars" spent on gender reassignment surgery. It ruffles my feathers as a psychiatrist, but then again if I thought a fair number of people on I see on dialysis is a waste of "my tax dollars" and that probably would ruffle a nephrologists feather.

But it doesn't matter. The government covers gender reassignment surgery in the civilian community so not covering it for servicemembers would make the prejudice very explicit. Kind of like making servicemembers of color sit in the back of the bus while they would sit in the front if they were civilians. Can't do that.

Have you had the honor of treating transabled patients as well?

The "transabled" tag smells more media-driven than anything. And of course when the transgender community started advocating more loudly for their rights, the "transabled" tag started getting tossed around more by those against those rights (e.g. comparing someone who wants gender reassignment surgery to someone who intentionally mutilates/disables themselves).

It's a red herring. Different things. Transgender folks seeking gender reassignment would fall under gender dysphoria whereas the folks who intentionally mutilate themselves would typically not. Some are throwing around the term body integrity identity disorder for the "transabled," but it's not a recognized/DSM diagnosis. It's also not really accurate, as the way "transabled" was being used before it got co-opted by the anti-TG folks was for people whose motivation was not the act of mutilation or loss of function but the end-game of becoming disabled.

Actual cases of body dysmorphic disorder are interesting, but in most of the self-mutilation cases I've caught (why always with the eyes...?), it was inevitably something along the psychotic spectrum.

 

[TheEarDoc]

Yeah...I had a patient with faulty breast implants that were eroding on her chest. But because the had the puppies put on before military service...tricare wouldn't pay. Did they care that toxic, cancerous material was spewing into her? Not a bit.

They also fought tooth and nail over removing a nevus off a guy's face. He would shave over it daily cutting it, making it bleed, and it was starting to scar. They called it cosmetic surgery.

I'm going laugh my butt off watching the military try to handle this transgender topic. We will all be wear awful looking trans uniforms in no time. Will they start requiring women to shave their faces? Can men start wearing fashionable hair buns? I can't wait

I remember one C&P where the person was active duty guard full time and just stayed stateside for 4 years. Got breast implants while in the military, then began having problems and had to have them removed. Got service connection for the scars and pec muscle injuries......SMDH

 

[TheEarDoc]

When transgendered patients seek out gender reassignment surgery isn't a body image disconnect, it's a gender disconnect.

Prior to evaluation for surgery, a patient needs to have gone through hormonal treatment for a year , lived as a non-birth gender for a year or two (I believe this varies by locale), and had gender dysphoria diagnosed and managed by multiple clinicians. If folks think of it as cosmetic surgery, they're not understanding the health issues at play (including psychiatric and surgical).

There's a lot of prejudice against the transgender community, so I understand if folks want to rail against "my tax dollars" spent on gender reassignment surgery. It ruffles my feathers as a psychiatrist, but then again if I thought a fair number of people on I see on dialysis is a waste of "my tax dollars" and that probably would ruffle a nephrologists feather.

But it doesn't matter. The government covers gender reassignment surgery in the civilian community so not covering it for servicemembers would make the prejudice very explicit. Kind of like making servicemembers of color sit in the back of the bus while they would sit in the front if they were civilians. Can't do that.

The "transabled" tag smells more media-driven than anything. And of course when the transgender community started advocating more loudly for their rights, the "transabled" tag started getting tossed around more by those against those rights (e.g. comparing someone who wants gender reassignment surgery to someone who intentionally mutilates/disables themselves).

It's a red herring. Different things. Transgender folks seeking gender reassignment would fall under gender dysphoria whereas the folks who intentionally mutilate themselves would typically not. Some are throwing around the term body integrity identity disorder for the "transabled," but it's not a recognized/DSM diagnosis. It's also not really accurate, as the way "transabled" was being used before it got co-opted by the anti-TG folks was for people whose motivation was not the act of mutilation or loss of function but the end-game of becoming disabled.

Actual cases of body dysmorphic disorder are interesting, but in most of the self-mutilation cases I've caught (why always with the eyes...?), it was inevitably something along the psychotic spectrum.

And these are all classified as mental disorders according to the DSM correct? If so then why are we paying for such things when technically if these folks had been honest on their enlistment physical at MEPS they would have been PDQ correct?

 

[notdeadyet]

And these are all classified as mental disorders according to the DSM correct? If so then why are we paying for such things when technically if these folks had been honest on their enlistment physical at MEPS they would have been PDQ correct?

It's a little funky due to DSM-5 coming out and the regs (at least Army) still referring to DSM-IV. There were fairly significant changes to gender dysphoria in DSM-5.

But to answer your questions, this stuff will likely come down in a few flavors:

• Servicemembers were knew they were transgender prior to enlisting and did not disclose. This was a disqualifying condition. They could be administratively discharged and not eligible for treatment.
• Servicemembers did not know they were transgender prior to enlisting but learned this after enlisting (yes, I know). Assuming they follow the correct protocol, they would be eligible for treatment for their gender dysphoria in the military, just as they would as civilians under things like Medicare.
• Servicemembers know they are transgender and are now enlisting. As long as they disclose this fact (which is now becoming non-disqualifying), they are eligible for services assuming they follow the correct protocol.

That's my take on it. We'll see how it pans out.

 

[j4pac]

When transgendered patients seek out gender reassignment surgery isn't a body image disconnect, it's a gender disconnect.

Prior to evaluation for surgery, a patient needs to have gone through hormonal treatment for a year , lived as a non-birth gender for a year or two (I believe this varies by locale), and had gender dysphoria diagnosed and managed by multiple clinicians. If folks think of it as cosmetic surgery, they're not understanding the health issues at play (including psychiatric and surgical).

There's a lot of prejudice against the transgender community, so I understand if folks want to rail against "my tax dollars" spent on gender reassignment surgery. It ruffles my feathers as a psychiatrist, but then again if I thought a fair number of people on I see on dialysis is a waste of "my tax dollars" and that probably would ruffle a nephrologists feather.

But it doesn't matter. The government covers gender reassignment surgery in the civilian community so not covering it for servicemembers would make the prejudice very explicit. Kind of like making servicemembers of color sit in the back of the bus while they would sit in the front if they were civilians. Can't do that.

The "transabled" tag smells more media-driven than anything. And of course when the transgender community started advocating more loudly for their rights, the "transabled" tag started getting tossed around more by those against those rights (e.g. comparing someone who wants gender reassignment surgery to someone who intentionally mutilates/disables themselves).

It's a red herring. Different things. Transgender folks seeking gender reassignment would fall under gender dysphoria whereas the folks who intentionally mutilate themselves would typically not. Some are throwing around the term body integrity identity disorder for the "transabled," but it's not a recognized/DSM diagnosis. It's also not really accurate, as the way "transabled" was being used before it got co-opted by the anti-TG folks was for people whose motivation was not the act of mutilation or loss of function but the end-game of becoming disabled.

Actual cases of body dysmorphic disorder are interesting, but in most of the self-mutilation cases I've caught (why always with the eyes...?), it was inevitably something along the psychotic spectrum.

While I agree with much of what you said, I think you're splitting hairs with the differences between the DSM diagnoses. Everyone knows that much of Psych is complete BS. They are starting to make compromises on their disgnoses based on cultural opinions and not objective medical opinions. I mean...does anyone doubt that identity disorders will disappear entirely from DSM-6?

The average person is becoming more acceptable of transgender folks, however, the average person would think that transabled folks are pretty f'ed up. The truth is that folks electively mutilating their bodies, whether it's their genitalia or other limb have more in common than not...it's just our culture that determines what is acceptable.

 

[notdeadyet]

While I agree with much of what you said, I think you're splitting hairs with the differences between the DSM diagnoses. Everyone knows that much of Psych is complete BS.

What you're calling "splitting hairs," some would just call diagnosis. Folks might struggle to recognize the difference between someone who wants to amputate an arm in order to be disabled vs. someone who wants to have their penis removed/altered to have their physical body in line with their gender. But folks who make dealing with these distinction a part of their practice shouldn't.

As for much of psych being BS, it's like anything in medicine: if it sounds confusing or weird or you can't make any sense of it (or in this case, sounds like maybe all three), you refer to a specialist. Dismissing it out of hand as "BS" is about as smart medicine as ignoring an exam finding on a patient you can't wrap your head around because your experience was limited to a rotation or two in medical school. Some of psychiatry is BS, but the problem is that if you're not a psychiatrist, you don't really know which part.

Which isn't a dig at you. I forgot most of what I learned about cardiology, so if I see a weird EKG, I consult. I can't appreciate all the subtleties.

They are starting to make compromises on their disgnoses based on cultural opinions and not objective medical opinions. I mean...does anyone doubt that identity disorders will disappear entirely from DSM-6?

Gender identity disorder will likely continue to change with the more we learn, but it won't go anywhere.

And you're right that psychiatry does change based on changing culture. So does all of medicine, but since much of mental illness is more exacerbated by cultural factors than much of physical illness, it's more transparent in psych.

The average person is becoming more acceptable of transgender folks, however, the average person would think that transabled folks are pretty f'ed up. The truth is that folks electively mutilating their bodies, whether it's their genitalia or other limb have more in common than not...it's just our culture that determines what is acceptable.

You may have a more generous opinion of the tolerance of the average person than me. But maybe I'm just cynical.

But I'm curious why you're so fixated on this "transabled" thing. It has absolutely nothing to do with being transgendered. Amputating your limb because you have the belief it is not a part of you or because you cherish the role of being an amputee is not related to being transgendered. Google that $hit. It's true. This sounds like when folks talk about homosexuality and someone makes vague comparisons to pedophilia.

 

[j4pac]

What you're calling "splitting hairs," some would call accuracy of diagnosis. Folks might struggle to recognize the difference between someone who wants to amputate an arm in order to be disabled vs. someone who wants to have their penis removed/altered to have their physical body in line with their gender. But folks who make dealing with these distinction a part of their practice shouldn't.

As for much of psych being BS, it's like anything in medicine: if it sounds confusing or weird or you can't make any sense of it (or in this case, sounds like maybe all three), you refer to a specialist. Dismissing it out of hand as "BS" is about as smart medicine as ignoring an exam finding on a patient you can't wrap your head around because your experience was limited to a rotation or two in medical school. Some of psychiatry is BS, but the problem is that if you're not a psychiatrist, you don't really know which part.

Which isn't a dig at you. I forgot most of what I learned about cardiology, so if I see a weird EKG, I consult. I can't appreciate all the subtleties.

Gender identity disorder will likely continue to change with the more we learn, but it won't go anywhere. And you're right that psychiatry does change based on changing culture. So does all of medicine, but since much of mental illness is more exacerbated by cultural factors than much of physical illness, it's more transparent in psych.

You may have a more generous opinion of the tolerance of the average person than me. But maybe I'm just cynical.

But I'm curious why you're so fixated on this "transabled" thing. It has absolutely nothing to do with being transgendered. Amputating your limb because you have the belief it is not a part of you or because you cherish the role of being an amputee is not related to being transgendered. Google that $hit. It's true. This sounds vaguely like when folks talk about homosexuality and someone makes vague comparisons to pedophilia.

How dare you minimize the suffering that these poor transabled folks have to struggle with every day. How would you feel if you woke up every day with two legs and two arms, and no will to live? Thinking "Damn, there they are!" Everyone around you either not taking you seriously or thinking you were ill.

I would expect these type of dismissive beliefs from a more subjective professional like an internist, but definitely not someone objective like a psychiatrist. I understand that this is a military forum, but I guess that I'm just naive to believe that we live in a more tolerance medical climate. I guess not...

 

[notdeadyet]

How dare you minimize the suffering that these poor transabled folks have to struggle with every day. How would you feel if you woke up every day with two legs and two arms, and no will to live? Thinking "Damn, there they are!"

It's probably a lot funnier when you haven't treated folks like this. It's less funny when you have a patient on your unit claw their eyes out. It gets even less funny when you're able to treat the psychosis with medications and then get to do therapy with someone who is then coming to the realization that they will be blind the rest of their life.

I realize you're being cute, but as long as GMOs, primary care docs, or specialists refer the mental health stuff to psych, they can have whatever prejudices they want about gender, mental health, race, or politics. The issue is that even if you think it's BS, you just don't know what you don't know. Just like when I'm dealing with a pilot or crew member who reports feeling what sounds to me like anxiety but comes awful close to being dizzy, I always send them to the flight surgeon. I may think I know the cause, but I don't have the background. I don't know what I don't know either. Patients start to get hurt when we forget this.

 

[notdeadyet]

Anywho, didn't mean to derail the thread.

Suffice to say that early on there will be a fair bit of misinformation, prejudice, discrimination, sexual abuse, and poor management of these soldiers by peers, command, and providers. This will lead to a whole bunch of online coursework (development that will probably make some company rich) and a bunch of mandatory in-person trainings.

Result? Probably not much. Maybe it's different in other branches, but on Army side, there has been s a crazy amount of attention paid to rape and sex abuse over the past couple of years and a whole lot of commanders making bullet points on their OERs, but the problems keep growing. In fact, some of the folks in charge of the anti-rape and sexual abuse programs have been drummed out for sexual abuse and running prostitution rings. Can't imagine the TG thing will be handled any differently.

 

[j4pac]

It's probably a lot funnier when you haven't treated folks like this. It's less funny when you have a patient on your unit claw their eyes out. It gets even less funny when you're able to treat the psychosis with medications and then get to do therapy with someone who is then coming to the realization that they will be blind the rest of their life.

I realize you're being cute, but as long as GMOs, primary care docs, or specialists refer the mental health stuff to psych, they can have whatever prejudices they want about gender, mental health, race, or politics. The issue is that even if you think it's BS, you just don't know what you don't know. Just like when I'm dealing with a pilot or crew member who reports feeling what sounds to me like anxiety but comes awful close to being dizzy, I always send them to the flight surgeon. I may think I know the cause, but I don't have the background. I don't know what I don't know either. Patients start to get hurt when we forget this.

BTW...I love Psychiatrists. A few of my best friends are Psychiatrists, and I don't think that there is question that Mental Health is whom I refer to more than anyone, and they're awesome. But I do have an issue with DSM. They are suppose to be the world renown experts on the topic of mental health. So why is Hollywood and media able to dictate what is and what is NOT considered mental illness? Either something is mental illness or it's not...I'm not interested in our culture's opinion on the topic...I'm interested in objective medical opinion.

Prediction- Identity disorder will disappear from the pages of DSM-6. You will not be able to give a transabled or transgendered patient a diagnosis unless you are able to tag him/her with a psychotic disorder. But I'm not sure that the desire to remove part of your anatomy to appease your self-image would meet criteria. The Army is going to have a heck of a time justifying treatment for something that isn't a disorder. And even if they can justify it...I highly doubt Tricare will pay.

 

[HighPriest]

The military/Tricare picks and chooses what it will pay for based upon the level of political heat that any particular treatment draws. Its entirely hypocritical, regardless of how one feels about transgender service members, and therefore intrinsically BS. It's BS on the outside, too, but again we have the option to have a better system, but we seem to squander that. Variations on whether or not reconstructive surgery is covered, whether or not hearing aids are covered, and the lack of coverage for things like IVF make me thing that blanket coverage for gender re-assignment surgery is ridiculous and politically motivated. And yeah, I can't wait for the online training to begin.

 

[HighPriest]

Man, the things I learn on the internet ... laryngeal shaving and voice therapy. Had no idea that was part of the process, but I guess it fits.

There's also types III and IV Ishiki thyroplasty, which is basically something that only happens with gender reassignment - very few exceptions.

 

[Shikima]

The military/Tricare picks and chooses what it will pay for based upon the level of political heat that any particular treatment draws. Its entirely hypocritical, regardless of how one feels about transgender service members, and therefore intrinsically BS. It's BS on the outside, too, but again we have the option to have a better system, but we seem to squander that. Variations on whether or not reconstructive surgery is covered, whether or not hearing aids are covered, and the lack of coverage for things like IVF make me thing that blanket coverage for gender re-assignment surgery is ridiculous and politically motivated. And yeah, I can't wait for the online training to begin.

There's a TMS module for that. 😆

 

[TheEarDoc]

It's a little funky due to DSM-5 coming out and the regs (at least Army) still referring to DSM-IV. There were fairly significant changes to gender dysphoria in DSM-5.

But to answer your questions, this stuff will likely come down in a few flavors:

• Servicemembers were knew they were transgender prior to enlisting and did not disclose. This was a disqualifying condition. They could be administratively discharged and not eligible for treatment.
• Servicemembers did not know they were transgender prior to enlisting but learned this after enlisting (yes, I know). Assuming they follow the correct protocol, they would be eligible for treatment for their gender dysphoria in the military, just as they would as civilians under things like Medicare.
• Servicemembers know they are transgender and are now enlisting. As long as they disclose this fact (which is now becoming non-disqualifying), they are eligible for services assuming they follow the correct protocol.

That's my take on it. We'll see how it pans out.

I realize just like me you often probably feel constrained by the law and how to practice in your field, but in your opinion what are your thoughts on it? I mean do you feel it's a travesty to spend tax payer money on this when the people who will be reaping these benefits most likely knew beforehand that they had this condition and should have never been able to enlist?

Also I feel it's an injustice if they will waive such a thing as this for a mental condition to enlist, but the poor kid who once saw a psychologist because he was depressed is PDQ! Just my opinion there FWIW.

 

[TheEarDoc]

There's a TMS module for that. 😆

Hey try being an audiologist and having to sit through a long presentation on TMS about MST.......

Unless someone stuck a portion of their genitalia in your ear, I highly doubt MST is going to be something I encounter in the C&P process.....

 

[DD214_DOC]

I wish I saved the article that recently came out suggesting that, "gender" isn't an actual thing. I see the under 18 crowd and 12 year olds are labeling themselves now as, "lesbian", or, "gender fluid" or whatever else you want to call it, when in reality what many describe is simply the androgeny that most of us are; an appreciation that they maybe don't fit the gender stereotype that their same-sex parent is, so naturally assume they must be a completely different gender. It's a very difficult thing to evaluate and manage, and I still argue that sex reassignment surgery doesn't do much to help with that. A man/woman will NEVER EVER be a woman/man. At the very best, you will be, "transgender", "trans", or whatever other label society has. There's too much emphasis on the search for a label and not enough on just being yourself and not caring too much what other people think.

 

[Promethean]

Transgender people have been serving in the military for years... often delaying necessary medical treatment in order to do so.

Not every transgender person requires extensive surgery, or really even any surgery, in order to reach a state of transition which is acceptable to them. But transgender healthcare is absolutely medically necessary healthcare.

Without access to transition related medical care, we have more psychological problems, more suicide attempts, worse quality of life. Allow us to live in the gender role to which we are best suited, and the vast majority of that psych pathology melts away. It is as if we aren't lying when we say that we are who we say we are. I went from being agoraphobic, too anxious to leave my home unaccompanied, let alone be productive, to being able to go to school and have a successful career as a nurse.

Later, I was inspired by the difficulty people like me have to access health care (even when we have ample funds to pay for it out of pocket, no government or insurer involved.) I decided to go to medical school because I and people dear to me were turned away when we sought care, basic health care that anyone would need, not just transition related care. Now, in medical school, I was recently turned away from the only two endocrinology practices in Erie, being told by one that they "did not provide services for my diagnosis." And by the other that "our physicians do not feel comfortable providing care to transgender patients."

I was fortunate to find a family medicine doctor who was receptive to managing my care. For me, all that was needed was a mastectomy and hormone therapy took care of everything else. Even paying for all of that out of pocket, I'd say that I've only spent around $12k over the last decade on transition related healthcare. The benefit of that expense has been enormous. I can't think of too many other treatments for the kind of crushing anxiety and depression I used to experience that would have been so cost effective, had such a profoundly positive impact on my quality of life, and made me a more productive member of society. Treating the underlying problem, gender dysphoria, by the internationally recognized standard of care, that is medically assisted transition, saved my life and made me a more capable person.

Denying such care to transgender people who serve in the military is asking them to endure undue personal hardship, for no benefit other than to avoid offending some busybody somewhere. Providing medically necessary care enhances their capacity to serve and makes them more fit for duty. Pretending that transgender soldiers aren't out there, right now, serving in silence, is doing a disservice to those troops.

 

[DrMetal]

Transgender people have been serving in the military for years...

I don't think any one would disagree with anything in your post, with respect to medicine in the civilian world. The question is: should the military a) allow unstable transgender patients to join the military? and b) should the military make an active attempt to treat them if they become unstable, or rather just discharge them from service (as we do for many other diagnoses).

Military medicine is a different beast, you have to understand that. We provide services to take care of a fighting force. We're not a charity, we're not a philanthropic service. We can disqualify anyone from joining per a medical condition----whether it be an ASD, severe asthma, unstable mental health issues, unstable transgender issues----and we can decide to discharge someone for similar diagnoses as well. Military medicine is not responsible for taking care of every type of diagnosis/pathology; it is primarily responsible for taking care of that which is compatible with military service.

 

[DD214_DOC]

I don't think any one would disagree with anything in your post, with respect to medicine in the civilian world. The question is: should the military a) allow unstable transgender patients to join the military? and b) should the military make an active attempt to treat them if they become unstable, or rather just discharge them from service (as we do for many other diagnoses).

Military medicine is a different beast, you have to understand that. We provide services to take care of a fighting force. We're not a charity, we're not a philanthropic service. We can disqualify anyone from joining per a medical condition----whether it be an ASD, severe asthma, unstable mental health issues, unstable transgender issues----and we can decide to discharge someone for similar diagnoses as well. Military medicine is not responsible for taking care of every type of diagnosis/pathology; it is primarily responsible for taking care of that which is compatible with military service.

True story. Gender identity issues consume tons of resources to evaluate, manage, and treat, and the effects of all of this can be profound. It's a condition that should never, "arise as an adult" as I cannot think of any circumstances in which it would not be a pre-existing condition (gender identity or whatever you want to call it should be pretty well established by late adolescence) Despite this, the evaluation and management of transgender issues effectively removes someone from being completely fit for duty and should be grounds for separation. The military boards and medically retires people for things like PTSD, and something such as gender dysphoria -- that is nearly always pre-existing in some form -- should not be medically discharged. It should be an administrative discharge. The medical system is already severely crunched and funds are in short supply; we should not be frivolously throwing resources (both money and time) at an issue simply because of the potential, "it's not PC" fallout. Providers are already overwhelmed as it is. Let's not add to it with silly things like this.

Commence, "You're a bigot" comments in 3 ..... 2 ....

 

[Promethean]

Commence, "You're a bigot" comments in 3 ..... 2 ....

Nah, you aren't necessarily a bigot. You just aren't necessarily well informed either.

Like I said, the total costs of my transition over the past 10 years, paid out of pocket entirely, tally to around 12k, or about $100 per month, with more recent costs more along the lines of $40/month for medication and lab work. So, it needn't consume massive amounts of resources. While people like to talk about laryngeal, tracheal, and other obscure surgeries, for a great many transgender people, the care needed in order for them to achieve a satisfactory quality of life may involve little to no surgery, just hormones. So, it is a little unfair to use the extraordinary costs of procedures that very few transgender folks avail themselves of, even when money isn't a big concern, as the basis for denying care that can be provided for little more expense than covering a single prescription and occasional labs.

Also, gender identity issues can arise in adulthood, or at least exacerbate. I didn't realize that transition was an option until I was in my late 20s. Other people have found that their methods of coping with gender identity issues which may have worked at one point in life may be less effective later.

I get that military medicine isn't civilian medicine. But transgender people can be effective soldiers, can contribute to their units and to the over all mission. Plenty of them have done so and are doing so now. If judicious application of appropriate medical care is provided that helps those soldiers to be more able, that isn't a waste of resources.

 

[Shikima]

Enter the entitlement mentality.... fair vs unfair.

 

[TheEarDoc]

True story. Gender identity issues consume tons of resources to evaluate, manage, and treat, and the effects of all of this can be profound. It's a condition that should never, "arise as an adult" as I cannot think of any circumstances in which it would not be a pre-existing condition (gender identity or whatever you want to call it should be pretty well established by late adolescence) Despite this, the evaluation and management of transgender issues effectively removes someone from being completely fit for duty and should be grounds for separation. The military boards and medically retires people for things like PTSD, and something such as gender dysphoria -- that is nearly always pre-existing in some form -- should not be medically discharged. It should be an administrative discharge. The medical system is already severely crunched and funds are in short supply; we should not be frivolously throwing resources (both money and time) at an issue simply because of the potential, "it's not PC" fallout. Providers are already overwhelmed as it is. Let's not add to it with silly things like this.

Commence, "You're a bigot" comments in 3 ..... 2 ....

I agree completely and it's what I've been saying since this topic came up. It is a pre-existing issue and if someone is having the psychological conditions that go along with it when they enlist then they are completing fraudulent enlistment. If you won't let the person in who has bypass surgery to lose weight then why treat this condition any different? There is way too much fraudulent enlistment that ends up turning into a medical discharge and then a large tax free disability payment for the rest of the person's life. The system is going to come crashing down soon because of this. Too many are treating the VA system as another SSI disability fund for themselves after they commit fraudulent enlistment. I have people I went to high school with who had mental issues (well documented too!) and lied on enlistment, got into service, and magically they got med boarded out for it and now collect fat checks for it when the military had not one iota to do with their mental conditions.

End rant.

 

[TheEarDoc]

Nah, you aren't necessarily a bigot. You just aren't necessarily well informed either.

Like I said, the total costs of my transition over the past 10 years, paid out of pocket entirely, tally to around 12k, or about $100 per month, with more recent costs more along the lines of $40/month for medication and lab work. So, it needn't consume massive amounts of resources. While people like to talk about laryngeal, tracheal, and other obscure surgeries, for a great many transgender people, the care needed in order for them to achieve a satisfactory quality of life may involve little to no surgery, just hormones. So, it is a little unfair to use the extraordinary costs of procedures that very few transgender folks avail themselves of, even when money isn't a big concern, as the basis for denying care that can be provided for little more expense than covering a single prescription and occasional labs.

Also, gender identity issues can arise in adulthood, or at least exacerbate. I didn't realize that transition was an option until I was in my late 20s. Other people have found that their methods of coping with gender identity issues which may have worked at one point in life may be less effective later.

I get that military medicine isn't civilian medicine. But transgender people can be effective soldiers, can contribute to their units and to the over all mission. Plenty of them have done so and are doing so now. If judicious application of appropriate medical care is provided that helps those soldiers to be more able, that isn't a waste of resources.

I disagree. You are claiming you experienced mental anguish and other conditions secondary to a gender identity problem. That right there is grounds for PDQ from military service. That's what you don't seem to be grasping.

 

[TheEarDoc]

Enter the entitlement mentality.... fair vs unfair.

Yeah why won't the tax payers give me free gastric bypass surgery

Enter the entitlement mentality.... fair vs unfair.

Exactly. The rules are quite clear and gender identity issues if the applicant is being truthful would = PDQ for service.

I know kids who went through the foster care program and someone gave them a PTSD diagnosis once (the kid did see some crazy stuff in one of the homes, but he is a very motivated and stable adult now) and he is PDQ forever from service even though he's never been medicated or seen a therapist in over 10 years.

Again I think people fail to realize the military isn't there to accept people. They are there to complete a mission and they have medical standards to meet to be eligible for service. It's not a right. It is a privilege. Is it fair? No! I've seen plenty of people who would have made awesome contributions to the country and the military be turned away, but such is life. It isn't fair.

 

[Homunculus]

To be clear, your problem is with allowing transgender people in the military, no?

it must be telling that when I read the memo I thought the issue was being voluntold to participate in yet another multi-D clinic. the rationale behind it either didn't register with me as important or as something that wouldn't be utilized much. I have to admit the hand-wringing and concern that there will be a significant demand for these services reminds me of the same concern raised by the far right about allowing gays to openly serve. what happened to all the predictions about the impending cataclysm this was going to cause in the military?

True. We've seen that if the elements of inclusion left to the military, it would still be white, male, and Christian.

I give a "meh" to the hand-wringing over allowing LGBT folks in the military and downroad effects. The military had absolutely no problems with "moral waivers" when it suited their needs and talk to anyone in mental health about the downroad effects of that. That 10% makes up at least 50% of the drama.

agree. the "perfect" military would be single white Christian (protestant if I had to choose) male conservatives. unfortunately for the powers that be, the service tends to reflect (to a degree) society at large and these social issues simply don't have the same guttural reaction they do with the older folks.

stepping back and looking at it from @TheEarDoc and @HooahDOc 's point of view, it sounds like it basically comes down to a cost issue (correct me if I am wrong). 1) that the cost of the treatments themselves consume a disproportionately large amount of resources (I would argue they don't-- without having an iota of data on the subject of course) or 2) it should constitute a fraudulent enlistment because of the *potential* that they will somehow be PTSD and disability cases that will drain VA resources.

from a practical standpoint, the overall population of servicemembers who are transgender is likely small. even smaller would be the ones that would want to proceed with surgery. so from a simple cost management standpoint I suspect, like above, the actual cost will be minimal compared to some of the costs associated with other diseases. look up the cost of treating hep C. orkambi for CF. hgh for short stature. these run to the 6 figures *per patient*. TRICARE covering a handful of transgender active duty servicemembers pales in comparison. now if it turns out that costs skyrocket I'd have a different opinion, but the staff are there, the expertise (should be) there, so why not treat them? because of a value judgment of it being an administratively disqualifying psychiatric condition?

to the second point-- predicting who will utilize VA services and claim disability is a total crapshoot. but if doing the above saves people from utilizing the disability system, shouldn't you then actually *support* the transition process? I agree the military isn't fair and some people aren't a good fit and that not everyone can serve. but the argument you are making, that they "may" cost more doesn't make sense to me. if we screened out everyone what could potentially use or "abuse" the VA system we'd have no one left. besides, the people gaming the VA and disability system aren't the gays and transgenders, it's the same largely right wing conservative Christians who complain about civilians on government welfare while readily soaking up their own.

as a sidenote, very interesting discussion, and I think it shows something that the thread has gone on as long as it has without anyone invoking hitler or personal insults. it's almost like it isn't the internet!

--your friendly neighborhood watch now the trolls will come caveman

 

[j4pac]

True story. Gender identity issues consume tons of resources to evaluate, manage, and treat, and the effects of all of this can be profound. It's a condition that should never, "arise as an adult" as I cannot think of any circumstances in which it would not be a pre-existing condition (gender identity or whatever you want to call it should be pretty well established by late adolescence) Despite this, the evaluation and management of transgender issues effectively removes someone from being completely fit for duty and should be grounds for separation. The military boards and medically retires people for things like PTSD, and something such as gender dysphoria -- that is nearly always pre-existing in some form -- should not be medically discharged. It should be an administrative discharge. The medical system is already severely crunched and funds are in short supply; we should not be frivolously throwing resources (both money and time) at an issue simply because of the potential, "it's not PC" fallout. Providers are already overwhelmed as it is. Let's not add to it with silly things like this.

Commence, "You're a bigot" comments in 3 ..... 2 ....

But seriously...you're not a bigot..only "PC-fluid". It's cool.

 

[TheEarDoc]

it must be telling that when I read the memo I thought the issue was being voluntold to participate in yet another multi-D clinic. the rationale behind it either didn't register with me as important or as something that wouldn't be utilized much. I have to admit the hand-wringing and concern that there will be a significant demand for these services reminds me of the same concern raised by the far right about allowing gays to openly serve. what happened to all the predictions about the impending cataclysm this was going to cause in the military?



agree. the "perfect" military would be single white Christian (protestant if I had to choose) male conservatives. unfortunately for the powers that be, the service tends to reflect (to a degree) society at large and these social issues simply don't have the same guttural reaction they do with the older folks.

stepping back and looking at it from @TheEarDoc and @HooahDOc 's point of view, it sounds like it basically comes down to a cost issue (correct me if I am wrong). 1) that the cost of the treatments themselves consume a disproportionately large amount of resources (I would argue they don't-- without having an iota of data on the subject of course) or 2) it should constitute a fraudulent enlistment because of the *potential* that they will somehow be PTSD and disability cases that will drain VA resources.

from a practical standpoint, the overall population of servicemembers who are transgender is likely small. even smaller would be the ones that would want to proceed with surgery. so from a simple cost management standpoint I suspect, like above, the actual cost will be minimal compared to some of the costs associated with other diseases. look up the cost of treating hep C. orkambi for CF. hgh for short stature. these run to the 6 figures *per patient*. TRICARE covering a handful of transgender active duty servicemembers pales in comparison. now if it turns out that costs skyrocket I'd have a different opinion, but the staff are there, the expertise (should be) there, so why not treat them? because of a value judgment of it being an administratively disqualifying psychiatric condition?

to the second point-- predicting who will utilize VA services and claim disability is a total crapshoot. but if doing the above saves people from utilizing the disability system, shouldn't you then actually *support* the transition process? I agree the military isn't fair and some people aren't a good fit and that not everyone can serve. but the argument you are making, that they "may" cost more doesn't make sense to me. if we screened out everyone what could potentially use or "abuse" the VA system we'd have no one left. besides, the people gaming the VA and disability system aren't the gays and transgenders, it's the same largely right wing conservative Christians who complain about civilians on government welfare while readily soaking up their own.

as a sidenote, very interesting discussion, and I think it shows something that the thread has gone on as long as it has without anyone invoking hitler or personal insults. it's almost like it isn't the internet!

--your friendly neighborhood watch now the trolls will come caveman

Cost issue really isn't what grinds me to be quite honest. I think it's more the fraudulent enlistment issue that gets to me and then the eligibility for med board and disability/retirement that bugs me. They won't let people in who have one flare up of gout or a documented history of depression after a traumatic life event and they will give no waivers, but we will let transgender folks in with their issues they are experiencing? Makes no sense to me. If you talk to the recruiters right now they aren't having problems meeting their billets. Now in times of war that will change. Trust me if you look at my other postings you will see I play no favorites on anyone gaming the system. I think people gaming the system are the lowest of the low and are sucking up monetary resources and appointment slots that veterans will real problems should be getting.

You're transgender? Awesome. Dress however you want when you're not on the clock. None of my business. Does it cause you mental issues secondary to your perceived gender and your actual sex not aligning? If so then sorry you are PDQ for military service just like someone with a past history of depression or a suicide attempt etc.. So sorry if you're transgender that's not the military's issue. The military didn't cause it. The military and the VA shouldn't be paying for it. I feel the same about a lot of other pre-existing conditions or genetic conditions that veterans claim and get paid for. Flat feet, shaving bumps, Meniere's disease, etc..

 

[j4pac]

I'm right along side eardoc. If you want to help protect our country...I would love to have you. But there are very rigid entrance requirements for a reason. Some people aren't a good fit for the military...especially those with ongoing medical needs.

What exactly does gender reassignment surgery treat? I am asking based on my own ignorance. I've read a number of articles that suggested that surgery goes not reduce suicide...some actually show that suicide is higher at long-term follow-up (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043071/). Perhaps I'm missing the ones that show the contrary. Even the studies that speak toward the possible benefits of reassignment surgery point out the need for close long-term follow-up with mental health. I'm sorry...that's an issue for military service.

I would love for a psychiatrist to point me in the direction of evidence based medicine that suggests that these folks could be compatible with military service.

 

[occams_razor]

I'm right along side eardoc. If you want to help protect our country...I would love to have you. But there are very rigid entrance requirements for a reason. Some people aren't a good fit for the military...especially those with ongoing medical needs.

What exactly does gender reassignment surgery treat? I am asking based on my own ignorance. I've read a number of articles that suggested that surgery goes not reduce suicide...some actually show that suicide is higher at long-term follow-up (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043071/). Perhaps I'm missing the ones that show the contrary. Even the studies that speak toward the possible benefits of reassignment surgery point out the need for close long-term follow-up with mental health. I'm sorry...that's an issue for military service.

I would love for a psychiatrist to point me in the direction of evidence based medicine that suggests that these folks could be compatible with military service.

Gender reassignment surgery is used to treat gender dysphoria. Gender dysphoria is defined by the DSM-5 here - http://www.dsm5.org/documents/gender dysphoria fact sheet.pdf

The study you linked suggests that suicide rates are higher at long-term follow up when compared to suicide rates in a healthy control population, not that suicide rates are higher post gender reassignment when compared to pre gender reassignment or to trans people who do not undergo gender reassignment.

This is a great excerpt from the study linked - "It is therefore important to note that the current study is only informative with respect to transsexuals persons health after sex reassignment; no inferences can be drawn as to the effectiveness of sex reassignment as a treatment for transsexualism. In other words, the results should not be interpreted such as sex reassignment per se increases morbidity and mortality. Things might have been even worse without sex reassignment. As an analogy, similar studies have found increased somatic morbidity, suicide rate, and overall mortality for patients treated for bipolar disorder and schizophrenia. This is important information, but it does not follow that mood stabilizing treatment or antipsychotic treatment is the culprit."

I also found this section of the results telling - "The survival curve (Figure 1) suggests increased mortality from ten years after sex reassignment and onwards. In accordance, the overall mortality rate was only significantly increased for the group operated before 1989. However, the latter might also be explained by improved health care for transsexual persons during 1990s, along with altered societal attitudes towards persons with different gender expressions."

 

[Gastrapathy]

What the nonmilitary types in this discussion don't grasp is that deployment is a zero sum game. If someone can't go, someone else goes twice. Once you've been the loser whose family bore that extra burden, it really makes you want everyone who joins to be fully ready and able to do the job. It isn't PC but these folks are going through something that will impact their likelihood of being deployable. All of you who want the other members of the military to bear that extra burden can feel free to sign up.

 

[j4pac]

Gender reassignment surgery is used to treat gender dysphoria. Gender dysphoria is defined by the DSM-5 here - http://www.dsm5.org/documents/gender dysphoria fact sheet.pdf

The study you linked suggests that suicide rates are higher at long-term follow up when compared to suicide rates in a healthy control population, not that suicide rates are higher post gender reassignment when compared to pre gender reassignment or to trans people who do not undergo gender reassignment.

This is a great excerpt from the study linked - "It is therefore important to note that the current study is only informative with respect to transsexuals persons health after sex reassignment; no inferences can be drawn as to the effectiveness of sex reassignment as a treatment for transsexualism. In other words, the results should not be interpreted such as sex reassignment per se increases morbidity and mortality. Things might have been even worse without sex reassignment. As an analogy, similar studies have found increased somatic morbidity, suicide rate, and overall mortality for patients treated for bipolar disorder and schizophrenia. This is important information, but it does not follow that mood stabilizing treatment or antipsychotic treatment is the culprit."

I also found this section of the results telling - "The survival curve (Figure 1) suggests increased mortality from ten years after sex reassignment and onwards. In accordance, the overall mortality rate was only significantly increased for the group operated before 1989. However, the latter might also be explained by improved health care for transsexual persons during 1990s, along with altered societal attitudes towards persons with different gender expressions."

Thanks...I misinterpreted the article a bit. It will be interesting to see a true surgery versus no surgery morbidity/mortality stats.

In regards to military service, I am going to make the assumption that hormone therapy is a no go. Perhaps surgery is an alternative that can prove ok for military service (assuming the associated co-morbidities (namely depression) are felt to be compatible with service.

I am interested though in the term disorder. Does a patient with gender dysphoria still have the diagnosis AFTER surgery?

I'm anxiously awaiting to see how they handle the DSM-VI regarding the diagnosis. The worst thing that the DSM-VI could do is remove diagnosis...as it could remove the opportunity for insurance to pay for a billable procedure. But at the same time, who wants a DSM diagnosis for what many people consider to be normal? I guess an out is to have gender dysphoria before surgery and revise the condition thereafter. I don't know anyone with gender dysphoria (that I know of)...and it would be interesting to know their opinion of the diagnosis.

 

[jabreal00]

What the nonmilitary types in this discussion don't grasp is that deployment is a zero sum game. If someone can't go, someone else goes twice. Once you've been the loser whose family bore that extra burden, it really makes you want everyone who joins to be fully ready and able to do the job. It isn't PC but these folks are going through something that will impact their likelihood of being deployable. All of you who want the other members of the military to bear that extra burden can feel free to sign up.

This is a delicate subject. However, I do agree with the above statement in general terms. The military should continue to discriminate against those who cannot deploy from joining/enlisting. The list of those who should not be able to join include; disabled, medically unfit, those on high risk medications, those with religious beliefs that interfere with wearing protective military uniforms or other day to day tasks of the military. I would think someone who is on hormone therapy for gender identity issues will not be able to readily get their medications if deployed to an austere environment. The military can and does make exceptions especially if someone has a specialized skill set where it can be utilized stateside. Alternately, one can serve alongside the military in other capacities such as in the civil service or as a contractor if they have a condition that precludes them from deploying.

 

[TheEarDoc]

What the nonmilitary types in this discussion don't grasp is that deployment is a zero sum game. If someone can't go, someone else goes twice. Once you've been the loser whose family bore that extra burden, it really makes you want everyone who joins to be fully ready and able to do the job. It isn't PC but these folks are going through something that will impact their likelihood of being deployable. All of you who want the other members of the military to bear that extra burden can feel free to sign up.

Exactly! IF you want the perks (what little there are) of being in the military, then you gotta take the good with the bad. Deployments suck for families. I've seen it firsthand. Had many friends who have been in the sandbox multiple times over the years as reservists and NG members. If you can't deploy, then at least be honest with yourself and be honest with the recruiters and don't sign up if you can't do the job.

 

[Homunculus]

What the nonmilitary types in this discussion don't grasp is that deployment is a zero sum game. If someone can't go, someone else goes twice. Once you've been the loser whose family bore that extra burden, it really makes you want everyone who joins to be fully ready and able to do the job. It isn't PC but these folks are going through something that will impact their likelihood of being deployable. All of you who want the other members of the military to bear that extra burden can feel free to sign up.

does being transgender make one non deployable? i wholeheartedly agree that there are so many non deployable people out there for whatever bogus reasons (ranging from fibromyalgia to a remote history of "hives with exercise") that the deployable pool continues to shrink to the point where it's the same people getting tasked while these profile riders work their way to retirement. it's hardly a medical corps issue in the army: http://www.army.mil/article/158897/Dailey__Non_deployable_Soldiers_No_1_problem/ i can't really see how this would make people non deployable any more than the other stuff i've seen sent downrange. mental health (if that's the direction people argue) has historically been almost entirely neglected when it comes to deployment screening. even at NTC i saw people who had no business being out their for their own safety-- let alone the safety of others.

I would think someone who is on hormone therapy for gender identity issues will not be able to readily get their medications if deployed to an austere environment.

i saw people on medications much worse than hormones who deployed. last time i checked they aren't scheduled narcotics and don't require refrigeration. they may require surveillance labs- no idea if they do but in my experience that didn't stop people from deploying, either. i don't see the fact someone is on hormones as any more of an issue than OCPs are for females.

i still posit this is really a non-issue when looking at the global readiness of the force. the fact is no one really knows how it will play out, and it comes down to people's expectations of what they think the army (or military at large) should look like socially or what they feel is important in regards to cost containment (or a combination thereof). i don't think it's an issue with the former, and personally think the latter is probably budget dust.

--your friendly neighborhood feeling a bit of fibro coming on caveman

 

[jabreal00]

does being transgender make one non deployable? i wholeheartedly agree that there are so many non deployable people out there for whatever bogus reasons (ranging from fibromyalgia to a remote history of "hives with exercise") that the deployable pool continues to shrink to the point where it's the same people getting tasked while these profile riders work their way to retirement. it's hardly a medical corps issue in the army: http://www.army.mil/article/158897/Dailey__Non_deployable_Soldiers_No_1_problem/ i can't really see how this would make people non deployable any more than the other stuff i've seen sent downrange. mental health (if that's the direction people argue) has historically been almost entirely neglected when it comes to deployment screening. even at NTC i saw people who had no business being out their for their own safety-- let alone the safety of others.



i saw people on medications much worse than hormones who deployed. last time i checked they aren't scheduled narcotics and don't require refrigeration. they may require surveillance labs- no idea if they do but in my experience that didn't stop people from deploying, either. i don't see the fact someone is on hormones as any more of an issue than OCPs are for females.

i still posit this is really a non-issue when looking at the global readiness of the force. the fact is no one really knows how it will play out, and it comes down to people's expectations of what they think the army (or military at large) should look like socially or what they feel is important in regards to cost containment (or a combination thereof). i don't think it's an issue with the former, and personally think the latter is probably budget dust.

--your friendly neighborhood feeling a bit of fibro coming on caveman

Just because someone was able to get through SRP with a non-deployable medication doesn't mean they should have deployed in the first place. While I was deployed, I would have service members sent over to me who were on immunosuppressive therapy for Crohn's, ulcerative colitis or on medical therapy for active Grave's disease. I just started the paperwork to get them a one way ticket home. The cost of gender reassignment surgery is pittance compared to the DoD's budget for weapons systems. Some planes cost in the tens of millions individually. If there are no post-op issues, surgery is also not an issue.

AR-40-501 is pretty explicit about medications that are a no-go for deployment to theater. Any medication that requires lab monitoring, any immunosuppressives, medications that require refrigeration will preclude someone from deploying to theater according to AR-40-501 (Army manual). I was at a battalion aid station with rudimentary supplies. We had bare bones lab and xray capabilities. Our level 2 TMC had capabilities of a small primary care clinic. Getting a TSH would take 6 weeks because it had to be sent to Germany.

Honestly, I don't know where the hormone therapy for those with gender identity issues will fall. Maybe these medications will be added to the formularies at the CSH in theater? I am doubtful they would be available at the Level 1 or 2 treatment facilities. Generally these hormones are given and managed by an endocrinologist or a very experienced internist or maybe family practioner. In theater most of the care is given by mid-levels (PAs), GMOs (with an internship under their belt) and PROFIS doctors of various different specialties. The Brigade or Division surgeon who is the most experienced physician in that Brigade (outside of the PROFIS doctors) are relegated to administrative work 90% of the time. I am not sure someone who is on hormone therapy will be best served by a PROFIS dermatologist or gastroenterologist, PA or a GMO with 1 year of training trying to manage their hormone levels. It's not like OCP for birth control. The doses may have to be titrated to effect, avoiding under or over dosing. For those who are not on hormone replacement, this is moot point.

It's definitely uncharted territory.

 

[Homunculus]

Just because someone was able to get through SRP with a non-deployable medication doesn't mean they should have deployed in the first place. While I was deployed, I would have service members sent over to me who were on immunosuppressive therapy for Crohn's, ulcerative colitis or on medical therapy for active Grave's disease. I just started the paperwork to get them a one way ticket home. The cost of gender reassignment surgery is pittance compared to the DoD's budget for weapons systems. Some planes cost in the tens of millions individually. If there are no post-op issues, surgery is also not an issue.

AR-40-501 is pretty explicit about medications that are a no-go for deployment to theater. Any medication that requires lab monitoring, any immunosuppressives, medications that require refrigeration will preclude someone from deploying to theater according to AR-40-501 (Army manual). I was at a battalion aid station with rudimentary supplies. We had bare bones lab and xray capabilities. Our level 2 TMC had capabilities of a small primary care clinic. Getting a TSH would take 6 weeks because it had to be sent to Germany.

Honestly, I don't know where the hormone therapy for those with gender identity issues will fall. Maybe these medications will be added to the formularies at the CSH in theater? I am doubtful they would be available at the Level 1 or 2 treatment facilities. Generally these hormones are given and managed by an endocrinologist or a very experienced internist or maybe family practioner. In theater most of the care is given by mid-levels (PAs), GMOs (with an internship under their belt) and PROFIS doctors of various different specialties. The Brigade or Division surgeon who is the most experienced physician in that Brigade (outside of the PROFIS doctors) are relegated to administrative work 90% of the time. I am not sure someone who is on hormone therapy will be best served by a PROFIS dermatologist or gastroenterologist, PA or a GMO with 1 year of training trying to manage their hormone levels. It's not like OCP for birth control. The doses may have to be titrated to effect, avoiding under or over dosing. For those who are not on hormone replacement, this is moot point.

It's definitely uncharted territory.

my experience at a level 1 was similar. except i didn't have the same capability to send people home-- some of the immunosuppressed patients were in the command team. there were also multiple soldiers on polypharmacy psych meds which, while theoretically ok, definitely caused issues when our resupply wasn't efficient. on a good day we'd get maybe 70% of what i ordered, and more likely than not the stuff left off was the stuff i really needed. BMSO would send a gajillion ibuprofen though, lol. the "war stories" we have all seen of shenanigans and buffoonery at the battalion aid station (or even level II) would be a fantastic thread, lol.

if the psych diagnosis does not render them non deployable, and their medication regimen does not render them non deployable, it kind of makes the argument of military fitness moot-- and it simply comes down the acceptance of cost of treatment. a quick googling and i found this
http://www.bumc.bu.edu/endo/clinics/transgender-medicine/guidelines/ which doesn't seem too onerous *if* they are stable. but that's no different than psych meds, which people deploy with all the time.

uncharted territory-- no kidding. the adult and peds endocrine societies are still figuring it out. i don't blame people for being skeptical or critical, i just tend to fall on the "meh" side of the argument. probably because i've been in long enough to see so much gaming of the system from all angles the money argument in most cases doesn't do it for me, and because i've witnessed great soldiers who are gay (no transgenders yet) fear for their careers for no other reason than because the military at large has a thinly veiled undercurrent of right wing conservatism that thinks it's incompatible with military service. or at least used to. in spite of gays having fought and died in wars since time immemorial.

--your friendly neighborhood centrist caveman