By Justin Curry, Ph.D.

U.S. Army photo by Sgt. Joseph Black

Across the United States some people do not seek or receive medical services because of stigma and barriers to care (e.g., distance to clinics, unavailability of after-hours appointments, competing child-care demands, etc.). As a result, medical concerns that might benefit from the intervention of a medical professional may go unaddressed. Not only is this likely to increase the health burden on our nation (e.g., reduced productivity, decreased quality of life, increased disability, etc.) but, for the Department of Defense , unaddressed health concerns may reduce readiness.

While stigma and barriers to care can impact every member of our society, their effects may be more pronounced amongst historically marginalized groups such as transgender and gender diverse (TGD) service members. The DOD does not maintain data on gender identity, but the 2015 DOD Health Related Behaviors Survey  found that roughly six in every thousand active duty respondents identified as transgender. ¹ The most recent HRBS (conducted in 2018) did not report information on gender identity.

A recently published study carried out by researchers at the Uniformed Services University of the Health Sciences considered how stigma and barriers to care may impact TGD service members. They surveyed 177 TGD service members in the active component who were recruited through social media advertisements, flyers posted on military installations, and referrals from other participants. Researchers found that nearly two-thirds of survey respondents experienced at least one stigmatizing interaction in health care settings or encountered a barrier to accessing gender-affirming care. Roughly 60% of respondents reported having trouble accessing transition-related health services. Around 28% of those surveyed reported having a health care professional characterize their gender identity as a mental health issue. Just over 22% of TGD respondents said that they had been referred by their provider to mental health services even when they did not have concerns with their mood. Finally, 13% of respondents said that health care providers had made cruel remarks, ridiculed them, or called them names.² While referrals to mental health may be perceived as (or may be) stigmatizing, it is important to note that current policy (DHA-PI 6025.21) requires a diagnosis of gender dysphoria (a condition typically diagnosed by mental health professionals) before service members are eligible for gender-affirming care. Additionally, methodological issues such as instrumentation and sampling strategy may limit the generalizability of the study findings.²

Even accounting for these limitations and caveats, it's not hard to see how stigmatizing experiences such as those described in the USU study might have a chilling effect on help seeking and health care delivery for TGD service members. The problem of stigma is widespread in our country and its health care systems, and the solutions are not obvious. In part, the answer lies with improved training for health care professionals, but this doesn’t address societal factors (such as the persistence of stigmatizing attitudes and beliefs in the broader U.S. culture) that drive stigmatizing behaviors. Policy-level interventions within the DOD may also prove useful. For example, DOD Instruction 6490.08 establishes a requirement to limit disclosures to command when service members seek mental health care and charges commanders with protecting any authorized disclosures. Public health campaigns that raise awareness around stigma and encourage help-seeking offer a promising mechanism to facilitate changes in beliefs and attitudes at a population level. The Psychological Health Center of Excellence is working to strengthen DOD efforts in this arena. Check out the Real Warriors Campaign website at https://www.health.mil/RealWarriors.

Policies

• DHA-PI 6025.21: Guidance for Gender-Affirming Health Care of Transgender and Gender-Diverse Active and Reserve Component Service Members
• DODI 6490.08 Command Notification Requirements to Dispel Stigma in Providing Mental Health Care to Service Members
• Review of Policies to Eliminate Stigmatizing Language Related to Mental Health

References